Have We Replaced Efficacy With Efficiency: The Current Medical Standard Versus The Old Way Of Treating Hypothyroidism

By John Billings posted 08-26-2011 11:11 AM

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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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