What is The Circadian T3 Method?

I felt it was time that I did one single blog post that provides an overview of the circadian T3 method (CT3M) as a starting point for a thyroid patient or doctor who wishes to find out about it.

What is the Circadian T3 Method (CT3M)?

The Circadian T3 Method is a subset of the T3 Dosage Management Process that I used to regain my health.

In the book 'Recovering with T3' I describe a dosage management process that describes how I used T3 safely, successfully and systematically to get well. The T3 Dosage Management process is described over the following chapters:

Chapter 19: Preparation for T3 Replacement Therapy
Chapter 20: The Goals of T3 Dosage Management
Chapter 21: Using Symptoms and Signs
Chapter 22: Taking Body Temperature Readings
Chapter 23: Recognising a T3 Dosage that is Too High
Chapter 24: Phase 1: Clearing T4
Chapter 25: Phase 2: Determining a Safe, Effective and Stable T3 Dosage
Chapter 26: Phase 3: Long-Term Monitoring
Chapter 27: Conclusions on T3 Dosage Management

I believe that the information in the book 'Recovering with T3' presents a best-in-class safe, effective and systematic way of using T3 that results in the least amount of T3 being required in order for someone to get well again. This approach is likely to result in fewer issues and far less chance of tissue over-stimulation occurring than with any other approach using T3. Other approaches may be used, e.g. taking T3 in one dose per day, but I believe more people will find that the process I have developed will meet their needs.

The Circadian T3 Method is just one element contained in the T3 Dosage Management process and is described in essence in Chapter 16: Adrenal Lessons and in detail in Chapter 25: Phase 2: Determining a Safe, Effective and Stable T3 Dosage.

The CT3M may be applied with a variety of thyroid medications:

  1. T3
  2. Natural desiccated thyroid (NDT)
  3. NDT/T3 combination (often with T3 as the circadian dose)
  4. T4/T3 (with T3 as circadian dose and possibly some other doses during the day)

In fact, the T3 Dosage Management process is itself an innovation and for many people this process may enable them to be well on T3 medication without the need to use the CT3M.

Many hormones follow a circadian rhythm with a pattern of secretion that is repeated every twenty-four hours and is typically linked to our cycles of sleeping and waking, or daylight and night. Cortisol is secreted by the adrenal glands, with a steady rise in production during the last four hours of sleep. For someone who gets up out of bed at 8:00 am, this means the highest level of cortisol production occurs between the hours of 4:00 am and 8:00 am. It is the rising level of cortisol that helps us wake up in the morning, with the highest level of cortisol in the bloodstream at around 8:00 am (for your typical person). Cortisol levels then fall gradually during the day and are at their lowest between midnight and 4:00 am in the morning. The exact times may vary depending on when someone gets up in the morning (e.g. shift workers may experience a different circadian rhythm).

The Circadian T3 Method (CT3M) utilises the circadian natural action of the adrenal glands and requires thyroid medication, which contains pure T3 (natural desiccated thyroid may also be used). Once low adrenal function has been confirmed with a twenty-four hour adrenal saliva test, then the CT3M may be used. The CT3M will not work if the thyroid patient has Addison’s disease or hypopituitarism (these conditions usually require lifetime treatment with adrenal steroids).

The basic idea behind the CT3M is to address low levels of the active thyroid hormone (T3) in the adrenal glands when they are producing their highest volume of cortisol. The thyroid patient sets an alarm clock or mobile phone for a time between 1.5 and 4 hours prior to the normal time that they would get out of bed. A dose of T3 or natural desiccated thyroid medication is taken at that time and the thyroid patient then goes back to sleep. By carefully varying the time and the size of this circadian dose of T3-containing thyroid medication and assessing the results, it is possible to significantly help the adrenal glands to produce more or all of their hormones, including cortisol (which is often low in thyroid patients). Once this process begins to work and the adrenal glands begin to function well, then the quality of the sleep that follows this circadian dose is often far better than the thyroid patient has been used to experiencing.

