by Jeffrey Dach MD
Web Sites like Janie Bowthorpe’s, Stop the Thyroid Madness and Dana Trentini’s, Hypothyroid Mom are very popular for a very good reason. They identify and alert readers to the errors in modern thyroid endocrinology. Before we discuss these errors in detail, you might first ask the question, “How is this possible, that there could be errors in modern thyroid medical practice?”
How Are Errors in Thyroid Medical Practice Possible?
The answer to this question becomes obvious considering the money flowing from the drug industry to thyroid societies and doctors. In various forms, your doctor might be taking financial incentives (AKA bribes) from the drug industry. For example the American Thyroid Association and the Endocrine Society, the Endocrine Journals, Endocrine Research Grants, Endocrine Speakers Fees and Endocrine Meetings are all heavily funded by the Major Drug Companies, including the ones that make Synthroid, Levothyroxine and T4 only thyroid medications. This is all public information.
Creating Guidelines For the Benefit of the Benefactors
In 2012, the American Association of Endocrinologists and the American Thyroid Association, (ATA), published Guidelines for prescribing thyroid pills, which says:
“There is no evidence to support using desiccated thyroid hormone in preference to L-thyroxine monotherapy in the treatment of hypothyroidism and therefore desiccated thyroid hormone should not be used for the treatment of hypothyroidism.”
By some strange coincidence. the ATA (American Thyroid Association) receives substantial financial support from three drug companies: Pfizer, AbbVie, and Akrimax, makers of Levothyroxine, the same drug which is “Standard of Care” according to their “Guidelines”.
Endocrine Society is proud to publicly disclose their funding which comes from (among others) :
AbbVie Inc. Akrimax Pharmaceuticals Alexion Pharmaceuticals, Inc. Amarin Pharma Inc. Bayer HealthCare Boehringer Ingelheim Pharmaceuticals, Inc. & Lilly USA, LLC Burroughs Wellcome Fund Corcept Therapeutics Incorporated Dexcom, Inc. Eisai Inc. Endo Pharmaceuticals Inc. Esaote North America, Inc. Ethicon Endo-Surgery, Inc. FNA Path Genentech, Inc. Janssen Pharmaceuticals, Inc. Lilly USA, LLC Merck & Co., Inc. Mindray Thyroid Ultrasound by CSD Novartis Pharmaceuticals Corporation Noven Pharmaceuticals, Inc. Novo Nordisk Inc. NPS Pharmaceuticals, Inc. Pfizer, Inc. Salix Pharmaceuticals, Inc. sanofi-aventis U.S. Inc sanofi-aventis U.S. Inc, Regeneron Pharmaceuticals Alliance Takeda Pharmaceuticals U.S.A., Inc. Toshiba Head and Neck Ultrasound Veracyte, Inc.
I think you are starting to get the idea. You might be surprised to know that these Guidelines are wrong, a fact admitted by the ATA when they came up with different guidelines in 2014. nonetheless, the new Guidelines still serve the Drug Industry by rejecting natural desiccated thyroid in favor of T4 only medications, a recommendation having no basis in medical science. We will discuss this in detail below.
Medical practice in the US is strongly influenced by guidelines promulgated by the medical societies. So when the leading Thyroid Endocrinology societies issue incorrect guidelines, you can understand how this leads to errors in the practice of thyroid endocrinology.
A frequent question that comes up a few times a day in my office is: “Why won’t my endocrinologist listen to me?” Many of these patients are actually escapees from the endocrinology office, having been ignored and mistreated by a succession of “cookie cutter” endocrinologists who give them minuscule amounts of T4 only medication (usually Levothyroxine), which keeps the TSH in the “reference range” These poor miserable souls finally arrive in my office where we switch them from Levothyroxine to natural desiccated thyroid in a dosage that gives them some relief from low thyroid symptoms. We use Natural Desiccated Thyroid from RLC Labs called Naturethroid, One Grain Tab (65mg) contains 38 mcg T4 and 9 mcg T3 per tab, the same ratio produced by the normal thyroid gland.
Shorter Half Life Makes Natural Thyroid Safer
T3 has a shorter half life (T1/2) of one day (24 hrs), compared to the 7 day half life of T4 (Levothyroxine). This difference explains why NDT is a safer choice compared to T4 only meds such as levothyroxine. Symptoms of thyroid excess dissipate within a few hours of stopping NDT, while for the T4 only Levothyroxine, it may take a week for symptoms to resolve. We check labs prior to starting and aftert 6 weeks: TSH, FT4, FT3, TPO and Thyroglobulin Abs. We also routinely check serum selenium and spot urinary iodine.
