By Dr. Izabella Wentz, Pharm D.
There are quite a few options for thyroid medications for hypothyroidism, however most people are only familiar with synthetic T4-containing thyroid medications. Some people report feeling better on combination T4/T3 medications (like Armour®, compounded T4/T3 or Nature-Throid®), others may feel better taking synthetic T4 medications (like Synthroid®, Tirosint® or Levoxyl®), while other patients may benefit from a synthetic T3 medication (like Cytomel® ***may be cross-contaminated with gluten***)
Conventional Thyroid Medication Treatment
Conventional physicians will usually prescribe Synthroid® or levothyroxine, a synthetic version of T4. The T4 hormone is an active thyroid hormone, but it is less physiologically active than T3, and needs to be converted to T3 by our bodies. Many people do very well on Synthroid, Levoxyl and Tirosint (a new T4 medication that is hypoallergenic), once they are dosed appropriately and stabilized.
Conventional treatment guidelines state that there is no benefit from taking combination T3/T4 products, and that T4 products are superior, however most of these claims are based on studies funded by pharmaceutical companies with a vested interest in promoting the use of their own products. (10)
Thyroid Medications and Thyroid Physiology
Understanding thyroid physiology, I do believe that combination products may be advantageous for many patients with Hashimoto’s. Some Hashimoto’s patients are not able to properly and efficiently convert T4 to T3. For example, zinc is required to convert T4 to T3, and Hashimoto’s patients are often deficient in zinc.
Under stressful situations, T4 gets converted to Reverse T3 instead of T3. Reverse T3 is inactive molecule related to T3 but without any physiological activity-it is a dud that just takes up space! In the case where a lot of Reverse T3 is produced, adding a combination product that contains T3 will help ensure that the right hormone is getting to the right receptors. Additionally, many patients report that they feel better taking a combination T4/T3 product.
Natural Desiccated Thyroid
Many patients who did not feel well on conventional treatments have reported feeling much better after switching to a natural desiccated thyroid medication like Armour®, Nature-Throid® or WP Thyroid®. These medications are derived from the thyroid glands of pigs and considered bio-identical to the hormones produced by our own thyroid glands.
Armour® and other animal organ-derived products are not usually recommended by conventional physicians because of past issues with quality control. In the past, Armour® has had some discrepancies in the dosages between the batches, however, this does not seem to be the case at present time due to improved quality control. Nature-Throid®, another desiccated thyroid medication has never been recalled for inconsistent T4 and T3 hormones, and this particular drug has been on the market since the 1970’s.
The National Institute of Health, a government agency (not funded by pharmaceutical grants) conducted a clinical trial to see if desiccated thyroid therapy is advantageous to T4 alone (8) The authors of the study concluded: “DTE (Desiccated Thyroid Extract) therapy did not result in a significant improvement in quality of life; however, DTE caused modest weight loss and nearly half (48.6%) of the study patients expressed preference for DTE over l-T4 (Levothyroxine). DTE therapy may be relevant for some hypothyroid patients”. (13)
Controversies in Natural Desiccated Thyroid
Some proponents of natural thyroid medications, including Dr. Alan Christianson (author of Healing Hashimoto’s) advise that the desiccated glands of animals may be the best option as they also have trace amounts of T1 and T2, which may have undiscovered biological functions.
In contrast, Dr. Alexander Haskell (author of “Hope for Hashimoto’s”) and Dr. Mark Starr (author of “Hypothyroidism Type II”), report that for some patients, natural thyroid formulations from animal thyroids, such as Armour®, may be perpetuating the autoimmune attack due to containing thyroglobulin and TPO, and they only recommend compounded and synthetic thyroid medications for people with Hashimoto’s (6,7). I have heard the same from multiple pharmacists and patients alike. Clinically, I see this in a small percentage of clients, and like Dr. Christianson, I have noticed that some people’s thyroid antibodies actually decrease with the use of natural desiccated thyroid medications.
Nonetheless, I always advise testing thyroid antibodies before and after starting natural desiccated thyroid medications. If someone starts feeling worse after initially feeling better on desiccated thyroid or has an increase in TPO antibodies after starting desiccated thyroid, switching to a compounded T4/T3 medication is advisable.
Additionally, some patients may have ethical objections to using animal-derived natural desiccated products.
Compounded T4/T3 products offer another alternative. These medications also offer the advantage of being
made without fillers such as lactose or gluten, which are present in some thyroid medications and can be problematic for thyroid patients.
However compounded T4/T3 products need to be prepared by specially trained compounding pharmacists. These compounds are usually much more expensive and may need to be refrigerated to preserve activity.
Thyroid compounds are usually prepared in the same physiological ratio that is found in natural-desiccated thyroid products, however, physicians can elect to change the amount of T3/T4, as the compounding pharmacists are literally making the medications from scratch. This can be a huge advantage for those patients that did not feel well on conventional treatments or natural desiccated treatments.
The benefit of the T4/T3 is that they can be made devoid of any fillers that people may not tolerate, and they do not increase autoimmunity. Most T4/T3 compounds are immediate release versions, like natural-desiccated thyroid products, however, compounding pharmacists can also make sustained release versions. Some professionals recommend sustained release formulations so that the hormone is released continuously throughout the day, however, these types of formulations may not be absorbed properly by people with Hashimoto’s and gut issues.
The downside of T4/T3 compounds is that specially trained compounding pharmacists need to make them, and do take some time to prepare. Additionally, not all compounding pharmacies are equal, and a specialized process is required to prepare an accurate dose of compounded thyroid medications. Thus, patients might have to travel out of their way to find a compounding pharmacy.
Questions to ask your compounding pharmacist:
- What types of fillers are used?
- What is the source of the materials?
- Is the compound slow release or immediate release?
Compounded medications, Nature-Throid®, WP Thyroid® and Tirosint® are hypoallergenic options for those with multiple intolerances.
The bottom line: There are many options for thyroid hormone treatment. Each person should work with an open-minded physician to find the thyroid medication that works best for him/her.
Thyroid hormone therapy should be individualized with the patient in mind.