A Doctor's View on Treating Hypothyroidism Including Using T3 Therapy

Dr. Theodore Friedman Shares His Approach to Treating an Underactive Thyroid.

Doctor examining female patient
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One of the nation's leading endocrinologists, Theodore Friedman, MD, PhD, shares his thoughts about what constitutes optimal treatment for hypothyroid patients, as part of this series on practitioner perspectives on the best treatments for an underactive thyroid.

The Basics on Hypothyroidism Treatment

Dr. Theodore Friedman optimizes thyroid hormone replacement based on three factors:

  • how the patient is feeling
  • the patient's thyroid function tests
  • side effect profile of the thyroid mediciine

One issue is the thyroid medicine the patient has been prescribed. Dr. Friedman prescribes various combinations of thyroid hormone replacement to patients depending on their circumstances and conditions. Most of the time, he starts with T4 replacement -- that could be Synthroid, Levoxyl, generic levothyroxine, or a new product called Tirosint, which is a liquid form of thyroid hormone in a gel that has no additives, preservatives, or dyes.

If the patient is on T4 treatment, Dr. Friedman primarily looks at the TSH and aims for a TSH between 0.5 and 2.0. Within this range, Dr. Friedman may adjust the thyroid hormone dose slightly, based on the patient's symptoms. For example, if a patient is having some hypothyroid symptoms, he might increase it so the TSH is near the bottom of the range. If a patient is having some hyperthyroid symptoms, Dr. Friedman may decrease the thyroid hormone so the TSH is near the top of this range between 0.5 and 2.0.

At times, Dr. Friedman fine tunes the thyroid dosage by having the patient take one dose 5 days a week and another dose on weekends. For example, he may have a patient take 100 mcg of Levoxyl on weekdays and 112 mcg on weekends.

What If a Patient Has Persistent Hypothyroid Symptoms?

If a person is still having hypothyroid symptoms with just T4 treatment, Dr.

Friedman considers an Armour/T4 combination or a T4/T3 combination. His rational is that although T4 is long-lasting and most patients do fine on T4, there are some patients who do not convert T4 to T3 properly (possibly a genetic defect). 

Armour has T4 and T3 in it in a fairly good mixture and also contains other thyroid factors that may be beneficial. Because the T4 and T3 in Armour is mixed in with other proteins, Armour's half- life is a little longer than if the patient is just taking T3, which would have a very short half-life. Due to this very short half-life, Dr. Friedman recommends Armour twice a day. In addition, Dr. Friedman adds T4 to Armour because he feels that Armour has too much T3 in it by itself -- so, he gives a somewhat lower dose of Armour and supplements with T4.

If Dr. Friedman gives T3 plus T4, he gives the T4 once a day and the T3 dose two or three times a day, or he gives slow-release T3 compounded for daily use.

Dr. Friedman's Thyroid Hormone Goals

If a patient is on an Armour/T4 combination or T4/T3 combination, Dr. Friedman will often see a low TSH.

He does not like the TSH to be completely zero, but is comfortable with it being slightly below the normal range. The suppressed TSH occurs because the T3 quickly suppresses the TSH after it is administered, even though the free T4 and free T3 are normal. According to Dr. Friedman, it's unlikely a patient will have side effects from having this suppressed TSH, but he watches carefully for any heart problems or osteoporosis.

On the flip side, too much thyroid hormone can give palpitations, a jittery feeling, trouble sleeping, and other symptoms of hyperthyroidism. If this is the case, Dr. Friedman would back down on the thyroid hormone replacement. 

What if Hypothyroid Symptoms Still Do Not Improv?

Usually a patient sees a fairly rapid improvement in her symptoms with treatment if she is truly hypothyroid. Sometimes though, a patient needs a little bit longer time or a little adjustment of either the dose or type of thyroid medicine before an improvement is seen. If there is no improvement seen, then the diagnosis of hypothyroidism needs to be re-evaluated, as there are other health conditions that can mimic that of hypothyroidism.

The Bottom Line

It's important to understand that the use of T3 therapy for treating persistent hypothyroid symptoms is still a controversial issue. More research studies to better understand its usefulness and safety would be helpful.

The big picture here is that optimizing your thyroid health requires a delicate balance between your medication dosage and your symptoms -- the best thing you can do is take note of how you feel (even writing it down in a journal is useful) and follow closely with a trusted endocrinologist. 

Theodore Friedman, MD, PhD is Chairman of the Department of Internal Medicine, and Chief, Division of Endocrinology, Metabolism and Molecular Medicine, Endowed Professor of Cardio-Metabolic Medicine, and Professor of Medicine at The Charles Drew University of Medicine & Sciences in Los Angeles, and a Professor of Medicine at UCLA.


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