The Thyroid Gland Produces T3 and T4 in 1:4 ratio, same as the T3/T4 ratio in NDT. Thyroid hormone is made by organifying iodine to thyroglobulin in the follicle at the apical membrane of the thyrocyes. This organification requires oxidation of Iodine by the TPO enzyme using hydrogen peroxide as a substrate. Various thyroid pathologies can be explained by overproduction and lack of degradation of H2O2, such as thyroiditis, cancer etc. This T3/T4 ratio of 1:4 is found in Natural Dessicated Thyroid which has 9 Mcg T3 and 38 Mcg T4 in each one grain tablet.
The List of Errors in Thyroid Endocrinology
- Reliance on TSH Only to Monitor Treatment. .(Bianco 2016)
- TSH Suppression may be needed for Adequate Treatment.(Ito 2012)
- Reliance of T4 Only-Monotherapy (Levo or Synthoid) (Gullo,2011)
- NDT –Natural Dessicated Thyroid Better Choice. (Hoang, 2013)
Shorter Half Life-makes NDT safer choice.
NDT Combines T3 and T4 – more robust for poor converters.
TSH Can Be Unreliable
The TSH can be unreliable in a number of medical conditions such as: Hypothalamic Dysfunction, Chronic Fatigue, Fibromyalgia Patients (Teitelbaum, Holtorf, Skinner)
Relying on TSH WIthin Reference RAnge
Dr Antonio Bianco’s study: 469 Levothyroxine (T4) treated patients were compared to controls. The Levothyroxine treated patients more likely to have lower serum T3:T4 ratios,
Higher BMI(Weight), more likely to be taking Beta-Blockers drugs, Statin drugs, and SSRI Anti-depressant drugs. And they were more likely to suffer from cognitive Impairment. (Peterson, Sarah J., Antonio C. Bianco. (2016).
Dr Antonio C. Bianco, MD, PhD, past president of the American Thyroid Association and professor of medicine at Rush Medical School says this:
Despite normal TSH tests, these patients still have many nagging symptoms of hypothyroidism. “Patients complain of being depressed, slow and having a foggy mind,” said “They have difficulty losing weight. They complain of feeling sluggish and have less energy. Yet we doctors keep telling them, ‘I’m giving you the right amount of medication and your TSH is normal. You should feel fine.’”
“Better medications (than Levo) are needed to treat hypothyroidism….Patients who continue to have symptoms on Levothyroxine monotherapy might try a pill that contains both T3 and T4. “ (Antonio Bianco MD 12-Oct-2016)(Peterson, Sarah J., Antonio C. Bianco. (2016)
TSH Suppression May be Needed for Adequate Treatment
TSH Suppressive doses of Levothyoxine may be needed to achieve pre-operative T3 levels after thyroidectomy (Ito, 2012). More than 20% of patients, despite normal TSH levels, do not maintain FT3 or FT4 values in the reference range, reflecting the inadequacy of peripheral deiodination to compensate for the absent T3 secretion.” (Gullo, 2011)(Ito,2012)(deCastro, 2015)
Levothyroxine-T4 Alone does not resolve symptoms of Hypothyroidism
“Unfortunately therapy with L-T4 alone does not resolve symptoms in all hypothyroid patients, with approximately 12% of the patients remaining symptomatic despite normalization of serum TSH and TH levels. Impaired cognition, fatigue, and difficulty losing weight are the main residual symptoms of these patients, for which we lack understanding and have no mechanistic explanation.” Quote from: (McAninch 2015)
Conclusion: Errors in Modern Thyroid Endocrinology are understandable considering the corrupting influence of industry funding of thyroid endocrine societies, meeting, research and key opinion leaders. The main error is dogmatically insisting the TSH stay within the reference range when TSH suppression may be required for adequate therapy. The second error is dogmatically insisting on T4 monotherapy when natural desiccated thyroid (containing both T3 and T4) is more effective and safer than T4 monotherapy.
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Jeffrey Dach MD
7450 Griffin Road, Suite 190
Davie, Fl 33314
Articles with related interest:
Links and References
Peterson, Sarah J., Elizabeth A. McAninch, and Antonio C. Bianco. “Is a Normal TSH Synonymous With “Euthyroidism” in Levothyroxine Monotherapy?.” The Journal of Clinical Endocrinology & Metabolism 101.12 (2016): 4964-4973.
