Doctors' Individualised Protocols
CASE STUDY: Thyroxine replacement was not sufficient despite “adequate” test results
I have been using a variety of methods of thyroid hormone replacement including T4 alone, T4/T3 combinations and Thyroid USP (thyroid organ extract – typically porcine) for the last 3 to 4 years. My impression is that the choice of therapy is an individualised one based primarily on the patients presenting symptoms. Some people do perfectly well on thyroxine alone, others require a combination of the two hormones. My usual protocol now with any new patient is to typically prescribe thyroxine alone and carefully monitor the patients symptoms using a questionnaire to be filled out by the patient at the initial and subsequent visits. The blood tests are a secondary monitoring tool. I say this because the diagnosis of hypothyroidism was based on symptoms for a long time before thyroid function tests were ever available. I have several patients whose values of T3, T4 & TSH were normal at the time of presentation – whose symptoms were highly suggestive of hypothyroidism and responded appropriately to thyroid hormone replacement therapy. The following case illustrates a patient whose thyroxine replacement was not sufficient despite “adequate” test results.
Mr. P was 48 yrs old when he first saw me. He had a very responsible job working in the computer industry. Between 5 and 10 years prior to seeing me he had noticed a decline in his health – notably increasing lethargy, depression, poor memory, constipation, scaly skin, an increased tendency to pick up infections including shingles and cold intolerance. The year prior to seeing me, a blood test performed at the time of a routine blood donation revealed the clue to the diagnosis of hypothyroidism. Subsequently Mr. P was prescribed thyroxine. When he saw me he was taking Oroxine 400mcg daily. Despite this high dose of thyroxine he was still complaining of fatigue, depression, irritability, poor short term memory (particularly with people’s names, names of objects and places), joint aches, reduced libido and generally feeling older than his age. The only abnormalities revealed on physical examination included a heavily coated tongue, a slow pulse rate (56/min), dry skin, vertical nail ridges and numbness (reduced sensation) on his heels.
A range of blood tests was performed including FBE, U&Es, LFTs, glucose, Rheumatoid screen, androgen studies, thyroid function tests (including T4, T3 & TSH), thyroid antibodies, vitamin B12. All tests were within reference range, except his B12 - 131pmol/L (in the “equivocal range”), the presence of thyroid autoantibodies (microsomal 6400, normal <100) and his TFTs, with free T4 22.2 (range 10-25), free T3 6.5 (range 2.5-5.5) and TSH <0.05. I kept his Oroxine dose the same and arranged B12 injections for him after testing for presence of Gastric Parietal Cell antibodies (the test being positive). Seven weeks later after having had 4 B12 injections for pernicious anaemia (despite a normal FBE) he returned noting a slight increase in energy, less achy joints and feeling less “muddle headed”. His nails had also improved. His androgen studies revealed a low normal free androgen index of 49.3%. When I prescribed Andriol (testosterone capsules) 6 weeks later he reported feeling a lot better, his joints were not as sore as previously and in the week prior to this review his energy had increased (self reported as 85 to 90% of normal).
Synthetic T4 and T3 Combination
I saw him again 2 months later when he reported feeling well, up until 3 weeks prior to the visit and he was complaining of feeling tired and lethargic. He had further B12 injections (despite a B12 level of 308) which helped and a month later I asked him to reduce his Oroxine to 350 mcg for 2 weeks and then to 300 mcg up until the review appointment 7 weeks later. On 300mcg Oroxine his T4 was 21.0, T3 3.8 and TSH 0.55. I then prescribed 10mcg of T3 (Tertroxin). 6 weeks later he returned and reported feeling the “best in years”. His T4 was now 23.0, T3 4.9 and TSH 0.50. 3 months later he was still feeling extremely well with the exception of his poor memory. I recommended that he increase his T3 to 20mcg each morning and to reduce his T4 to 250 mcg daily. Approximately 8 weeks later his T4 was 20.8, T3 3.9 and TSH 0.07. A further 5 to 6 months down the track he was still having memory problems and his T4 was now 12.3, T3 3.0 and TSH 0.35. I suggested increasing his T3 to 30mcg (20 in the morning, 10 in the evening). 7 weeks later his T4 was 12.6, T3 3.7 and TSH 0.33. His memory had not improved so I recommended increasing his T3 to 20mcg twice daily. This had no impact on his memory so I reduced it to the previous 30mcg daily and he has remained on this combination to date.
This case illustrates a few points – firstly that some patients respond better to a T4/T3 combination, and that coexistent diagnoses should be thought of – the association with Pernicious Anaemia is well known, B12 deficiency/Pernicious Anaemia was present despite a normal FBE, therefore B12 levels should be checked routinely in patients with autoimmune thyroid disease. Symptoms are more reliable than thyroid function tests alone.
- Anonymous, 2002
CASE STUDY: Sub-clinical Hypothyroidism
The following case is from the patient files of a naturopath consulting in the outer eastern suburbs of Melbourne.
A 40 year old female patient presented with the following general symptoms – headaches, recurrent infections and dry, scaly skin. Her menstrual bleeding was prolonged and heavy, with a short cycle of 24 days. She suffered from cold hands and feet, had thin, brittle nails, tired easily and had gained weight. She had been on a low fat diet to try to lose the extra weight but it remained unchanged. She was also feeling depressed. She was studying and working as a nurse part time and was finding exam pressures to be stressful. She had little time or energy to relax or exercise. An oral zinc tally test showed low zinc levels. Her blood pressure was 110/70.
Her initial treatment was vitamins (B Group), minerals (PPMP & zinc) & herbs to support her nervous system. She was advised to include more deep sea fish, avocado, and LSA (a blend of linseeds, sunflowers & almonds) in her diet to increase EFA levels to further support the nervous system and to address dry skin.
She was also asked to take her basal body temperature in the morning on the second, third & fourth days of menstruation, as sub-clinical hypothyroidism was suspected (a low basal body temperature is an indicator for this condition).
When the patient returned 2 weeks later, she reported that she was feeling better able to cope with stress, but the other symptoms remained. It was revealed that her basal body temperature was indeed low (averaging 35.2°C – normal range 36.4°C – 36.7°C). Combined with her symptoms, sub-clinical thyroiditis was the diagnosis.
The previous prescription was continued and it was recommended that she include more iodine-rich foods in her diet, such as iodised salt, seafood and seaweed based products.
It was also recommended that she start to exercise 5-6 days per week, as exercise stimulates thyroid gland secretion and increases tissue sensitivity to thyroid hormone. Exercise also encourages the release of endorphins – the feel good hormones, which help to address depression. Meditation was also recommended to further help her to deal with stress.
She returned 4 weeks later and reported that her symptoms were starting to improve and she was feeling that she had more energy. She was particularly pleased that her menstrual cycle had increased to 26 days duration. She was now enjoying her regular exercise routine and meditating for 10 minutes a day, which she felt was helping her to be more relaxed about the stresses in her life.
- Anonymous, 2002