All treatments for hypothyroidism need to be personalized, based on a combination of laboratory tests and the patient's signs and symptoms. Both patient symptoms and laboratory tests are important. There is no one-size-fits-all treatment regimen.
Of course, before beginning treatment of hypothyroidism, other causes of the patient's complaints should be evaluated and ruled out, including anemia and low adrenal function.
In most cases, all relevant laboratory tests should be kept "within normal limits" (WNL) during treatment. These include TSH, T4, T3, fT4, fT3, and rT3. Please see laboratory testing for further information. However, there do exist situations where one or more of the above tests may be deliberately allowed to go out of bounds. In these cases, clinical reasoning and patient informed consent must be carefully documented.
In most cases, conventional (allopathic) doctors (MDs and DOs) will only order a TSH test, and will refuse treatment if that is within normal limits. This is in part because insurance regulations generally discourage further testing, and insurance requires a diagnosis code to justify treatment. If TSH is WNL then the prevailing allopathic standard of care says there is no diagnosis of hypothyroidism (perhaps the patient has a Prozac deficiency!).
Dr. Weyrich practices "Naturopathic Functional Medicine," which seeks to achieve a natural balance of optimum physiologic problems. In practice this means that Dr. Weyrich recognizes that a patient with symptoms of hypothyroidism and a TSH value of 4.0 (which is higher than the optimum value of 1 but still within normal limits) may require treatment, even though conventional allopathic doctors consider this patient to be within normal limits (and hence requiring no treatment; insurance companies would consider treating this patient "fraud" [no appropriate supporting diagnosis code], "waste" [unnecessary use of medical resources], and "abuse" [of those paying for the insurance - e.g. taxpayers]).
Naturopathic Functional Medicine is not recognized by most insurance companies, which means that patients must be prepared to pay out of their own pocket (or maybe a Health-Care Savings Account - see your plan coverage). This includes office visits, tests other than TSH, medications other than levothyroxine, and any hypothyroid treatment that is not supported by a TSH value that is out of the normal range.
The most common conventional (allopathic) treatment for low thyroid conditions prescribed by MDs and DOs is pure T4, which has the generic name levothyroxine or L-thyroxine. Common trade names are Synthroid, Levoxyl, and Tirosint.
Some patients do well on pure T4, but others do not. As Dr. Weyrich discusses on the web page how the thyroid system works, T4 is a pro-hormone that is not particularly biologically active. T4 must be converted to the active form "free T3" (fT3) in the body before it can provide benefit. Some patients can do this well, while others cannot. Those who cannot convert T4 to fT3 often do not see any benefit from taking T4 (Synthroid, Levoxyl, Tirosint, etc.).
One common problem with taking T4 is that food, especially acidic foods like orange juice, interferes with its absorption. It is therefore important to take T4 on an empty stomach and wash it down with water only, waiting at least an hour before eating or drinking anything else. Most people find it most convenient to take the T4 first thing when they wake up in the morning, before their daily grooming.
One additional caveat with taking T4 is that there is some controversy regarding which brand of T4 to take. Although the FDA has declared that the different brands of T4 (Synthroid, Levoxyl, Tirosint, etc.) are bioidentical (interchangeable) and therefore "generic", many experts have disagreed. This does not mean that one brand is necessarily better than another, but only that if you are doing well on a certain dose of one brand, switching to a different brand may require an adjustment in dose. The worst-case scenario is to have a prescription for generic levothyroxine. In this case, every time you fill the prescription you may be given levothyroxine from a different manufacturer, and therefore may be constantly chasing the ideal dose.
Patients who are now doing well when taking T4, and do not mind having to take it for the rest of their lives, can stop reading here: T4 is cheep, readily available, and covered by all insurance plans. Just be sure that you get the same brand with each refill, and take it on an empty stomach.
Treat the Adrenals
There are considerable interactions between adrenal hormones (especially cortisol) and thyroid function. In particular, low cortisol levels appear to exert a negative effect on the conversion of T4 to T3 (see how the thyroid system works).
If a patient does not respond well to treatment with levothyroxine, laboratory testing of adrenal function and correction of any problems found is indicated before any other treatments are attempted. Supplementing a patient with thyroid medications of any kind is likely to make the patient's symptoms worse, rather than better, if the patient's adrenal status is low.
Dr. Weyrich discusses adrenal fatigue further on his Adrenal Insufficiency web page.
T3 Only (Cytomel)
For patients whose lab tests indicate that they make adequate amounts of T4 but cannot convert the T4 to adequate amounts of fT3, there is also a pharmaceutical drug that is pure T3, that has the generic name liothyronine, which has the trade name Cytomel.
