Hypothyroidism - Medication & Treatments

5th September 2008

Hypothyroidism - Medication & Treatments

posted in Health/Nutrition, New Research |

Part four of the ongoing hypothyroidism series will address the various forms of treatment for people diagnosed with hypothyroidism. This information is available after the jump, but first, I’ll share what happened at my follow-up appointment with the endocrinologist this week. I think the experience sums up some of the many frustrations other people with hypothyroidism face when seeking out treatment.

Since I was diagnosed with hypothyroidism in my early 20s, I’ve always gone to my family doctor for annual blood tests and prescription refills. My tests all read normal but I’m still highly symptomatic so I saw an endocrinologist in July with hopes that a field specialist would be better able to help me. I prepared a two-page agenda with my questions, concerns and symptoms before my first appointment and discussed all of them with the doctor. She agreed with me that I shouldn’t be having these symptoms and bumped up my Synthroid prescription to from 112mcg to 125mcg. She also promised to consider adding Cytomel to my regiment at my next appointment in six weeks should my symptoms persist (Cytomel works on T3 whereas Synthroid is T4-only).

I met with my doctor again on Tuesday and reported feeling no noticeable difference from the medication increase. I repeated my interest in adding Cytomel and again, my doctor seemed agreeable in adding it, but wanted to do a blood test first to see how the medication increase affected my TSH levels. She said she would have the office call me with the results and the new prescription. They called yesterday and here’s how that conversation went:

Nurse: Hi, we have the results and your thyroid is low, so the doctor wants to reduce your dosage back to 112 mcg.

Me: Oh, okay. We had also discussed adding Cytomel. Did she mention that?

Nurse: Hmmm… no, but I will ask her and call you back.

Several hours later….

Nurse: Hi, the doctor said that since your thyroid was low, she didn’t want to try Cytomel at this time. So, it’s just the prescription for 112 mcg of Synthroid.

Me: Wait… I don’t understand. I thought we had discussed the Cytomel and she agreed to add it. I was on 112 mcg when I first came to see her and yet I was still having hypothyroid symptoms. Obviously, Synthroid alone isn’t working and now I’m right back at square one.

Nurse: And what were those symptoms again?

Me: They’re the same ones I discussed with the doctor at length at both of my appointments [I give her another brief rundown]. I’m really frustrated now. What was the point seeing a specialist if she’s just going to prescribe the same prescription my family doctor — who has a much cheaper copay — already prescribes? I’m still having the same health problems I had on 112mcg and now I’m right back where I started. Why did I even come in?

Nurse: Hmmm… I’ll have to talk to the doctor. I’ll call you back tomorrow.

That was yesterday. I have yet to hear from the office or my doctor. You can see how frustrating this is. Two appointments with an expensive specialist and I’m right back at square one. I’m prescribed the same medication and dosage I was taking initially that left me with recurrent symptoms. I still suffer from a variety of symptoms that affect my quality of life, but because the test reads normal, my doctor dismisses me as fine. Test results are important, sure, but doctors should listen to patients first and foremost when determining health care.

If you are being treated for hypothyroidism and your test results read normal but you still experience symptoms, you aren’t well. Other available treatments and medication are available, but it is often the patient who has to first initiate conversation about them with doctors. More information after the jump.

So, you’ve been diagnosed with hypothyroidism and chances are, you’ve been prescribed Synthroid (levothyroxine). Medication can sometimes take up to a month to kick in, but if you’ve given it a reasonable amount of time and you’re still feeling symptomatic, you’re obviously not well. Yes, even if your TSH levels measure in the normal range. So, what treatment plans are available to you? This section explains exactly that.

Thyroid Hormone Replacement

Natural Thyroid – Non-synthetic thyroid hormone replacement is made produced from the thyroid glands of pigs slaughtered for food, and therefore work on both T4 and T3 hormones. The top seller in this category is Armour Thyroid, but other brand names include Naturethroid, Westhroid and Biotech. All are legal, regulated, prescription-only drugs. Armour Thyroid has been on the market for more than 100 years and in 2002, saw more than two million prescriptions written for it. Still, many conventional endocrinologists and physicians are generally opposed to prescription natural thyroid, in part, because of ignorance or biasness amongst doctors about natural thyroid replacements, but also because Synthroid drug representatives are quite lavish in proselytizing their product. If you’re taking Synthroid or its generic equivalent and you’re still symptomatic and want to try a natural thyroid drug, be persistent. Some doctors will prescribe it after their patients ask enough times. If your doctor will not budge, see another practitioner who is willing to accommodate you with at least a trial period.

