Collection of RESEARCH Papers Pointing the Way to A New Paradigm for Thyroid Treatment
I have decided to put another blog post out that collects all the great research papers I have talked about on my website blog into one place. I used many of these in the writing of 'The Thyroid Patient's Manual'.
Together, these point the way to a better approach to thyroid treatment. This new paradigm for thyroid treatment includes several key elements:
- It places the symptoms of the patient much more centre-stage.
- It uses thyroid lab test results but only in a supporting role.
- It watches how all the thyroid labs change with respect to each other as treatment is changed and symptoms adjust.
- Critically the thyroid labs tested must include FT3, as this is the only one that tracks symptom improvement as it adjusts.
- All the thyroid treatments have to be available for the doctor to prescribe - if one does not work well, another can be tried.
Here is the list with a brief statement before each about its focus:
1.The use of TSH in monitoring thyroid hormone therapy is highly unsatisfactory and should be replaced by triple FT4/FT3/TSH measurement. The presentation symptoms of the patient should be the primary focus, above lab-test results, but supported by them. Unthinking automatic biochemical definition of treatment success independent of the patient must cease. Individuality is the decision maker for optimum therapeutic outcomes:https://bmcendocrdisord.biomedcentral.com/articles/10.1186/s12902-019-0365-4
2. Here is a collection of amazing and incredibly pertinent research papers that have been written over the last few years. It points the way to a new and better way of managing thyroid treatment. My new book 'The Thyroid Patient's Manual', is consistent with this research, as I worked with some of the researchers to ensure that it was : https://www.frontiersin.org/research-topics/4262/homeostasis-and-allostasis-of-thyroid-function You can click on the above link and then click on 'Download Ebook PDF' to download the file containing the research papers.
3. Previous clinical trials with T4/T3 were flawed and current treatment is flawed. These two papers do several things. They blow away ALL the research that has ever concluded that T3 has little or no benefit. They show the flaws in trials that support the simplistic reference range use of TSH or FT4 in a generalised way to manage treatment. They also point to a better way to manage thyroid treatment that is more focused on the patient and on the patient response to treatment. They finally puts a bullet into the crazy conclusions that T3 does not help (that so many doctors and endocrinologists have clung onto for so long): https://www.hindawi.com/journals/jtr/2018/3239197/ and this second one, although not about thyroid issues, shows the Simpson's Paradox, which goes a long way to explain why past studies have missed the need for T3 in many patients (because studies have mixed up patients who don't need T3 with those that do and therefore, they have missed the correlation: http://www.pnas.org/content/115/27/E6106
4. T4/T3 study that showed excellent long-term outcomes: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965938/
5. Only FT3 tracks symptom improvement during treatment. This is a fairly recent and terrific piece of research that clearly places FT3 centre place as the most useful lab test measure, as it correlates to symptoms more than the others. In addition to this, the research shows that in T4-monotherapy many patients did not find symptomatic relief until FT3 was elevated in the range and TSH suppressed: https://www.thieme-connect.de/DOI/DOI?10.1055/s-0043-125064
6. Here is another relevant article on why the current paradigm of T4 monotherapy is flawed - this time by Dr Toft: http://www.rcpe.ac.uk/sites/default/files/jrcpe_47_4_toft.pdf
7. The way TSH is currently used is wrong, the way people are treated as if they are all the same is wrong, and simply being 'in range' on levothyroxine monotherapy is not going to guarantee a good outcome. The next piece of research is undoubtedly one of the most important studies done in the last ten years. It finally begins to be more clear that TSH is one of the least useful tools in assessing thyroid hormone levels and whether someone is actually getting enough T3 in the cells: http://www.ncbi.nlm.nih.gov/pubmed/26635726
8. This is an older research paper but shows that reverse T3 (rT3) is a T3 blocker and not an inactive metabolite: https://www.jci.org/articles/view/111313
9. Here is a new piece of research that further supports our experience that T4 monotherapy using Levothyroxine is problematic and cannot re-create our previously healthy levels of FT4 and FT3. The study in rats at present actually found that T4 monotherapy resulted in lower than required FT3 levels. This was corrected with continuous release of both T4 and T3 medication in an appropriate ratio: http://www.jci.org/articles/view/77588
10. A new research paper has been published by Rudolf Hoermann, John E.M. Midgley and Johannes W. Dietrich. It is published in the Clinical Endocrinology Journal. Some of the take away conclusions are that "in some people no amount of T4 will regain normal FT3 levels" and that "...gurus now admit that some people cannot handle T4 and regain health". The links to the abstract and to download the full paper are: http://onlinelibrary.wiley.com/doi/10.1111/cen.12527/abstract and http://www.thyroiduk.org.uk/tuk/TUK_PDFs/Homeostatic-equilibria-cen-final-080714.pdf