One problem with liothyronine is that it has a much shorter half life (1 day) compared with the longer half life of levothyroxine (7 days). This means that liothyronine leaves the body so fast that one day after taking a single dose, the blood level has dropped to one half the blood level immediately after taking the dose. This results in alternating symptoms of hypothyroidism and hyperthyroidism each day.
Of course, the problem can be reduced by taking smaller doses of liothyronine several times a day, but it is inconvenient for the patient to remember to take each dose on schedule, and also to ensure that each dose is taken on an empty stomach.
The same caveat against taking generic forms of liothyronine applies.
Compounded Sustained Release T3 Only
Specialized pharmacies can make prescription drugs in forms (and doses) other than the commercially available generic and brand names sold at most pharmacies. In particular, T3 can be formulated into a sustained release capsule that slowly releases T3 over the course of about 12 hours. This solves the problems associated with taking standard liothyronine (Cytomel) products. Disadvantages of this form is that many insurance companies will not reimburse for custom-compounded products, and the cash price is significantly higher (e.g. $110/50 days, compared to $15/30 days for generic liothyronine or $4/30 days for generic levothyroxine).
The other concern with compounded sustained release T3 is that since each batch is made to order for an individual patient, and cannot be subjected to quality control practices of testing a sample of each batch for potency and consistency, consistent product potency may be subject to question. This problem can be reduced but not eliminated by always ordering product from the same compounding pharmacy.
Desiccated Pork Thyroid
All treatments discussed above are synthetic products made in the laboratory. An older treatment is to use naturally occurring T4 and T3 that can be found in the dried pork thyroid gland (DPT). The most famous brand is called "Armour Thyroid", but other brands include "NP Thyroid", "WP Thyroid", "Nature-Throid", "Westhroid". These products are not covered by most Medicare and insurance plans.
This is the form of thyroid recommended by famous thyroid experts including Dr. Broda Barnes and Dr. Mark Starr, as well as Dr. Weyrich (for most patients). However, most conventional (allopathic) doctors recommend against DPT because of the belief that quality control is poorer than the synthetic compounds, although (as discussed above), the synthetic products are also not without their share of consistency problems. The best answer to the question of consistency is to pick a brand and stick with it.
Armour Thyroid brand was off the market for an extended time (in about 2009), without any convincing reason why. Theories floated at the time included FDA demands for proof of safety and efficacy of the product, which had long been used without problem before the FDA was empowered to regulate drugs. It is now back on the market, but at significantly higher price. Currently (2017-18), the availability of WP Thyroid, Nature-Throid, and Westhroid has been greatly curtailed, again for unclear reasons. The official reason given by the manufacturer, RLC Labs, is a shortage of raw materials. Well, maybe, whatever. The bottom line is that WP Thyroid is currently unavailable (although Dr. Weyrich still has a few bottles of WP Thyroid and Nature-Throid in inventory for his current patients), while Nature-Throid is still being manufactured but is back-ordered due to demand exceeding supply.
This situation is very unfortunate, given the need to pick a brand and stick with it. Dr. Weyrich preferred WP Thyroid for his patients, because of its purity (low allergenic binders) and the reputation of the maker, RLC Labs, for good quality control. Dr. Weyrich is in the process of converting his patients from RLC products to NP thyroid or Thyrolar (see below) after his existing inventory of the specific dose of RLC products is exhausted.
It is true that not all dried pork thyroid gland products (DPT) are reliable. On August 17, 2018 the FDA issued a recall notice regarding certain products sourced from China. While this is unfortunate, this does not mean that all DPT products are unreliable.
Another criticism of the use of DPT is that it contains a ratio of T4:T3 of about 4:1 (25% T3), whereas humans produces T4 and T3 in a ratio of about 14:1 (7% T3). This seems like a non-issue, since levothyroxine (Synthroid) contains 0% T3 and liothyronine (Cytomel) contains 100%; this puts DPT in the middle. If a patient is having trouble converting T4 to T3, either DPT or liothyronine (Cytomel) would be a better choice than levothyroxine (Synthroid). Despite this fact, conventional (allopathic) doctors consistently favor levothyroxine, without testing to see what their patients' free T3 (fT3) levels are, or considering whether their patients are properly converting the pro-hormone T4 into fT3.
