Why I Believe T3 Should Be The Very Last Treatment That Thyroid Patients Consider

I developed thyroid disease over twenty years ago. I suffered during the early years as many thyroid patients do. I was given the standard levothyroxine (T4) thyroid treatment and when I was told "you're cured!', I asked "why do I still have all the symptoms of hypothyroidism then?"

The answers to the question were varied depending on the doctor I spoke to. I was told I had some unknown disease that appeared to have symptoms reminiscent of hypothyroidism. I was told that I had a psychological problem - possibly depression. I was consistently told I could no longer have any problems with thyroid hormones because my thyroid hormone levels were 'normal' as determined by laboratory testing. I was asked to join a growing number of patients in an ME support group by one endocrinologist. I believed that since these were thyroid patients with symptoms of hypothyroidism (or ME) then this simply meant that my endocrinologist at the time was happy to stick a label on me and push me into a room to commiserate on my bad luck and lack of future with others that he had failed to help. I was refused any more blood tests or referrals by one GP unless I took Prozac for some time. The level of treatment I received from some of these 'doctors' seemed to border on abuse.

Far too many thyroid patients who do not feel well on T4 thyroid hormone medication have encountered these ridiculous attempts to justify poor diagnostic work and even poorer treatment. I did my own research. I read endocrinology books - real ones that are used during medical training. I bought books I could not find or borrow. I used the emerging Internet resources. I concluded that a trial of T3 was necessary. This was needed at the very least to see if I could learn more about what 'broken' inside of me. I knew something was broken because such a wide range of T4 dosages had been tried and had all failed. I also knew that this had all occurred after the advent of my autoimmune thyroid problem - Hashimoto's thyroiditis. I was totally healthy prior to this point.

Eventually, I found a doctor who allowed me to try natural desiccated thyroid (NDT) and then T4/T3. We also used hydrocortisone and prednisolone. None of these treatments made a bit of difference. Then eventually I got the T3 trial that I had wanted for so long.

With T3 the lights went on. Within a week I could get up the stairs at home easily. My digestive problems all vanished within days. I began to be able to think clearly and function once again. Within a few weeks I felt like I was a different person - not the shambling wreck of a human being, old before his time. T3 on its own was the answer and the clue. My problems had definitely been occurring at a cellular level and beyond the ability of any blood test to see them. I now refer to this type of issue as 'impaired cellular response to thyroid hormone' because I know now that there are many causes for this. In my case it is not a reverse T3 issue as so many people immediately leap to.

It tool me nearly three years to completely finalise my dosage and understand how to use T3 correctly. I had to apply all my background in science and applied research to understand everything I needed to know to get to grips with T3. It was worth it however. I have now been using T3 for around fifteen years and am fit and well. I have no weight issues or any other symptoms of hypothyroidism.

So, why have I chosen the title for this blog? When I first began to discuss T3 on forums I frequently met ignorance, defensiveness, incredulity and even abuse from other thyroid patients. There was so little discussion about T3 and so few people who had good experiences of using it that I found the Internet forums to be quite difficult places to inhabit. The situation is quite different today. More and more thyroid patients in the UK and the USA are trying to gather information about T3. In the past couple of years I have spoken to dozens of thyroid patients who have managed to recover their health using T3 and many patients are now hungry for information about this relatively unknown and under-prescribed thyroid medication.

However, increasingly I get questions from people who want to know if they might be able to get well by taking T3 instead of T4. Some people even consider switching directly from their current T4 medication to T3. This increasing trend has provided me with the title of this short article. T3 is not an easy drug to use and any patient and doctor who begins to introduce T3, whether on its own or in combination with T4 or NDT, must know quite a lot about it before commencing its use.

My own personal view is that some of these thyroid medications are more difficult to use than others. I believe that the order goes like this (with increasing difficulty):
1. T4 (levothyroxine)
2. T4 / T3 in combination
3. Natural desiccated thyroid (NDT)
4. NDT / T3
5. T3 on its own (pure T3)

I'm prepared to debate where 2 and 3 are relative to each other and possibly even 4. What is clear to me is that 1 is definitely easier to use than 2-4 and 5 is definitely a lot harder to use than any of them. Why should I say this? Once the nature of the T3 hormone is understood and the reasons why people resort to it is also taken into account then it should become clear why T3 is a medication that should be not to seen as a simple panacea. In the human body, the biological half-life of T4 is approximately seven days, which means a patient could take their entire daily dosage of synthetic T4 in one go, without any issues, because it is used up relatively slowly. In contrast, the biological half-life of T3 is believed to be twenty-four hours. A single dose of T3, taken on an empty stomach, is rapidly absorbed and reaches peak circulating concentration in just two to three hours after ingestion. Blood serum concentrations of T3 are elevated for six to eight hours. After this, blood serum concentrations then decline again, unless another dose of T3 is ingested.

The other interesting fact about T3 when taken as a medication is because it arrives in the body extremely quickly it has the effect of rapidly suppressing the TSH. Therefore, patients who are receiving only T3 replacement therapy should expect unusual laboratory tests of thyroid hormone levels. Low FT4 levels should be expected. FT3 results could be low, normal or elevated, depending on how much T3 is being prescribed and the exact time of the thyroid blood test, in relation to the time that the last dose of T3 was taken. TSH could be highly suppressed or at the very least TSH is likely to fluctuate far more with the use of T3 medication than with T4.