11. Here is a new 20 year observational piece of research. It dismisses the incorrect views that T3 has adverse effects on the bones and heart! It confirms that T3 has no adverse effects on heart and bones. This disproves some of the major reasons that doctors use to avoid prescribing T3 - risk to the heart and to bone loss are the two most common reasons used to avoid prescribing T3 to patients, although many of us suspect that cost is the unsaid reason behind non-prescribing of T3: http://www.endocrine-abstracts.org/ea/0038/ea0038OC5.6.htm
12. Another fantastic research article that is putting the knife into TSH as a truly unhelpful diagnostic test of whether thyroid patients are being properly treated. At last it appears that medical research is telling us what we have know for years: http://www.thyroid.org/wp-content/uploads/publications/clinthy/volume25/issue2/clinthy_v252_33_34.pdf
13. Getting TSH into the reference range is no guarantee of good health. Here are some research papers that begin to show how simplistically and poorly TSH is being used today by most doctors. These medical research papers are complex but for those that want to read them they will show that the TSH is not something that should be relied upon in the way it is being done at the present time:
http://www.hindawi.com/journals/jtr/2012/438037/ and http://www.hindawi.com/journals/jtr/2012/351864/ and http://www.ncbi.nlm.nih.gov/pubmed/23423518 and http://www.ncbi.nlm.nih.gov/pubmed/23184912
14. It makes very interesting reading and really shows that the current protocols for managing thyroid hormone issues are so very wrong. The way TSH is currently used is wrong, the way people are treated as if they are all the same is wrong, and simply being 'in range' on levothyroxine monotherapy is not going to guarantee a good outcome. I and you all know that we are all individuals and many of us require either some T3 with T4, or all T3 in a few cases. We also know that we can't be managed by simplistic measures like TSH. It is a quite a complex article but well worth the read: https://www.frontiersin.org/articles/10.3389/fendo.2017.00364/full
15.This study finally begins to be more clear that TSH is one of the least useful tools in assessing thyroid hormone levels and whether someone is actually getting enough T3 in the cells. It states clearly that TSH should be downgraded to a merely supporting role, and that the role of free thyroid hormones are more important. It also states that other/new biological markers are actually required to assess if thyroid hormones are actually sufficient and working well for the individual: Abstract: http://www.ncbi.nlm.nih.gov/pubmed/26635726 and for the full article: https://www.frontiersin.org/articles/10.3389/fendo.2015.00177/full
16. See also this recent blog post of mine which references an article by several doctors, that shows the benefits of T3 to the heart: http://recoveringwitht3.com/blog/follow-blog-post-physiological-replacement-therapy-t3-beneficial-ischemic-heart-disease
17. FT4 and FT3 ranges for individual people are less than half as wide as the large laboratory test population ranges: https://academic.oup.com/jcem/article/87/3/1068/2846746
18. There is a need for individualised requirements for the optimal treatment of hypothyroidism. There is no 'one size fits all' in both treatment and necessary lab values and patient symptoms need to highly in focus.
The paper highlights that:
- The TSH measure alone is really not sensitive enough to tell a doctor when a patient is properly treated.
- Everyone has their own individual needs and set points for levels - there is no one size fits for thyroid levels and lab results for all patients.
- T4 leaves many feeling unwell.
- T3 often needs to be in the treatment, as many conditions and thyroid tissue loss leaves patients low in conversion of T4 to T3.
- Many issues get in the way of conversion including loss of thyroid tissue, deiodinase defects etc.
- Patient symptoms need to be at the forefront of treatment - not placed after lab results which only include TSH and FT4.
- There need to be other biochemical markers of being adequately treated - TSH, FT4 and FT3 are not enough.
Here is the link to the new paper by Hoermann, Midgley, Larisch and Dietrich: https://www.drugsincontext.com/individualised-requirements-for-optimum-treatment-of-hypothyroidism:-complex-needs,-limited-options/
(You can download the full paper from the link within the abstract)
19. Here is a new research paper published on 15 October 2019. The paper shows the uncertainty and worry now abroad in thyroid thinking re use of T3 (and NDT) in treatment and inadequacy of T4 as a broad and always useful treatment. Perhaps this very realisation that all is not well could begin to unsettle those with the firm (but wrong belief) that Levothyroxine monotherapy is all that is needed:
Here is the link: https://link.springer.com/article/10.1007/s12020-019-02052-2
I hope you found these both interesting, instructive and useful in your own struggles to regain or maintain your thyroid health and in working with medical professionals.