Returning to a Patient-Centered Approach in the Management of Hypothyroidism.
Available from: researchgate.net/publicatio... [accessed Aug 12 2022]. The historical context sheds light on this topic by highlighting the shift from patient-centered symptom management to one based on laboratory values, which diminishes room for the patient experience. Before the 1970s, hypothyroidism was treated with desiccated thyroid products (dehydrated porcine or bovine thyroid). Desiccated thyroid products contain a combination of thyroxine (T4) and triiodothyronine (T3)in an approximately 4:1 ratio, and historically were titrated to the cessation of symptoms, while monitoring for thyrotoxicosis.2 In the 1970s a shift occurred in both the supplementation and measuring of T3 andT4, which led to better assessment of what happened with replacement of individual synthetic hormones. It was noted that replacing T3 alone led to large swings in T3 levels shortly after taking the drug which did not mimic physiologic levels seen in euthyroid individuals. When, however, synthetic T4 (levothyroxine) was introduced it resulted in T3 levels that were normalized throughout the day instead of fluctuating. Thus, the idea that peripheral tissue conversion supplied all the T3 that was needed to normalize thyroid function took hold. This was confirmed by the development of the assay for thyroid stimulating hormone (TSH), which measured stability of thyroid function over time, and remained steady with levothyroxine-only dosing. As such, the end goal for the treatment of hypothyroidism shifted from symptom control to achieving a normal TSH.3 The focus on normal TSH, and concerns over the lack of batch-to-batch consistency in desiccated thyroid products (they are standardized for iodine content) led to the use of desiccated thyroid products being actively discouraged.4 This one-size-fits-all approach for treating hypothyroidism does not work, however, for all patients. Emerging evidence shows that for many patients, symptoms persist despite normal TSH values.5 In a qualitative study, patients who continued to feel unwell with normalized TSH reported feeling that their physicians were not willing to look further into why their symptoms were persisting.6 In addition, patients often reported that the vague nature of their symptoms along with lack of control over their symptoms, leave them feeling invalidated and without answers.7 In fact, these ongoing symptoms may have a physiologic cause. New information has emerged that conversion of T4 to T3 by exogenous tissue is more complex than previously described. For instance, patients on levothyroxine alone have higher T4, lower T3, 8 lower energy expenditure,9 and ongoing abnormalities of lipid metabolism8; all pointing to a lack of appropriate thyroid metabolism. Further, in thyroidectomy patients the amount of supplementation needed to achieve normalization of T3 levels is such that it leads to suppression of TSH,10,11 which may explain why some patients lack complete resolution with normal TSH and feel resolution of symptoms with suppressed TSH levels. One possible way of addressing these imbalances and persistence ofsymptoms is the addition of T3, which desiccated thyroid products naturally contain.A barrier to their use, however, is the ongoing con-cern that TSH will not be consistently maintained within normal ranges. Kuye et al 12 has contributed to our understanding of this concern in their retrospective matched cohort study in this issue. They begin a much-needed investigation into whether patients prescribed synthetic levothyroxine compared with desiccated thyroid had differences in TSH stability over the course of 3 years. Their results in 870 hypothyroid patients matched for age, sex, and ethnicity showed no difference in longitudinal TSH stability between desiccated thyroid products and synthetic levothyroxine,and despite more variation in visit-to-visit TSH levels variability in the patients taking desiccated thyroid, all patients regardless of the thyroid medication were euthyroid 79% of the time (PDF)
Returning to a Patient-Centered Approach in the Management of Hypothyroidism.
'As you say diogenes , not before time. Just wish we had something similar here in the UK.
'This study does, however, provide helpful informa-tion that desiccated thyroid products are a reasonable choice for treating some hypothyroid patients. Keep-ing desiccated thyroid medications as an option in our tool kit will allow for improved shared decision mak-ing, while allowing for patient preference, and offer an option for those patients who remain symptomatic on levothyroxine monotherapy.'
If only we had even just one manufacturer of desiccated thyroid in either the UK or Europe, that could potentially be licensed for our NHS to prescribe, it might help our cause. The extortionate price charged for US brands of NDT is hugely prohibitive for us.
It seems madness as, in Europe, we actually have (at least) two manufacturers of desiccated thyroid powder (Thyroid USP - the standardised Active Pharmaceutical Ingredient - API).
Jumbelina , the paper you refer to here contains a useful quote to support keeping TSH below 2.5. so i';v added it to my list of evidence to chuck at GP's "A Renewed Focus on the Association Between Thyroid Hormones and Lipid Metabolism
Leonidas H. Duntas1* and Gabriela Brenta2.
Treatment With L-T4: Why, Who, and How~
....therefore, TSH values can be considered a good predictor of cardiovascular disease, notably when its levels are above 10 mIU/L (75). In particular, a TSH above 2.5 mIU/L in women of childbearing age may induce oxidative damage to membrane lipids and unfavorably alter the lipid profile, suggesting that TSH levels in this population should preferably be maintained below 2.5 mIU/L (76) ".
Thank you for this report, diogenes. I'm very much a learner regarding thyroid issues.
But my first question is a T patient population average of 79% euthyroid good enough? Anyone? Does this sound good to you?
Secondly, 'patient-centred' is something the NHS struggles with across the board and, imho, has rarely achieved.
And third, 'shared decision-making' ditto. The fact that I know so little about thyroid and my supplementation is indicative of the level of information-sharing which is a sine qua non of shared decision-making. (I was told in a by-the-way manner, at the end of a lengthy GP consult - 15mins - about a pile of auto-immune/arthritic issues/scans, that I have to take these levo tabs - and it's for the rest of my life...then out the door.)
Something that seems to me to be a plus point: amongst a growing section of the US medical industry generally there appears to be a quiet, slow shift from wholly chemical medication towards broader ranges of more effective natural remedies in combination with synthetics. In time it'll catch on here! As yet though I can't see how the NHS is going to be able to deal with such necessarily more personalised treatment regimes.
I think they are still using the TSH definition of euthyroidism, which we know to be faulty. Actually the fact that DTE and synthetic hormones had the same effect is the really important finding.
Though one might like to, it would be unwise to "rub the medical world's face in it". Organisations do not like their errors fully broadcast and therefore if one tries (before the discipline is ready for it) the donkeys will simply refuse to budge. Since the realisation that to admit new evidence would require by implication, the binning of 30 odd years of inferior or missed diagnoses, and resulting patient harm, this would be and is, too hard a finding to swallow. I also note that there seem as usual to be two camps who appear either to want or not to want to follow or contribute to the argument. On one side there are the US and UK and some European medics, who simply ignore the evidence, with Australia, Israel andJapan being examples of the other who are actively studying it. After a lifetime of publication in two fundamentally different fields, I note that US "exceptionalism" is the driver for the refusal to admit anything except US work. It is called the NIH syndrome (Not Invented Here).
It is, but the medical world won't accept that idea. They want their cake and eat it! That is, incorporate the new ideas without letting go of the old ones. Not possible, but they don't yet realise it.
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New Study By Dr. Bianco on DIO2 Polymorphism
High TSH - and GP not advising treatment, any advice?
Not at the patients demand!
