Have We Replaced Efficacy With Efficiency: The Current Medical Standard Versus The Old Way Of Treating Hypothyroidism
John V. Billings ARNP
The
current climate in primary medical practice, to survive financially,
requires the practitioner to be efficient without sacrificing efficacy.
Evidence based practice and medical standards provide a margin of
safety that allows the practitioner to confidently treat effectively and
efficiently. The most time consuming aspect of medical treatment, yet
the most important, is the history and physical.
Fifty
years ago hypothyroidism was diagnosed almost exclusively by history
and physical and treated with medication derived from dessicated thyroid
glands of pigs and cows. Because of the dependence on the signs and
symptoms, this form of treatment was highly effective. Unfortunately it
was also not very efficient and occasionally the patients developed
serious complications of cardiac arrhythmia and bone loss.
Since
the advent of Synthroid (Levothyroxine) in the 1960’s and the
subsequent dependence on TSH for both diagnosis and treatment, the old
way of treatment for hypothyroidism, with dessicated thyroid glands and
the use of history and physical for diagnosis and treatment, have lost
favor. Unfortunately, since the practitioners are not assessing for the
signs and symptoms of hypothyroidism before and after treatment, they
are missing valuable information that would tell them if their patients
have improved. As a result, only one third to one half of all patients
treated for hypothyroidism have reported feeling any better after
treatment.
The
justification for the dependence on the TSH rather than dependence on
the findings from the history and physical to assess and treat
hypothyroidism, is the oft quoted research findings that suppressing the
TSH puts the patient at risk for developing cardiac arrhythmia and bone
loss. As a result, all of the patients presenting with an elevated TSH
and subsequently treated with Levothyroxin without suppressing the TSH,
are spared from the possibility of developing cardiac arrhythmia and
bone loss from over treatment with thyroid hormone replacement therapy.
As
far as the concerns for cardiac arrhythmia and bone loss, which is
attributed to hyperthyroidism caused by over treatment of
hypothyroidism, logic and anecdotal evidence suggest that the initial
effect of dropping the TSH below the normal reference range causes a
decrease in T4 and T3 levels and a worsening of the hypothyroidism. The
medical definition of hyperthyroidism is a TSH less than normal
reference range, but when the thyroid gland decreases or stops
production of T4 as a result of over-treatment with Levothyroxin, the
medical definition, which applies only to the thyroid gland, is
misleading and leads to an erroneous assumption that the T4 and T3 are
too high. The initial cardiac arrhythmia and bone loss are actually a
result of a decrease in T4 and T3, not and increase. This observation
needs to be confirmed with published research.
Furthermore,
essentially all of the research on hypothyroidism in the past 50 years
has been conducted within the standard, which prohibits suppression of
TSH. Very little research has been done on the effects of treatment
outside of the accepted medical standard, and any research done with TSH
suppression has almost exclusively been on patients that have thyroid
cancer. There is essentially no peer reviewed published research on the
efficacy of treating hypothyroidism using the ‘Old Way’. Perhaps to
conduct such research would be deemed unsafe and unethical.
There
is a growing interest in looking at a neglected thyroid function test,
free T3, that may explain why the ‘Old Way’ of treating hypothyroidism
was so successful. This increased interest in free T3 and subsequent
research has shown that free T3 is a reliable marker for predicting
increased mortality in hospitalized patients. Low free T3 is also a
common finding in those treated for hypothyroidism and may explain why
the majority of patients treated don’t feel any better. In addition,
low free T3 may also be responsible for morbidity in those who are
euthyroid without thyroid hormone replacement treatment. This condition
is called Non-Thyroydal Illness Syndrome (NTIS). (1)
The
practice of measuring free T3 is seldom used and is very controversial.
Since very few practitioners use free T3, they have little or no
clinical experience in interpreting the results. However, is it
possible that ignoring the T3, and lack of assessing signs and symptoms
of hypothyroidism, may be responsible for the inefficient and expensive
practice of treating symptoms instead of the problems. The theoretical
model which suggests that free T3 levels are inversely related to
adrenaline and cortisol levels opens the possibility that low T3 is a
major player in aging, the development of cardiovascular disease, as
well as development and exacerbation of any auto-immune disease. It
will take time before these findings will have any effect on the current
standards for diagnosing and treatment.
The
practice of evaluating and treating hypothyroidism based on the TSH is
highly efficient and safe, and is supported by the research evidence.
However, when has treatment of any medical condition been acceptable at
a less than fifty percent efficacy? And more importantly, when has
treating other medical conditions relied on numbers at the exclusion of
evaluating the signs and symptoms? The old way of treating
hypothyroidism prior to 1960 was much more effective, but the increased
time it takes to assess and treat make is very inefficient. In
addition, the risk of developing cardiac arrhythmia and bone loss, and
the lack of research supporting such practice, make it unsafe. The old
way has been relegated into the realms of alternative medicine. It has
become a pariah and to use it would probably cost the medical
practitioner their medical practice.
The
current medical practice is costing the majority of patients being
treated for hypothyroidism their health. Additionally, NTIS very
possibly may be a major factor affecting the skyrocketing cost of health
care. The current standard for diagnosing and treating hypothyroidism
needs to be changed to include the routine assessment of the signs and
symptoms of hypothyroidism and the use of measuring free T3. Doing
these two things may initially decrease the efficiency of treating
hypothyroidism, but the payoff could effect subsequent research that
will elucidate the mechanisms that cause the cardiac arrhythmia and bone
loss, and drastically improve both the efficiency and efficacy of
health care.
1) Dangerous Dogmas in Medicine: The Nonthyroidal Illness Syndrome
Leslie J. De Groot
J. Clin. Endocrinol. Metab. 1999 84: 151-164, doi: 10.1210/jc.84.1.151
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