As discussed above, if levothyroxine as prescribed based only on a TSH test by a patient's conventional (allopathic) MD or DO and paid for by the patient's insurance is working well for them, there is no reason to consider anything else. The patients who Dr. Weyrich sees come to him, and pay out of pocket for extended testing and alternative treatments, precisely because the conventional treatment (which according to the statistical rules of "evidence-based medicine" may fail 5% of the population), has failed to relieve their symptoms.
Another option to consider is the synthetic T4+T3 product trade with the generic name liotrix and the brand name Thyrolar. This synthetic product contains the same T4:T3 ratio as desiccated pork thyroid, but is recommended to be dosed twice a day as opposed to DPT, which is once a day.
This product has similar benefits as desiccated pork thyroid, plus the added benefit of being Kosher/Vegan. However, at twice a day dosing, Thyolar-1 ($44/60 is quoted by GoodRX) is more expensive than NP Thyroid 120mg once a day ($20/30 is quoted by GoodRX).
While it is true that hypothyroidism can promote unwanted weight gain, and hyperthyroidism can promote weight loss, it is never appropriate to deliberately take too much thyroid medication in order to deliberately produce a hyperthyroid state to promote weight loss. The Food and Drug Administration (FDA) feels very strongly about this point, and have written what is called a "black box warning."
This does not mean that thyroid supplementation is not appropriate for people trying to lose weight and who are hypothyroid. It means that TSH and fT3 (etc) levels need to be monitored, and TSH not be allowed to go below normal or fT3 allowed to go above normal.
In some cases, the body can get locked into producing too much reverse T3 (rT3) and not enough regular free T3 (fT3), resulting in symptoms of hypothyroidism despite normal (or optimal) levels of TSH and T4. In particular, the conversion of T4 to rT3 can establish a self-perpetuating feedback loop that is harmful.
rT3 Syndrome (also known as Wilson's Temperature Syndrome) appears to occur most often in cases of "yo-yo dieting" in which a patient alternates strict caloric restriction dieting with unrestricted diets. In the face of extreme caloric restriction, the switching the body to a dominance of rT3 production has survival benefit. The problem occurs when the body gets locked into a rT3 loop that does not revert to normal fT3 production when the caloric restriction ends.
Dr. Weyrich discusses the control of the thyroid system further on his web page how the thyroid system works.
The treatment for this self-perpetuating feedback loop is to administer sufficient T3 to drive TSH and hence T4 production to near zero. In the absence of T4, the feedback loop driving rT3 excess is broken. Tapering off the T3 then allows suppression of TSH and T4 to resolve, and normal conversion of T4 to fT3 to resume.
The American Thyroid Association has rightly pointed out that evidence of the safety and effectiveness of Wilson's Temperature Syndrome is anecdotal. Nonetheless, when laboratory evidence fits the picture of elevated rT3 along with hypothyroid symptoms that are resistant to other treatments, a carefully monitored treatment with Dr. Wilson's protocol (or some variant thereof) may be in order, provided the patient is carefully screened to rule out other medical conditions (including "euthyroid sick syndrome," cardiac issues, certain drug therapies), and proper informed consent is obtained.
When applicable, variations on the Wilson protocol appear to promote remission of symptoms, as long as subsequent calorie-restricted diets are not undertaken by the patient.
Hashimoto's thyroiditis is an autoimmune condition in which the cells of the thyroid are destroyed. Initially the destruction of the thyroid cells causes a release of larger than normal amounts of thyroid hormone, resulting in transient acute hyperthyroidism. As destruction of the thyroid cells continues, eventually too few cells will remain to produce normal amounts of thyroid hormone and the patient will develop a hypothyroid state.
Diagnostic testing easily confirms the presence of Hashimoto's thyroiditis by the presence of auto-antibodies. However, conventional (allopathic) medicine does not provide any treatment for Hashimoto's thyroiditis except thyroid replacement therapy, usually in the form of levothyroxine. Thus, Hashimoto's thyroiditis is commonly viewed as a progressive disease that results in the patient being dependent for life on increasing doses of levothyroxine.
However, there is a disconnect between medical research and conventional (allopathic) medicine - it is well known that certain food sensitivities, such as gluten sensitivity, correlate with autoimmune disease. It is well established doctrine in the naturopathic medical community that treating food sensitivities, intestinal dysbiosis, and intestinal hypermeability (leaky gut) can often slow the progression of autoimmune diseases, or even promote regression of symtoms.
Immune modulators such as vitamin-D and Low Dose Naltrexone have also been found to be effective (although the evidence is anecdotal, since funding for research for products that cannot be patented is extremely limited).
