If you’ve been following me for a while, you will likely know that I am a big proponent of optimizing thyroid medications in people with Hashimoto's and hypothyroidism. Getting on the right dose of the right type of thyroid medication, can make a huge difference in one’s symptoms, and is often the first necessary step in feeling like ourselves again. However, this can be a lot harder than it sounds.
In 2013 & 2014, Synthroid was the #1 prescribed drug in all of the United States (based on number of prescriptions filled). This is a synthetic version of one of our active thyroid hormones, levothyroxine (T4). This medication works wonders for many people with Hashimoto’s and hypothyroidism, but some continue to struggle with hypothyroid symptoms, even when taking the correct dose of T4.
This is because T4 is known as a pro-drug, or a precursor hormone, as it needs to be activated to T3 (liothyronine), which is the more active thyroid hormone in the body.
In theory, this conversion should go off without a hitch, but in the real world, some people do not convert T4 to T3 adequately. In those cases, thyroid patients find that adding T3 directly to their bodies can make a big difference in how they feel.
My inbox and Facebook page are flooded with patient stories from people who have seen a huge improvement in their symptoms, with just a medication switch. Here are some typical stories I’ve collected over the last few years (names have been changed for privacy purposes).
- Lois, 43, lost 15 lbs within 2 months of switching from levothyroxine to Nature-Throid, without changing her diet.
- Analisse, 33, saw a reduction of hair shedding within 1 month of switching to Armour Thyroid. She began to have little “spikes” of new hair growth within the second month, and is now proud of her lustrous, shiny hair.
- Donna, 56, said that switching to WP Thyroid finally gave her enough energy to keep up with her grandkids! She saw changes within the first two weeks!
You’ll see similar stories of transformation on patient advocacy sites and thyroid patient forums all over the internet, yet most traditional medical doctors are very reluctant to prescribe anything but Synthroid!
Every system is perfectly designed to produce the results it produces. Change starts with education.
In pharmacy school, I was taught that T4 medications were the preferred therapy for people with hypothyroidism and Hashimoto’s, and that medications like Armour were unstable and should be avoided. “The only time a person should remain on Armour”, I remember hearing my professors and supervising pharmacists say, “is if they’ve been on it for many years and are unwilling to switch to the newer, better medications like Synthroid”.
This was what everyone was taught…
During pharmacy school, I worked as a pharmacy intern at a busy Walgreens pharmacy, where we filled on average 500 prescriptions per day. Most dosages of Synthroid and Levoxyl were in our “fast mover” section of the pharmacy, or in our automated counting machine because they were prescribed so frequently. On an average day, I filled 20-30 prescriptions for Synthroid/Levoxyl and we always had multiples of 1000-count bottles on hand to be sure we didn’t run out.
In contrast, we only carried a few doses of Armour Thyroid for the couple of patients we had on Armour. These tiny bottles sat on a lonely shelf in the back of the pharmacy, and we always made it a priority to check expiration dates on the bottles, as sometimes the medications would expire before we had a chance to dispense them, due to low prescription volume.
I often get letters from frustrated readers who say that their doctors are refusing to prescribe T3 containing medications. I decided to interview my colleague, Registered Pharmacist Carter Black, about why physicians (especially endocrinologists) are hesitant to prescribe anything except Synthroid, or Levothyroxine, commonly known as T4.
Here are a few issues that have made endocrinologists skeptical of any thyroid medication besides Synthroid, and its generic or branded equivalents.
Physicians are averse to any liability that may affect their practice or ability to continue their profession. Levothyroxine (T4) is often cited in studies, that it is sufficient for most patients. Anything containing liothyronine (T3) is looked at with fear that it may cause palpitations (tachycardia), or osteoporosis resulting in over-replacement.
- Historical (sometimes hysterical) prejudice
Before the mid 1960's, most thyroid patients were treated with Thyroid U.S.P., which like Armour, Nature-Throid and WP Thyroid, was derived from the thyroid glands of animals. This type of treatment has been used since the 1890’s in the United States! Thyroid U.S.P. was available in some dosage forms as tablets that were in a similar ratio to the current Armour Thyroid, but the assay standards to test the level of active hormones were nowhere near modern standards, sometimes resulting in inaccurate dosing.
- Misinformation about Compounding Pharmacies
Historically, “in between” doses were compounded with Thyroid powder U.S.P. Any pharmacist could put an amount into a capsule. Back in the day, this was not an exact process. The balance (scale) was not sensitive, and compounding was done by every pharmacist with a scale, some empty capsules and some powder. Today’s standards for pharmaceutical compounding have dramatically changed, so that most compounding is done with prediluted powders and ultra sensitive scales, by specially trained pharmacists, in specially certified compounding pharmacies. Note: when working with compounded thyroid medications, be sure to seek a pharmacist that compounds the bulk of their prescriptions, participates in organizations devoted to compounding and has an excellent reputation.