In recent years there has been research that confirms that T3 thyroid hormone peaks in the body when the adrenal glands begin to work hard in the early hours of the morning. These research findings support the ideas behind the CT3M. The research article is titled “Free triiodothyronine has a distinct circadian rhythm that is delayed but parallels thyrotropin levels.” and is published in J Clin Endocrinol Metab. 93(6):2300-6. June 2008. A link to the abstract is: http://jcem.endojournals.org/content/93/6/2300

A large number of thyroid patients have successfully used the CT3M over the past year. Many of these had previously found that the only way they could cope was through the use of adrenal steroids like hydrocortisone or adrenal glandulars that contain steroids at lower quantities. The CT3M often works well enough to allow these patients to slowly reduce and then stop the use of all adrenal steroids.

Some Important Things to Do Before Considering the CT3M

​I really can't stress this strongly enough that some laboratory tests really are very important. When people are sick they want to get started on a treatment as soon as possible. However, to recover from thyroid disease many of us have to be 'the tortoise' and not 'the hare'! 

An adrenal saliva test (sometimes called an adrenal stress test) takes four samples of saliva over the day. Because only free cortisol passes into saliva it provides a profile of bio-available cortisol from the morning to the late evening. This test will show any low cortisol and any periods of high cortisol. Just starting the CT3M because you or someone else thinks you have low cortisol is not a good idea. Getting the data is helpful because it will show if the CT3M might be relevant and also provides a baseline to compare with in the future. If someone is taking adrenal glandulars or hydrocortisone then they will not get an accurate reading with the adrenal saliva test and they may be suppressing their own adrenal function. In some cases it may be advisable for someone to wean any adrenal glandulars or HC prior to getting an adrenal saliva test but this would need to be discussed with the patient's doctor and done very slowly. Once someone has been off any adrenal steroids (glandulars or other steroids like HC) for 2-3 weeks then an adrenal saliva test could be done. More information on the adrenal saliva test can be found in 'Recovering with T3' Chapter 3, pages 45-46.

A full iron panel including serum ferritin, serum iron, transferrin saturation % should also be done, as low iron is a common cause of poor thyroid hormone action. If iron is low then thyroid hormones will be less effective and so will the CT3M. More information on the full iron panel may be found in Chapter 4 of 'Recovering with T3', pages 53-56).

Other tests may need to be done but this may depend on the individual's needs, e.g. B12, folate, other minerals (zinc/copper?), sex hormones and inflammation measures. Some patients may have such obvious symptoms of low adrenal function that they should have diseases like Addison's disease ruled out via a Synacthen test. This type of testing would usually also require that the patient not be on any adrenal glandulars or HC. More information on nutrient deficiencies may be found in Chapter 4 of 'Recovering with T3' and information on sex hormones and testing may be found in Chapter 5 of 'Recovering with T3'  pages 74-76.

It is sensible to be consider taking a broad range of basic supplements prior to starting the CT3M (or any thyroid hormone treatment). These will tend to avoid basic nutritional deficiencies that might be present and could potentially interfere with the action of thyroid hormone. These supplements are discussed in Chapter 4 of the 'Recovering with T3' book (pages and also in some of the blog posts referred to in the next part of this post.

Where to Find More Detailed Information on The CT3M

Although there is insufficient space here to cover the detailed process for using the CT3M, there are several blog posts, which may provide more useful information on this new protocol:

http://recoveringwitht3.com/blog/why-circadian-t3-method-so-important-vi...

http://recoveringwitht3.com/blog/why-circadian-t3-method-so-important-te...

http://recoveringwitht3.com/blog/background-circadian-t3-method-ct3m

http://recoveringwitht3.com/blog/why-both-time-and-dose-size-adjustments...

http://recoveringwitht3.com/blog/circadian-t3-method-ct3m

http://recoveringwitht3.com/blog/circadian-t3-method-supports-adrenal-gl...

http://recoveringwitht3.com/blog/circadian-t3-method-and-weaning-adrenal...

http://recoveringwitht3.com/blog/more-circadian-dose-size-and-timing-adj...

http://recoveringwitht3.com/blog/interpretation-signs-ct3m-hr-bp-temp

http://recoveringwitht3.com/blog/some-clarifications-circadian-t3-method...