According to the Low Dose Naltrexone home page [LDN], LDN has been seen to benefit Hashimoto's thyroiditis, which is considered to be an autoimmune disease. [LDN] reports that all patients with autoimmune processes who were treated by the late Dr. Bihari [Bihari2003] using LDN "have experienced a halt in progression of their illness. In many patients there was a marked remission in signs and symptoms of the disease." Dr. Bihari suggests a 50% to 70% overall response rate. Please see [LDN_Story] for an excellent documentary video, and [Elsegood2016] and [Moore2008] for books.
Dr. Weyrich notes that these reports are considered anecdotal, and without expensive double-blind placebo-controlled trials (which are unlikely to be funded, since LDN is a generic drug that cannot be patented), these results cannot be proven to be anything more than "spontaneous remissions"; however, given the low cost (less than $40/month) and extremely low side-effect profile, a therapeutic trial may be in order.
The main caveats are that patients cannot also be being treated with extended release opiates for pain control and cannot be organ transplant recipients. This is an off-label use, and as such is not likely to be covered by insurance.
Dr. Weyrich has been trained in the use of Low Dose Naltrexone (LDN) and offers these protocols as a complement to other therapies.
Although iodine deficiency has been relatively rare in the United States since Congress required iodine to be added to table salt, historically iodine deficiency has caused many problems in the United States, including goiter and cretinism. As people have been reducing their salt consumption, and switching to more natural salt sources such as sea salt, the incidence of iodine deficiency has been increasing in the United States. Although severe iodine deficiency can produce obvious results, such as goiter and mentally challenged babies (cretinism), less overt iodine deficiency can cause symptoms of hypothyroidism. [Too much iodine in a mother's diet can also cause problems in fetal development].
Protein deficiency can also case hypothyroidism, since synthesis of T4 in the body requires the essential amino acid phenylalanine (or tyrosine which the body can make if it has sufficient phenylalanine). Although health food stores sell phenylalanine and tyrosine supplements, Dr. Weyrich believes that adequate protein intake is preferred to supplementation with phenylalanine and tyrosine supplements. Patients who are malnourished do NOT need more thyroid hormone - that is like whipping a dead horse. Instead, malnutrition should be resolved before attempting to increase T4 or T3 production.
Other specific vitamin and mineral deficiencies may also prevent formation of T4 or its conversion into T3, particularly selenium and zinc. Please discuss these nutritional needs with a professional trained in human nutrition (for example any licensed Naturopath).
Heavy Metal ChelationAs discussed on the web page how the thyroid system works, mercury intoxication reduces T4 conversion to T3, and increases the conversion to rT3. It logically follows that mercury intoxication can cause the symptoms of hypothyroidism, and that removing the mercury via chelation would resolve the symptoms of hypothyroidism (as well as the other symptoms of mercury intoxication). Dr. Weyrich has a chelation protocol using the oral medication DMSA (meso-2,3-Dimercaptosuccinic acid, AKA Captomer or Succimer) which is effective for detoxifying the body of mercury.
Hippocrates, the "father of modern medicine", said "first look to the spine" for the cause of disease. In some cases, treatable problems with the spine can reduce blood flow to the brain and nerves of the autonomic nervous system that regulate the function of the thyroid, adrenal, and digestive systems. For additional information regarding the relationship between the spine and thyroid disease, please contact Dr. Robert Gear, Jr.
- [Bihari2003] Bernard Bihari, Kamau B Kokayi. Dr. Kamau B. Kokayi Interviews Dr. Bihari. Global Medicine Review. September 23, 2003, WBAI in New York City Text: http://www.lowdosenaltrexone.org/gazorpa/interview.html.
- [Bihari2013] Bernard Bihari. Low-dose Naltrexone for Normalizing Immune System Function. Altern Ther Health Med. 2013 Mar-Apr;19(2):56-65. PMID: 23594453. Text: http://todayspractitioner.com/wp-content/uploads/2013/10/Bernard-Bihari-MD-Low-dose-Naltrexone-for-Normalizing-Immune-System-Function-athm_19_2_bihari_56_65.pdf.
- [Elsegood2016] Linda Elsegood. The LDN Book: How a Little-Known Generic Drug - Low Dose Naltrexone - Could Revolutionize Treatment for Autoimmune Diseases, Cancer, Autism, Depression, and More. Chelsea Green Publishing (2016). Amazon.
- [LDN] Low Dose Naltrexone Home Page. Text: https://www.lowdosenaltrexone.org. Accessed: 07/26/2019.
- [LDN_Story] LDN Research Trust. The LDN Story. Text: https://vimeo.com/131314110. Accessed: 09/16/2016.