- Pharmaceutical Marketing Dollars
When Synthroid came to the market in 1955, Flint Labs, the manufacturer of synthetic thyroid “Synthroid” recognized that patients and physicians alike were frustrated with inconsistent results from the glandular-derived thyroid medications, as well as the other new synthetics on the market, so the manufacturer made an effort to create a predictable product that patients and physicians could trust.
This innovation resulted in more predictable outcomes from therapy, compared to the other previously available medications. Flint Labs pharmaceutical representatives began to educate physicians about the superior predictability of Synthroid to Thyroid U.S.P. Physicians and patients appreciated this; no more worries about becoming hypothyroid or hyperthyroid the next time you refill your medications! Soon enough, Synthroid became the drug of choice.
But Synthroid was not the only medication with improved predictability...
Eventually, Armour Thyroid was created to address the dosage variability weakness, but by that time, glandulars had fallen out of favor.
The patented levothyroxine (T4) in the name of Synthroid became a top ten seller in the United States (It has now become the #1 selling drug in the United States, as of 2013 and 2014 data). MOST patients were happy. Armour Thyroid did have a sales force but nothing compared with Flint Labs.
There has been quite a bit of controversy surrounding the marketing of Synthroid. In 2000, Synthroid was the third most commonly prescribed medication in the US, due to claims by the manufacturer that generic alternatives were inferior. The pharmaceutical company funded university researchers to perform studies to test generic equivalency with Synthroid. When the studies showed that the generic products were actually equivalent and would offer a cost savings to patients and insurance companies, the researchers were allegedly discouraged from publishing their results and the information was suppressed. This study was done in 1986, but suppressed from publication until 1997! The company settled, agreeing to pay $87 million dollars in a class action lawsuit.
Harold J. DeMonaco, in MGH Drug Therapy, Vol XI, Issue 8 called it a “Made for TV Movie” situation. It was a point in history when two other levothyroxine products were FDA approved and the maker at the time refused to seek approval because Synthroid was the standard product.
Meanwhile, Forest Lab, the manufacturer of Armour Thyroid, just kept making their product, without dedicating much of a marketing budget to the product.
According to Carter Black, RPh, Synthroid the brand and others have been recalled many times, and Synthroid was even reformulated in 1981. In his 40 years as a pharmacist, Mr. Black does not remember a recall of Armour Thyroid.
The interest in glandular products was finally revived (in my opinion) in recent years by RLC Lab, the manufacturer of Nature-Throid and WP Thyroid. The website for RLC Lab proudly states that their products have never been recalled due to inconsistent levels, while Synthroid has gone through numerous recalls in the last decade. Speaking to a pharmacist friend of mine, who still works at Walgreen’s (we used to be pharmacy technicians and pharmacy students together many moons ago), she noted that she is seeing an increased number of prescriptions filled for Nature-Throid, yay!
- Inappropriate Medication Use/Abuse
The 80's also cast T3 in a negative light. Weight loss clinics started prescribing Cytomel ***may be cross-contaminated with gluten***(T3), along with amphetamines, for people without thyroid disease, inducing hyperthyroidism in their patients, which resulted in quick (but dangerous) weight loss! As you can imagine, this combination given to an overweight person with a normally functioning thyroid often created a dangerous situation. Patients were admitted into the emergency rooms with life or death symptoms of high fever, palpitations, labored breathing, dehydration, delirium, nausea, vomiting and even coma. This is a difficult clinical situation. Death can result, as well as future problems of thyroid management (alternating hyperthyroid and hypothyroid), cardiac damage and mood disorders are among the consequences of the above.
As a result of this inappropriate abuse of medications, all thyroid medications are now required to carry a black-box warning (the most strict warning given by the FDA), that warn against the use of thyroid medications for weight loss.
Many of today's practicing endocrinologists witnessed the effects of this situation first hand, as young residents and medical students early in their training. One can certainly understand a doctor's aversion to T3 or T4/T3 combinations, because of past history of inappropriate use.
****Please note, you shouldn’t confuse this with appropriate use of thyroid medications for people who are overweight due to hypothyroidism. Using thyroid medications for a person who is hypothyroid is an appropriate use of medications, and anyone suggesting otherwise should be questioned for their understanding of basic physiology.