For more information on the CT3M please read the 'Recovering with T3' book, especially Chapters 3,16, 19 and 25. 

The 'CT3M Handbook' is also now released which provides even more in-depth information on CT3M.

Will the Circadian T3 Method Always Work for People?

1. The CT3M should only be used for someone suffering from cortisol insufficiency as determined by a cortisol test, e.g. ideally a 24-hour adrenal saliva test. Other tests for cortisol may be used but at least some form of laboratory testing should have been performed that provides clear evidence that the steroid cortisol is actually low. Treating low cortisol using the CT3M or with adrenal glandulars or a steroid hormone without having clear confirmation via a laboratory test is guesswork. The human body is complex and there are many reasons why someone might have symptoms reminiscent of partial adrenal insufficiency. Treating them without showing that cortisol is low is not sensible.

2. The CT3M should not be used by someone who has Addison's disease or hypopituitarism as determined by a qualified and competent medical doctor and via the appropriate laboratory tests. However, it would not be dangerous to use CT3M for these people as long as no adrenal hormone medication was removed and adequate medical checks of heart rate, blood pressure etc. were performed.

3. I have never said that by taking the first dose of T3 just before or during the main cortisol production window will correct adrenal insufficiency in all patients who have low cortisol. In the case of someone with permanently damaged adrenal glands, e.g. because of autoimmune destruction, hypopituitarism, or other disease then even providing adequate T3 in the main cortisol production window will not help and the use of adrenal hormone medication may be essential.

4. If someone had untreated diabetes or another insulin/blood sugar issue that was not being correctly treated then the CT3M may not improve symptoms, as the blood sugar problem will prevent thyroid hormones from working correctly. This is not unique to the CT3M - it is true for all thyroid hormone usage. If these conditions are being treated properly there should be no problems with the CT3M. Other conditions that sometimes affect how well CT3M works include: a nutrient deficiency (e.g. B12, iron of course, selenium, folate, vitamin D, zinc or copper, B vitamins, magnesium), an infection (e.g. Lyme disease, EBV), inflammation, digestive system issues (e.g. low stomach acid, microbial imbalance and leaky gut, gluten intolerance), poor performance of the hypothalamic pituitary axis (HPA axis). This list is not intended to be complete but it illustrates that many conditions can affect thyroid hormone action. 

5. For many the CT3M does correct cortisol insufficiency and in a manner that can be more effective than a bottle of pills containing adrenal glandulars or hydrocortisone. Some people have asked me does the CT3M heal adrenal glands. If 'healing adrenals' means developing better adrenal function then it most certainly supports this for many people. After the CT3M has been used for months or years then further improvement in adrenal gland function should be expected as in my own case. I try to avoid using terms like 'healing adrenals' though as it is too vague a description. Although the CT3M appears to work for many patients - it is just not possible to work out whether someone is going to be successful with the CT3M before they begin. For some patients it does not work well enough for them to completely wean off adrenal support and for a few it does not work at all. This does not detract from the immense value it offers and the fact that it is producing far better adrenal function in a growing body of those who are trying it.

7. The CT3M does not require pure T3 to be used as the only thyroid hormone treatment. Any T3 whether it is found in natural desiccated thyroid or T4/T3 combos may be used as well as pure T3 - just not slow release T3 as this cannot be adequately dosed and timed. However, the dose of thyroid hormone used in the CT3M does need to contain some T3 - usually at least 9-10 mcgs (and sometimes more than this). The T3 medication should be swallowed in one go also - sublingual absorption is not recommended, as it is too slow.

8. Adrenal support does not need to be weaned or removed prior to using the CT3M. It may be slowly weaned once the CT3M has begun. This should be done slowly and under the guidance of the patient's own physician. Of course for someone on a very low amount of adrenal support then weaning from this prior to using the CT3M may be the simplest way to go about things. If weaning of adrenal support is done after the CT3M has begun then it must be done slowly whilst symptoms, body temperature, blood pressure and heart rate are tracked. The 'Recovering with T3' book has been updated to incorporate this weaning of adrenal support during the CT3M as an option - based on the successful use of this approach in practice by thyroid patients. I also know of a few patients who have continued to take HC or other adrenal support and have still found some benefit from using the CT3M - however, the goal should really be to see if the patient's own adrenal glands can be fully brought back into action without the use of steroids as this will result in the best sense of well-being if it can be achieved.