The above information, on the rapidity with which T3 achieves peak serum concentrations and then declines again and the potential for unusual TSH, FT4 and FT3 results, is very important. This means that laboratory tests that attempt to assess the adequacy of replacement with T3 are extremely difficult to make sense of, because of the wide and rapid fluctuations of T3 in the bloodstream.

Patients that are using T3 on its own will certainly struggle to get any value at all from thyroid blood test results. Those that are using T3 in combination with T4 may also see some distortion of their thyroid blood test results depending on how much T3 is being used. This means that other methods need to be used to manage the T3 treatment and set the correct level of T3 medication. Symptoms and signs must be used but this is not easy.

In particular, it is critical to be aware that people who use T3 are taking it because something in their normal processing of thyroid hormone has broken. I refer to this as 'impaired cellular response to thyroid hormone' in my book. Some people inappropriately call this 'tissue resistance' (which is a very poor choice of terminology because many things can cause problems resulting in the need to use T3 to get well).  Many things can break down. However, we cannot tell in any individual case what the precise reason is because we cannot observe the inner workings of our cells. All we can see is that T4 or T4/T3 does not make someone well but that T3 does. It is crucial to realise that in this case the T3 is being taken to overcome whatever the problems are and that all that is important is that the patient feels well and that normal symptoms and signs are returned (including key measures like blood pressure and heart rate). In order to achieve this the right amounts of T3 need to be being effective within someone's cells. When this occurs the levels of hormones within the bloodstream are likely to be completely unrepresentative of the cellular activity of the T3. So, TSH, FT4, FT3 or reverse T3 in the bloodstream (which is the only place they can be measured currently) are very likely to be unrepresentative of actual cellular activities of these hormones.

Attempting to manage the dosage of T3 for someone who can only get well by using only T3 can only currently be done effectively and safely by using indirect measures of thyroid hormones, as described in my book. Attempting to do this by using thyroid hormone blood test results could even be dangerous as all of these thyroid hormone test results may have no bearing on cellular activity. This point is clearly only relevant for those patients using T3 only and this is a major reason why using T3 is harder than the other hormones. 

Unfortunately, many doctors appear to be unaware of any of this and still cling on to the idea that they can use thyroid blood test results to monitor T3 replacement and manage their patient's T3 level. This is stupid and dangerous.

Someone new to T3 replacement therapy may believe that the medication can be taken in a single daily dose, just like synthetic T4. This may work for a few people but for others, the daily dosage of T3 will need to be split up and taken in smaller doses, known as divided doses. This divided dose approach enables T3 to be taken at various intervals throughout the day, in order to provide a steady supply of T3 to the body. The use of divided doses also ensures that no single dose of T3 creates an exceptionally high peak level of T3 in the tissues of the body. The majority of patients successfully using T3 appear to be using between three and five divided doses of T3 per day.

Using divided doses of T3 clearly adds a lot of complexity to the life of thyroid patients. A further complication of the use of T3 is due to the suppressive effect that it can have on TSH. The level of TSH influences the conversion of T4 to T3. A high TSH results in the maximum level of conversion of T4 to T3. A fully suppressed TSH will result in the conversion rate of T4 to T3 being reduced to the minimum level. For the patient on a combined therapy with T4 and T3 then this is very significant indeed. Some doctors attempt to perform simple mathematical calculations when they add T3 to their patient's T4. They reduce their patient's T4 dosage when T3 is added. Often there is no understanding that the added T3 is likely to have a suppressive effect on TSH and this is likely to downgrade any T4 to T3 conversion rate. Taking some of the patients T4 away as well is only likely to make things worse. So, finding the right balance of T4 and T3 can be an extremely challenging task.

In summary, the use of T3 has a number of difficulties:

1. The half-life if T3 is short and the drug is very potent. T3 usually needs to be taken in three to five divided doses per day. Some people do find that they do better with one of two divided doses.
2. T3 acts quickly and will distort thyroid blood test results of TSH, FT4, FT3 and rT3. For someone using only T3 these thyroid blood test results are not reliable measures to be employed for managing the treatment.
3. T3 used in combination with T4 can also prove difficult. Blood test results can be distorted, divided doses of T3 need to be used and the conversion rate of T4 can deteriorate.

All of the above difficulties mean that using T3 on its own is not something that anyone should want to do unless everything else had been tried and failed. Using T3 in combination with T4 is simpler but has its own issues. As well as bearing the above in mind, investigations into deficient nutrients or low cortisol levels should be thoroughly performed and ruled out before ever considering the use of T3. T3 is just too hard to use to consider using it without exploring everything else first. I have been known to refer to T3 as the thyroid hormone treatment of last resort - I believe it should be viewed like that.

However, if all the necessary investigations have been performed and all the thyroid hormone therapies have all been tried and shown to fail then T3 can be a way of recovering your health. I know - I've done it.

I'll be writing more on thyroid blood tests and many, many other important pieces of information on this blog in the coming weeks and months.

Best wishes,

Paul