I once saw a poorly researched article written by an internet marketer who was saying that thyroid medications were not to be used by people with thyroid disease due to this warning! That’s like saying that dogs shouldn't eat dog food because it’s not appropriate for cats! :-)
- Reliance on TSH
In the good ol’ days, before the availability of thyroid testing, patients were dosed on thyroid medications based on their symptoms - this didn’t always turn out for the best, and patients were often overdosed. Thyroid symptoms can be nonspecific, and fatigue and weight gain are not always thyroid related.
With the emergence of thyroid testing, most physicians now dose thyroid patients based on their TSH levels. Of course, all health care professionals are taught to treat the patient, not the lab test, but very few actually seem to follow that advice.
I recommend working with a practitioner that relies on not just the TSH test, but also free T3, free T4 AND your symptoms, to paint a complete picture of how to properly adjust your medications.
You can read my articles When Your TSH is Normal and You Are Anything But, Six Types of Thyroid Tests and Top Things To Know About Thyroid Medication for more information.
- Research Funding
Clinical trials are very expensive and require funding. Most studies focusing on medications are funded by pharmaceutical companies that manufacture the medications, and thus the majority of studies done with thyroid medications will focus on T4 medications. However, National Institutes of Health, a government agency conducted a clinical trial not funded by pharmaceutical grants to see if natural desiccated desiccated thyroid therapy is advantageous to T4 alone. The authors of the study concluded: "DTE (Desiccated Thyroid Extract) therapy did not result in a significant improvement in quality of life; however, DTE caused modest weight loss and nearly half (48.6%) of the study patients expressed preference for DTE over l-T4 (Levothyroxine). DTE therapy may be relevant for some hypothyroid patients".
Additional searches of PubMed (the largest database of published medical research) will reveal that patients prefer combination therapy of T4 & T3. A recent article stated: “Physiologic combinations of Levothyroxine plus liothyronine do not offer any objective advantage over Levothyroxine alone, yet patients prefer combination treatment.” Annals of Internal Medicine 2005 Mar 15. Most endocrinologists do not like “subjective” evidence, and prefer “objective evidence”. Plainly defined; objective evidence includes numbers and tests, while patient responses to questions (how are you feeling?) are considered subjective. Objective numbers lead to less liability.
So what’s a patient to do?
If you’re not feeling well on your current medication, you shouldn’t suffer just because your doctor is not familiar with other types of medication.
Rather than getting upset at your doctor for not wanting to prescribe a medication he/she is not comfortable prescribing to you, my suggestion is for you to do the following:
- Educate yourself. Read through the above listed articles and get a copy of my new eBook on Optimizing Medications.
- If your doctor is not willing to prescribe anything besides Synthroid for you, find a doctor who has experience with the use of Cytomel ***may be cross-contaminated with gluten***, liothyronine, T3, Armour, Nature-Throid, WP Thyroid and/or compounded thyroid medications, and make an appointment. It’s better that you work with someone who is experienced in using these medications safely and correctly, rather than convince your current doctor to prescribe them for you! After all, you probably don’t want to be someone’s first patient on a medication they are not familiar with anyway! A database of practitioners is available on my website. If there are no practitioners are available in your area, check with your local compounding pharmacy to see if the pharmacists there have a recommendation for you.
- If you are hoping to have your current doctor involved and he/she is open minded, I suggest taking a team approach. You have the option of having another practitioner prescribe the medication to you, while you keep in touch with your current doctor, or you and your doctor can work with a pharmacist who is experienced in thyroid medication use and dosing, like Carter Black, who I interviewed for this article. Mr. Black is available for consultations about thyroid medication to patients and physicians.
Please note, some patients resort to ordering T4/T3 medications off the internet. I do not recommend this, due to quality concerns and the potential for overdosing yourself. You should always work with a qualified healthcare practitioner to optimize your medications!
About Carter Black, RPh:
Registered Pharmacist Carter Black is a graduate of the University of Illinois College of Pharmacy with undergraduate work at University of Illinois at Champaign/Urbana. He is a preceptor to pharmacy students and is a consultant by doctor referral for women and men's health, hormone and thyroid issues. He is a former professor of pharmacology at Pacific College of Oriental Medicine, and has over 40 years of experience working with compounded medications and bio-identical hormones. Mr. Black has extensive training through the Institute of Functional Medicine, Hacking Hashimoto's and the Hashimoto's Institute, and is Dr. Izabella's go-to resource for thyroid medications, compounded medications and appropriate use of hormones. He has been collaborating with Dr. Izabella since 2011.
Your Thyroid Pharmacist,
Dr. Izabella Wentz, Pharm D.