The Requirements

I will assume in this section that someone is getting up at 8:00am and their adrenals therefore are likely to make most of their cortisol for the day between 4:00am and 8:00am. This period of intense cortisol production, when the majority of the cortisol of the day is made occurs in the last four hours of sleep and I refer to it as the main cortisol production window. I sometime refer to the early dose of T3 containing medication as the circadian dose.

This CT3M should not be performed if:

a) Symptoms and signs and any cortisol testing suggest that cortisol levels are already normal. This is why proper laboratory cortisol testing is important before attempting the CT3M.

b) If the adrenal glands will not respond directly to the availability of more T3. Conditions that might mean the adrenal glands cannot respond include Addison's disease and hypopituitarism.

An alarm clock of some kind is needed. The circadian dose of medication must be ready by the side of the bed with a glass of water. Typically, this circadian dose is first taken 1.5 hours before the person normally gets up in the morning. The alarm goes off. The meds are taken and the patient then goes back to sleep. Once the adrenals begin the work correctly then the quality of sleep gained after this is often the best of the night. This is the start of the process. The circadian dose is moved slowly earlier and symptoms and signs are recorded and assessed. The circadian dose size may be increased once a good time has been found to take this early dose. Fine tuning of the circadian dose size and time will be done until adrenal function has improved. The 'Recovering with T3' book explains in detail how the circadian dose and timing is adjusted as time goes on.

The thyroid patient should have had a proper laboratory test for cortisol prior to attempting the CT3M and ideally the patient's doctor should agree that the CT3M is appropriate, as this will provide the support that may be needed (especially with additional laboratory tests).

The thyroid patient should have a full iron panel prior to attempting the CT3M also as iron can gravely undermine the action of thyroid hormone.

During the use of the CT3M the patient will need to record information on symptoms, heart rate, blood pressure (which will need a home meter) and body temperature. This data is useful to provide information on whether the treatment is working and what changes would be most helpful. Having said this any form of thyroid or adrenal treatment would benefit from a degree of rigor and note taking so as to provide the best quality information to make decisions on. Measurement of more than temperature is needed for any form of thyroid and adrenal treatment.  This is why endocrinologists and doctors who are treating thyroid or adrenal disease routinely take blood pressure measurements as well as other lab tests and patient examination. This is just a process of due diligence and if someone is not prepared to do this then they should not use the CT3M or any form of thyroid or adrenal treatment.

All thyroid patients should regularly have their blood pressure, body temperature and heart rate checked. It is not sufficient to merely look at temperature as blood pressure may be affected by the interaction of thyroid and adrenal hormones on the body. The use of blood pressure, heart rate, body temperature and symptoms within the Circadian T3 Method is something that is not uniquely required by this protocol - it is really the only safe way to track any changes in thyroid and adrenal hormones - it is not specific to the CT3M.

My paramount goal in writing 'Recovering with T3' was always to write everything with my own and any reader's safety in mind as well as ensuring that the information I provided was accurate and extremely helpful and effective for any doctors or patients that read it.

Adrenal Function and the CT3M

It is critical to be aware that some people cannot manage without taking their adrenal hormones. For people with Addison's disease or other conditions that dramatically affect the capability of the adrenal glands there is simply no option but to take adrenal hormones. Hypopituitarism is another condition for which adrenal hormones have to be taken.

It is also important to realise how many hormones the adrenal glands produce. Far more hormones are produced than just cortisol, DHEA, adrenaline and aldosterone. Many hormones are produced by the adrenal glands and the optimal way to achieve good health is to encourage the adrenal glands to work normally rather than compensate for them by taking adrenal hormones. Cortisol is just one glucocorticoid. It is unlikely that someone will feel completely well and healthy by taking one or two adrenal hormones from bottles of tablets.

