I did a poll on my Instagram stories about which thyroid medications worked best for people. Unfortunately it is nearly impossible to have accurate results when there are several brands for each drug that people may react to differently, but the overall consensus was interesting to me. Most people preferred a combination therapy (which is discussed below) over T4-only treatment. Yet, T4-only treatment is still the gold-standard of conventional medicine.
Here are the different kinds of thyroid medications available today
Levothyroxine
Commonly Prescribed Brands - Synthroid, Tirosint, Levoxyl, Eltroxin (canada), Euthyrox (EU), Oroxine.
Levothyroxine is a T4-only (thyroxine) hormone replacement medication. It comes in many brands, Synthroid being the most popular and most prescribed, and Tirosint being the cleanest in ingredients with just gelatin, water, glycerin and T4. Other brands of levothyroxine tend to have corn starch, sometimes milk and sometimes even gluten, dyes, and words no one can pronounce. This is something you’ll want to look out for when your doctor prescribes you treatment.
Levothyroxine (in its many forms) is the most stable, and trusted prescription for hypothyroidism that is currently on the market. That is why, whether you feel great or not, doctors will likely only offer you this treatment. Levothyroxine is known for great lab results, but this does not always correlate with how a patient feels. I have had people say to me, “well I switched back to levothyroxine because my labs are better than on combination therapy” to which I ask, “but do you feel optimal?” The answer is typically, no.
This is not to say it is not a good medication. Many people do very well on thyroxine-only therapy when it is dosed correctly, when they are stabilized and when other parts of the endocrine system, like our ovaries and adrenal glands, are also balanced.
Why T4-only Might Not Work for You
T4 is an inactive thyroid hormone that must convert a small percentage into T3. Though it is not a whole lot, T3 is responsible for maintaining a healthy weight, cognition, mental health, skin, hair, nails and more. When a doctor prescribes T4 treatment, they do so with the expectation that your body will convert it into enough T3. Unfortunately, this requires adequate gut health, liver function, micronutrients like zinc and selenium, healthy levels of inflammation, and more. How many thyroid patients do you know that have all these things? Probably not many.
Liothyronine
This is a T3-only treatment. Seems ideal, but this is one that you’d want to pair up with levothyroxine. Though I know some people only use T3, this can be dangerous and very hard to maintain. I would only ever suggest liothyronine with levothyroxine, or paired with other thyroid hormone treatments that require more T3. T3 is harder to dose, and must be monitored by a physician who understands thyroid health.
Commonly Prescribed Brands - Cytomel, compounded T3
30% of patients who take levothyroxine (T4) on its own experience abnormally low levels of free T3. This number may be significantly more if we factored in the patients with low, or low range T3, or even patients with middle range T3 who are not feeling optimal. Typically, Free T3 labs should be top end of the range to be considered “optimal” and to experience its full potential. I remember when I first started taking combo therapy and realized “wow, this is what life is supposed to feel like?” Yup, that’s how good you were designed to feel before your thyroid decided otherwise.
Why T3 Therapy is Considered Controversial
Let me tell you a wild story. When I was 19, I asked my doctor about T3. His response, “I don't know what you are talking about, you are a ‘know it all’”. I guess I'll take that as a compliment? I doubt that my doctor didn’t actually know what T3 was, and as I learned more about its history as a drug I understood why someone who hasn’t picked up a textbook in 30 years may be skeptical of this one.
You see, in the eighties there was a T3 scandal. Weight loss clinics used T3 therapy for patients who showed no signs of thyroid dysfunction as they understood the weight loss benefits of this drug. However successful it was, patients ended up in the emergency room with severe cardiac damage, thyroid damage, and major depression. People were dying because of this inappropriate practice. People and physicians alike, became weary of T3 therapy altogether. The FDA issued a ‘black box warning’ on the drug and the rest is history. I mean, don’t people realize that this is the case with many pharmaceutical medications, which is the whole reason you need a medical degree to prescribe them? It would be like giving heart medication to someone without heart problems, of course it's dangerous and will cause damage, that does not mean it isn’t a good medication for cardiac patients. In the past 20 years, T3 has mostly regained its good reputation in medicine, but for doctors who were practicing in the eighties, it may have left an emotional scar. The risks of T3 are only associated with inappropriate prescribing practices, and if your doc needs a refresher of the last 20 years, the literature shows a combination of both T3 and T4 are best for most patients.
Combination Therapy
Combination therapy means that either the drug contains more than one thyroid hormone, or the patient takes more than one thyroid hormone in a dose. There are two kinds of combination therapy available today, Desiccated Thyroid Extract and synthetic T3/T4 therapy.