Levothyroxine / Synthetic T4 – Levothyroxine, a synthetic T4 hormone replacement, has been on the market for more than 50 years as an alternative to the existing natural thyroid replacement. Levothyroxine – also known by its brand name Synthroid – is the most popular drug of choice prescribed by doctors for the treatment of hypothyroidism. In fact, it’s not only the top-selling thyroid replacement drug, it’s also one of the top-selling drugs prescribed in America period. My family doctor and my pharmacy both told me to ask specifically for the name brand of Synthroid, which costs about $10 more a month than generic versions Unithroid, Levoid and Levoxyl. According to them, the brand names do not work in the same way as Synthroid, although neither could fully articulate the differences. Author Mary Shomon also recommends not accepting generic versions of levothyroxine, and fortunately, does explain why. According to Shomon, each brand of levothyroxine contains different fillers and binders and some dissolve more quickly than others. Although all brand name levothyroxines are considered to be bio-equivalent, generic levothyroxine may have more ups and downs in potency from batch to batch. As well, some people are allergic to the fillers in one brand versus another, or have other allergic reactions after taking certain brands.

Liothyronine / Synthetic T3 and Liotrix, Synthetic T3/T4 – If the T4 to T3 conversion is working properly in the body, levothyroxine therapy will generally be effective. But if you take levothyroxine and still have persistent symptoms despite normal TSH levels, some doctors may prescribe additional T3. The only brand name drug of T3 is a synthetic version manufactured by King Pharmaceuticals called liothyronine or brand name Cytomel. No generic version is sold in the U.S. The synthetic T3/T4 combination drug Thyrolar (liotrix) is manufactured by Forest Labs. Again, there is no generic version of this drug available on the market. Most conventional doctors balk at prescribing either of these drugs. Osteopaths, naturopaths and holistic M.D.s are more apt to work with these treatments.

Alternative Medicine – Some people may choose to treat their hypothyroidism with alternative treatments like Ayurveda, Chinese medicine, herbalism, mind-body therapy, or naturopathy.

What if I don’t tolerate Thyroid Medication?

For people who don’t tolerate thyroid replacement medication well, Dr. Stephen Langer recommends working with a reputable compounding pharmacist to produce an aqueous (water-based) solution of thyroid medication. The dosage is then graduated until you reach the right quantity of thyroid using the aqueous solution. Many people can then eventually be transferred over to the tablets. If you’re taking a generic version of Synthroid, ask for a name brand, since each brand of levothyroxines contain different fillers and binders, which may cause an allergic reaction in some people.

General Thyroid Medication Tips

Take your medication every day. If you miss a dose, take it as soon as possible. If you’re close to your next scheduled dosage time, skip the missed dose and resume your regular dosing schedule.

Take your medication on an empty stomach. Different brands dissolve at different rates, but a good rule of thumb is to avoid eating for an hour afterward. Food can slow absorption of the drug and slow the process of the drug entering the stomach. Some drugs can also affect the absorption rates of levothyroxine. Do not take a multi-vitamin, supplement or other drugs at the same time you take your thyroid medication.

Be consistent. If you take your pill with food, always take it with food. If you’ve changed from taking it with food to taking it without food or if you take it with food and change to a high-fiber diet, have another TSH test done about 6 – 8 weeks later to ensure you’re receiving the proper amount of hormone.

Be aware. Taking some tricyclic antidepressants (Elavil, Norpamin and Tofranil) with your thyroid hormone can actually accelerate the effects of the antidepressant, while combining thyroid hormone replacement with Zoloft or Prozac may decrease the effectiveness of the thyroid hormone. There are other drugs that interact with thyroid hormone or affect thyroid function, so be sure your doctor know what drugs you are taking and the dosages of those drugs. Women who go on the pill or take estrogen hormone drugs may need additional thyroid replacement hormone. Various forms of the pill or estrogen hormones increase a particular protein that binds thyroid hormone to it, rendering the thyroid hormone partially inactive.

To soy or not to soy? There is debate about the consumption of soy products by people with hypothyroidism. My doctor said that consuming soy products is okay, as along as they are eaten at least four hours after taking my thyroid hormone. Others say soy consumption should be even more limited or avoided altogether. The soy controversy stems from the fact that soy is a rich source of isoflavones. Isoflavones belong to the flavonoid chemical family, which are considered to be endocrine disrupters and antithyroid agents. More research on soy consumption with hypothyroidism is still needed. Vegetarians like me, who rely on soy-based products for protein, will find it difficult to reduce soy consumption. Luckily, Quorn products are not only high in protein, they’re also soy-free (and delicious!).