There are many articles available on the Internet that discuss the merits of providing low levels of adrenal hormones for a short while during thyroid hormone treatment. These articles invariably state that this should only be done for a short period of time and then, once the thyroid hormone treatment is working, the adrenal hormones should slowly be reduced then stopped. However, many patients appear to still be on adrenal hormones after several years have passed by.

It is very important to use a cortisol laboratory test to get an assessment of cortisol levels during the process of using the Circadian T3 Method. This is because it is very easy to be misled by symptoms alone and an inappropriate first T3 divided dose may be selected.  An adrenal saliva test of cortisol will take much of the guesswork out of this process and potentially save a considerable amount of time and stress.

As I have stated elsewhere, some people simply cannot resolve their adrenal issues with T3 alone and have to use some form of adrenal support. However, it does appear that the Circadian T3 Method is helpful in reducing the need for this in many people.

I also had to adjust the timing of the first T3 divided dose and its size to ensure that my adrenal glands did not produce too high a level of cortisol. It takes months for under-stimulated adrenal glands to become highly effective again. Consequently, I needed to fine-tune my first T3 dose for some time after I realised my adrenal glands were functioning well once again. 

Medical Profession Response to CT3M So Far

The response from doctors has been slightly better than I expected. I have had dozens of reports from thyroid patients that their doctor is happy to work with them to use the CT3M as part of their treatment program. The demographics of these more open-minded doctors appears to be that most of these are in the USA and a few are scattered over Europe.

A typical response from an endocrinologist or doctor is that they have not heard of it, would not read the book and that it won't work. Of course most of these aren't even aware of the latest research on the circadian levels of FT3 and some may not even know about the circadian nature of cortisol production (which has been known for decades). This more typical response is what I expected. If something isn't taught in medical school and it isn't communicated by another doctor through a medical journal or other medically trusted mechanism then it is likely to be written off as nonsense ('not invented here' - NOI). So, the majority of doctors that have been made aware of CT3M by a patient have simply dismissed it with a comment like "This won't work!" This type of response is quick, based on not reading the book and is certainly not based on any pragmatic evaluation of CT3M. This type of response is pure NOI. It is a shame but entirely predictable.

Many endocrinologists and doctors of course don't even think someone has an adrenal issue if they either pass a Synacthen test or have a single blood cortisol test with a result anywhere in the reference range! So, why would they even believe in CT3M? CT3M is there to help improve adrenal function in the case of partial adrenal insufficiency. Many endocrinologists and doctors either think someone has Addison's disease (they fail a Synacthen test or have a blood cortisol lower than the reference range) or that the patient has no adrenal problems  - there is no middle ground. We refer to this middle ground as partial adrenal insufficiency (or sometimes adrenal fatigue). So, if a thyroid patient goes into their doctors office clutching the RWT3 book they should not be surprised to be told that the circadian T3 method is nonsense, won't work or even that T3 or natural desiccated thyroid (NDT) is not needed and that taking T4 (levothyroxine) once a day is all that is required to get their laboratory levels into the normal range and then they will be healthy! It is a predictable response.

We now know that the CT3M helps many thyroid patients with partial adrenal insufficiency. It may not work for all, as some issues appear to make it much harder to get CT3M to work well. However, we are learning more about the issues that prevent an optimal response to CT3M and I am hopeful that we will find more ways of dealing with these over time. I also hope that more doctors will become open-minded and consider supporting their patients who wish to try CT3M.

Finally

The Circadian T3 Method is actually only attempting to mimic the way the body raises FT3 to coincide with the time the adrenal glands work at their hardest.

The standard methods of providing T4/T3, T3 or natural thyroid do not mimic this natural physiological circadian process, as the T3 content of these medications is nearly always providing during the awaking hours. Far from being a strange concept, the Circadian T3 Method is actually far closer to a physiological replacement of T3 in these medications than any other method of dosing thyroid hormone has ever managed to achieve until now.

There is no magic in the Circadian T3 Method at all. It is simply the application of scientific understanding of the natural circadian rhythm of our hormones in order to mirror nature as much as possible. The only surprise is that it hasn't been used until now.

Please read the 'Recovering with T3' book prior to attempting the CT3M as this will answer many questions that may arise and potentially save an awful lot of time and effort.

Best wishes,

Paul