McAninch, Elizabeth A., et al. “Prevalent polymorphism in thyroid hormone-activating enzyme leaves a genetic fingerprint that underlies associated clinical syndromes.” The Journal of Clinical Endocrinology & Metabolism 100.3 (2015): 920-933.
Ito, Mitsuru, et al. “TSH-suppressive doses of levothyroxine are required to achieve preoperative native serum triiodothyronine levels in patients who have undergone total thyroidectomy.” European Journal of Endocrinology 167.3 (2012): 373-378.
Center for Excellence in Thyroid Care, Kuma Hospital, 8-2-35, Shimoyamate-Dori, Chuo-Ku, Kobe-City, Hyogo 650-0011, Japan
Gullo, Damiano, et al. “Levothyroxine monotherapy cannot guarantee euthyroidism in all athyreotic patients.” PloS one 6.8 (2011): e22552..
de Castro, Joao Pedro Werneck, et al. “Differences in hypothalamic type 2 deiodinase ubiquitination explain localized sensitivity to thyroxine.” The Journal of clinical investigation 125.125 (2) (2015): 0-0. quote:“normalization of serum TSH with L-T4 monotherapy results in relatively low serum 3,5,3′-triiodothyronine (T3) and high serum thyroxine/T3 (T4/T3) ratio”
Song, Yue, et al. “Roles of hydrogen peroxide in thyroid physiology and disease.” The Journal of Clinical Endocrinology & Metabolism 92.10 (2007): 3764-3773.
Hydrogen peroxide is degraded by seleno-proteins such as (Glutathione) GSH peroxidase and thioredoxin reductase. Selenium deficiency is associated with thyroid damage from excess hydrogen peroxide. We routinely check the serum selenium level and give selenium supplements to those in need.
Iodine Excess and Selenium Deficiency
In the face of selenium deficiency, excessive iodine intake will Induce Goiter, lead to thyroiditis, worsen lymphocytic infiltration, and damage the thyroid follicular structure in a dose-dependent manner in autoimmune mice.
Teng, X., et al. “Experimental study on the effects of chronic iodine excess on thyroid function, structure, and autoimmunity in autoimmune-prone NOD. H-2h4 mice.” Clinical and experimental medicine 9.1 (2009): 51.
However, supplemental Selenium alleviates the toxic effects of excessive Iodine on thyroid.”
Xu, Jian, et al. “Supplemental selenium alleviates the toxic effects of excessive iodine on thyroid.” Biological trace element research 141.1-3 (2011): 110-118.
Iodine Suppresses Thyroid Function
Occasionally a patient will walk into the office after taking high dose iodine for a few months, and report they feel fine, however, their thyroid labs are “out of wack” which disturbs their endocrinologust or primary care doctor. The TSH may be quite elevated (in the 50-70 range), caused by the suppressive effect of Iodine on the thyroid. This reverses upon stopping the high dose iodine, and labs return to normal in a few weeks. High dose Iodine reduces TPO activity, reduces Iodine Uptake and reduces Iodine organification by the thyroid gland. Autoimmune thyroid patients with Hashimotos or Graves are more sensitive to this suppressive effect of Iodine.
Man, N., et al. “Long-term effects of high iodine intake: inhibition of thyroid iodine uptake and organification in Wistar rats.” Zhonghua yi xue za zhi 86.48 (2006): 3420-3424.
TAJIRI, JUNICHI, et al. “Studies of Hypothyroidism in Patients with High Iodine Intake.” The Journal of Clinical Endocrinology & Metabolism 63.2 (1986): 412-417.
The deiodinase enzyme is responsible for the peripheral conversion of T4 to its more biologically active cousin, T3. This is done by removing of an iodine molecule from the tyrosine skeleton. About 20% of patient have difficulty with peripheral conversion of T4 to T3. These are the patients who do well by switching from Levothyroxine to NDT which contains T3 as well as T4.
Medical Model Determines Thyroid Usage
CASH Model-NDT: More Time w Pt. 30 min. Suppressed TSH May be required for adequeate treatment. Labs: Look at TSH, and FT3, FT4. Spend 5 min explaining risks and adverse effects of thyroid pills.
Insurance Model – Synthroid Levo : Less Time w Pt. 3-10 min. Keep TSH in Range, Adjust T4 Dosage based on TSH in range. No time to explain adverse effects,
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