Diet, Supplements & Vitamins

There is no natural or over-the-counter herb or plant that acts like thyroid hormone and can be taken in lieu of thyroid hormone (Armour is the only natural thyroid hormone replacement drug). There are, however, some alternative approaches that may help your thyroid function better.

Reevaluate your diet – Some doctors recommend a diet that includes whole cooked grains, fresh vegetables and fruit, legumes, nuts and seeds, and fish (if not vegetarian). Consumption of refined sugars and flours, alcohol and coffee should be limited. Excessive alcohol and coffee consumption can lead to impaired liver function, and the liver is the primary organ that converts T4 to T3.

Vitamins, minerals and herbs you may want to consider include:

Multivitamin
Vitamin C
Vitamin E

Vitamin A – A deficiency in vitamin A may limit the body’s ability to produce thyroid hormone.

Vitamin B2 – A shortage of this vitamin can depress endocrine function, especially the thyroid and adrenals.

Vitamin B3 – Helps keep cells working by aiding in respiration and delivery of energy to cells.

Vitamin B6 – Helps convert iodine to thyroid hormone.

Vitamin B12 – People with hypothyroidism may be less able to absorb sufficient vitamin B12.

Vitamin D – Necessary for the pituitary gland to produce thyroid hormone, and may play a role in T3 binding to its receptor and in T4 to T3 conversion.

Selenium – Most important mineral for thyroid function. Selenium activates an enzyme that is responsible for controlling thyroid function by thee conversion of T4 to T3. A selenium deficiency alone is thought to be a trigger of autoimmune thyroid disease in some people. Experts recommend 200mcg of selenium a day. Overdose of selenium can be harmful; intake is recommended to no more than 200 – 400 mcg a day.

Zinc – Needed by the thyroid for both hormone production and T4 to T3 conversion. Also necessary for proper hypothalamic functioning, which is related to the functioning of the thyroid. Zinc should always be balanced out with a small amount of copper.

Iron – Additional iron may be needed by some people with hypothyroidism. If you do take iron, allow at least four hours between taking it and your thyroid hormone.

Magnesium – An essential mineral that is often deficient in thyroid patients. It helps to maintain normal muscle and nerve function, keeps heart rhythm steady and bones strong, and is involved in energy metabolism.

There are also a number of herbal remedies recommended for thyroid treatment. You should select consult an herbalist to determine herbal treatments right for you.

Obviously you should consult your doctor before taking any kind of drug, supplement or vitamin. The above information is informational only and should not be construed as medical advice. Tomorrow’s series will address how to better manage both the depression and weight gain that are characteristic of hypothyroidism.

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This entry was posted on Friday, September 5th, 2008 at 1:01 am and is filed under Health/Nutrition, New Research. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

1 On September 5th, 2008, lilacsigil

said:

This is an excellent post - and it’s hard work to keep pushing those doctors when you feel like crap already! I was being greatly underdosed for my weight, and my T3/T4 levels were in the normal range for an 80-year-old, not a 30-year-old, but the doctor read this as “normal”, because her chart said so. My dose was tripled and I have stayed at that level, and my TSH has gone down to as close to zero as can be measured, as it should in a post-cancer patient.

One thing to add to the supplements post: any of the minerals (calcium, magnesium, selenium, zinc) should be taken at least two hours away from your thyroid medication, otherwise the mineral will absorb your medication, not your body!

Additionally, starting on thyroid hormones can change your minerals requirements. Every time I upped my dose of thyroxin (Australia’s T4) I had painful muscle cramps and developed restless leg syndrome. The doctors had no idea why this happened, but supplementation with 600mg of calcium daily plus magnesium every time I have a flare-up has helped keep these symptoms under control. I also take zinc.

I’m a bit concerned about your anti-generic stance, which doesn’t seem quite right to me. You are quite correct to say that different brands have different fillers and the bio-availability may differ from person to person. However, if manufacturing standards in the US are similar to those in Australia and the UK (I believe they are), the preparation does *not* differ from batch to batch of the same brand. As long as you stick to one brand, and aren’t allergic to the fillers in that brand, the bio-availability will not vary from batch to batch. It does not have to be the name brand that you use.

posted on September 5th, 2008 at 2:28 am

2 On September 5th, 2008, libbyloo

Also… avoid a calcium supplement within at least 2 hours of taking your thyroid meds. Calcium will seriously affect their absorption.