Desiccated Thyroid Extract
My precious, precious thyroid medication. Though not for everyone (clearly according to my poll on instragram) desiccated thyroid extract (DTE) seems to still be superior in many cases than T4 only treatment. In fact, the majority of people who said DTE did not work for them, still had more success with it than T4-only treatment.
Commonly Prescribed Brands - Nature Throid, Armour, ERFA (Canada), Thyroid, WP Thyroid, NP Thyroid
A quick google search about DTE medications could lead you down a hole of ‘research’ suggesting it is a useless medication, an unsafe option, and a controversial one. It is ironic that these pieces of research are often funded by T4-only pharmaceutical companies...I am looking at you, Synthroid. There is vast evidence that people have great success with DTE treatment, with studies from both the National Institute of Health and the Journal of Clinical Endocrinology and Metabolism, reporting DTE as the superior treatment. A study conducted from the department of Endocrinology at the Walter Reed Military Medical Center states that patients with Hypothyroidism who take DTE have an overall decrease in symptoms, improved cognitive health, and an increase in quality of life compared to those on T4-only treatment. DTE is a glandular medication that mimics the innate function of the thyroid gland, closer than any other treatment. It provides T1, T2, T3, T4 and Calcitonin, all hormones that a healthy functioning thyroid secretes. Though there is limited research about the physiological need for T1 and T2, they are produced in healthy thyroid patients, and therefore should be supplemented in thyroid therapy.
Controversy Around DTE
In the past, each batch of desiccated thyroid varied in terms of how active the thyroid hormones were. Because the thyroid requires consistency, this made DTE a dangerous option for patients trying to regulate their thyroid health. However, like the T3 controversy, this is an example of the importance of scientific improvements and technological advances. DTE is now measured using a device that ensures each pill has the exact same amount of thyroid hormone required for the patient. DTE has been completely safe for over 20 years and yet some physicians are still skeptical because of its history. Another side of controversy comes from ethical concerns as DTE is desiccated thyroid glands of animals, typically porcine.
Why DTE Does Not Work for Everyone
Some research suggests that those with cortisol complications and adrenal dysfunction do not respond well to desiccated thyroid extracts, though some report feeling great despite HPA issues. I have been on DTE for over 2 years now, and though it took 6-8 months to find a therapeutic dose, it is the best medication for me. It is the medication that helped me reach remission, and gave me back my quality of life. There are also many brands of DTE, so it's normal to have different reactions to different brands. Another reason people have issues with desiccated thyroid is that they don’t test enough, and they do not closely monitor their T3. Because of the T3 feedback loop, it can take months to find a therapeutic dose of desiccated thyroid. Patience is a virtue!
Synthetic Combination Therapy T3/T4
To be honest with you, I have no idea why this option is not used more often in conventional medicine. It is incredibly clear that T4-only medication is not the superior choice, and though I understand it’s the easiest to regulate and monitor, if a patient feels hypothyroid even with adequate T4 treatment, it is not enough and a doctor is not doing his/her job until they find you that happy medium (good labs AND no symptoms).
I am all about the least amount of medical intervention while maintaining a therapeutic dose. So if T4-only therapy works for a hypothyroid patient, that is fantastic news. It is extremely important for physicians to realize that this does not happen often, though. Available clinical evidence reveals that levothyroxine on its own does not “represent a universally adequate replacement for thyroid function” according to the NIH. T4/T3 therapy closely mimics (synthetically) a more accurate representation of what a normal, functioning thyroid produces.
So What Medication Works Best?
Regardless of what thyroid medication has worked best for you, it is abundantly clear that there is no one-size-fits-all thyroid therapy. In a study conducted at the department of clinical molecular endocrinology and oncology from the University of Naples, Italy, authors conclude that “innovative formulations of the thyroid hormones will be required to mimic a more perfect thyroid hormone replacement therapy than is currently available”. This means that the research reporting on which drug is superior in replacing thyroid hormone, must continue, and in my opinion, should not be reported by pharmaceutical companies with an agenda to sell their own drug.
An important takeaway from today’s post is not only that every thyroid patient will require a different approach to treatment, but also that thyroid medication is simply a replacement of hormones. It is not a cure, it is not a magic pill, and without lifestyle changes backed by empirical evidence, like diet, it is unlikely that thyroid medication, on its own, will give you an “optimal” life. This is another reason why polls, and studies could be inaccurate. Those with ultra processed diets, high-stress lifestyles and other chronic conditions could potentially have less success with treatments than those on whole-food diets, reduced-stress lifestyles and an overall healthy mind and body.
Everything that has happened in your life has led you here.
Thank you for reading,
Victoria
Diagnosed with Hashimoto’s Disease and Hypothyroidism, Victoria explores the reality of living with chronic illness through her blog, The Butterfly Effect.
Victoria seeks to spread awareness of autoimmunity and writes to inspire chronically ill patients to live wholesome lives beyond their health struggles.