(Hypothyroid, taking Armour and Cytomel)

posted on September 5th, 2008 at 6:40 am

3 On September 5th, 2008, Amethystrose

I am thoroughly convinced that I am hypothyroid, I have all the symptoms. I have been tested twice for it and all the results have come back “normal”. I have been to 2 doctors and they both said there is nothing wrong with me. Their only advice is to “eat less and exercise more.” I don’t have the option of picking and choosing a doctor because I am on medicaid. The only thing I can think to do is go to a naturopath, but I can’t afford one right now. I am at my wits end right now.

posted on September 5th, 2008 at 7:35 am

4 On September 5th, 2008, Keechypeachy

I’ve so been there. The endo I went to was so horrid to me, I left his office and nearly gave up and went home to suffer in silence. Luckily my hubbie believed in me enough to do some research and get me back on the road to feeling better. Not there yet, but I do feel better.

A couple of things I have learned that I didn’t see mentioned above:

Be careful of gluten if you are hypo/Hashi’s. A lot of people feel that gluten lifts their Hashi’s antibody levels, and that they do better on a gluten free diet. It might be worth a try just to see.

Taking B12 by mouth may not be enough, whatever your test levels show. I now self-inject B12 (weekly at the moment) and it is the next piece in the puzzle for me.

Most of us with long term Hypo end up with adrenal fatigue or exhaustion. It can stop you converting your thyroid meds properly, and if you switch to natural thyroid, or even add in T3, it can cause you to go very haywire. That happened to me! You can google for treatment for this, but it is worth taking B5 and perhaps switching to a very good seasalt, just to help support your adrenals.

Thanks for this series, it’s been great, and hopefully will give more people the knowledge they need to keep asking for help. I got so sick I could hardly put one foot in front of the other, but now I can see flashes of my old self coming to the fore. It can be a long road, but is well worth it.

F-word, keep searching for a doc who will listen. It doesn’t have to be an endo. I have a GP now who is great and will let me try anything. She knows I have done more reading on the topic than she has!

posted on September 5th, 2008 at 7:40 am

5 On September 5th, 2008, lilacsigil

Amethystrose - have they given you the actual numbers? “Normal” is a huge range, and at least one of my doctors read my results as in the normal range. They were normal for an 80-year-old, but her chart didn’t give ages, just a very big normal range. “Eat less and exercise more” is what I was told for 18 months and I had a malignant thyroid tumour, so keep at them.

Keep a health diary so you can track symptoms - it’s harder for a doctor to dismiss written evidence than your spoken words. Go to http://fathealth.org to get more tips on dealing with doctors, and links to lists of doctors, though this may not help you in your current situation.

posted on September 5th, 2008 at 8:22 am

6 On September 5th, 2008, Bean

One reason that some doctors are reluctant to prescribe natural thyroid (e.g. Armour) is that it is a much less stable compound. While levothyroxin can be safely assumed effective for up to a year after its fill date, natural thyroids can lose effectiveness as quickly as three months after *manufacture*. As someone who has been on both levothyroxin and Armour, and is also a pharmacy school grad, I feel safe saying that for some people there are definite disadvantages to the natural thyroid replacement. Particularly for patients who live in less environmentally controlled homes (experiencing a 30 degree temperature difference across a single month), the natural thyroid may stop working for them a couple of weeks after the scrip is filled. So, I don’t think it’s just an issue of doctors being unfairly prejudiced against the med. If you have a patient who has to use a three month scrip fill service (some insurance requires it), then natural thyroid is a terrible option.

Also, the issue with generics isn’t that they’re bad prima faci. It’s bad to switch between them. So, if a person starts out on the generic and is adjusted to the generic, it will work just as well as the name brand. (It’s worth noting that this means that people often have to stick to the same pharmacy. The local grocery carries a different generic than, say, WalMart, which makes its own.) For some people, the generic even works better than the name brand. It’s all a matter of individual metabolism. There’s no reason to be skeptical of the generic if you are just starting out on treatment, or if your treatment is failing.

Just for reference, I started out on Armour and eventually switched to a generic levothyroxin because Armour wasn’t working out well for me. It’s likely that even with all of my pharmaceutical background, I was still allowing the meds to experience too much heat variation and they were destabilizing on me. The levothyroxin has worked beautifully for me for the last four years. (And has the benefit of not smelling like rotting meat as the Armour did. Pew!)

Good Luck!

posted on September 5th, 2008 at 9:14 am

7 On September 5th, 2008, Amethystrose

lilacsigal- I don’t know the numbers, but I called the office and asked for a copy of the test sent to me. This is the second time I was tested in the past 6 months. The first time it was done, there was one number (I forgot which one) that was .5 below the normal range, but my other PCP said it was such a small deviance that it didn’t matter. I don’t think I ever had the antibody test. I will ask my doctor to order it, but I’m not going to hold my breath.

posted on September 5th, 2008 at 10:47 am

8 On September 6th, 2008, KMTBerry

I can’t thank you enough for this article. I think it has changed my life!

posted on September 6th, 2008 at 8:19 am

9 On September 7th, 2008, miquiecrew

this is very interesting and thank you for posting this series. i am diagnosed with Hypothyroidism and learning some of this info is very interesting. thank you.

posted on September 7th, 2008 at 10:39 pm

10 On September 8th, 2008, Katrina

Um, not to rush you but I’m very much looking forward to the next installment mentioned here(on depression and weight gain). There’s such a need to know about how to actually live with hypothyroidism. And how to deal with people telling you that if you just tried harder than you could lose weight and feel better…

posted on September 8th, 2008 at 8:00 pm

11 On September 9th, 2008, Hypothyroidism - Managing depression and weight » The-F-Word.org said:

[...] optimal treatment for your thyroid before accepting a depression diagnosis. As covered in the installment on medication and treatment, you may need a dosage change, a change in brand, or the addition of T3 [...]

posted on September 9th, 2008 at 12:15 am

12 On September 9th, 2008, Rachel

I didn’t have the time or the energy to finish it over the weekend as planned, Katrina. It’s up now, though.

13 On September 10th, 2008, Rachel

Oh, and an update to my own treatment saga. After another exchange between me and the nurse, the nurse suggested it would be better for the doctor to call me. She called this morning and I explained my concerns to her about Synthroid-only treatment. To my surprise, she said “Okay, so let’s add T3. Where would you like me to call in the prescription?” And that was that. So, I start a reduced dosage of Synthroid and Cytomel tomorrow. I’ll keep you posted on how it works for me.

posted on September 10th, 2008 at 1:04 pm

14 On September 10th, 2008, Hypothyroidism update » The-F-Word.org said:

[...] treatment for persistent symptoms of hypothyroidism — you can read about it in the third installment in the series on hypothyroidism. I’m currently on Synthroid, a T4 hormone replacement and the [...]

posted on September 10th, 2008 at 2:31 pm

15 On September 14th, 2008, Annie

I am on thyroxine but I still have major symptoms; always cold, dry skin and weight gain. My doctor refuses to look at changing my treatment (I am in the UK). I am having so much trouble with my weight that I have now developed an eating disorder. When I talked about it being hard to eat with my doctor, her answer was “Chill”. What can I do? I am scared to eat anything because I don’t want to gain weight and if I do have to eat, I purge.

I am desperate. Please can someone help me.

posted on September 14th, 2008 at 9:00 am

16 On September 15th, 2008, lilacsigil

Annie - you may not be getting enough thyroxine (this was the case with me) but it really sounds like you need to change doctors. Is the doctor taking blood tests? Has she given you actual numbers on the test rather than just saying “normal”? Can you see another GP, even a different one in that practice? “Chill” is a rude and dismissive answer, and totally unprofessional.

Additionally, there can be other conditions that lead to the same symptoms, or prevent your body absorbing the thyroxine, so if your doctor is not testing for those, you are not getting medical care. Make a *written* list of your concerns, have your records sent to another GP (maybe someone in your area can recommend one?) and take your list to that doctor. They might be able to refer you to an endocrinologist, or they might be able to treat you themself. If that doctor is no better, try again. It has taken me a while to find doctors, but it really can happen. Finding someone who listens and gives appropriate care is your right.

posted on September 15th, 2008 at 10:15 am

17 On September 15th, 2008, Rachel

Annie - I encourage you to see another doctor, one who will take your concerns and your health seriously. And I also encourage you to seek out a therapist to help with the eating disorder. Desperation can be a very demoralizing feeling, but please remember that you do have other, healthier options you can make here.

posted on September 15th, 2008 at 2:22 pm

18 On October 2nd, 2008, mimi

My Dr. just informed me that i have hypothyroidism and prescribed Synthroid. I never have taken any medicine except vitamins and not comfortable taking the medicine. I’m contemplating whether i should take the synthetic medicine or look for natural remedies? Any advice/suggestions would be greatly appreciated!!! Thanks!

posted on October 2nd, 2008 at 1:46 pm

19 On October 2nd, 2008, lilacsigil

Most people try the synthetic first - for a majority of people, it’s effective and safe. And there’s no shame in taking medication when your body isn’t working correctly - rather, it’s a wonderful benefit of living in modern times!

posted on October 2nd, 2008 at 10:58 pm