Treatment of low T3

By John Billings posted 08-26-2011 11:12 AM


Treatment of low T3

Treatment of low T3
John V. Billings ARNP
(revised 5/28/2010)

Prior to October 2009, when I tested the thyroid (TSH, freeT4, freeT3) I was acting under the assumption that mid-range freeT3 levels were between 3.0 and 3.3.  This was based on the reference range given by the medical laboratory I used, which was 2.3 - 4.2.  If the freeT3 were below 2.7 I would treat them with a 4:1 combination of Levothyroxine (T4) and Liothyronine (T3) One out of five of my clients met this criteria.  What I found interesting was that in the general population it only occurs one out a thousand (I had read that in a journal article, but don't have the reference).  Why would I have a population where 20% of clients had low T3? 

The bulk of prescribing health care providers don't bother to look at T3 because (I was told by an endocrinologist) it doesn't give any usable information on thyroid function.  The only measurement needed was a low cost Thyroid Stimulating Hormone level (TSH).  This is a true statement.  However, many of my clients with a freeT3 of 2.7 or below have normal thyroid function (meaning that the TSH is less than 3.0 and greater than 0.40 and the free T4 is above 0.9).  I was also told by this same professional that I shouldn't treat the T3 because it put the patient at risk for osteoporosis and heart disease.  

I was convinced, after talking with this professional, that my practice of treating for low T3 was not a good idea.  So I abandon my notions of low T3 that I had worked with for 7 years and started taking clients off the medication I used to elevate their T3 (Cytomel, or Liothyronine).  The result was disastrous.  When I normalized the TSH, the T4 was good, but the T3 went low and they relapsed to where they were before I started treating them.   After a couple of months of doing this I quickly went back to my previous methods and those clients recovered. 

Because of this experience I searched my mind for an answer as to why 20% of my clientele were ill.  The conclusion I finally came up with was that 90% of my clients came from the 4% of the chronically mentally ill that have failed treatment in at least two settings, Primary Care and Secondary Psychiatric care.  Usually they have been suffering with symptoms for most of their adult lives and even from childhood.  If I use the same paradigm as the majority of Primary Care Providers and Psychiatry, I will get the same results.  So I had to look for other reasons that didn't exist in the assessment of the other health care settings.

Looking for and treating low T3 when I find it has been very fruitful.  Primary Care Providers (PCP) will never see it.  The cost of measuring free T3 is roughly $50 dollars.  If the PCP screened for low T3 it would cost $50,000 dollars to find one person with that condition.  It is not cost effective and furthermore, there are no standards of treatment for low T3.  Most endocrinologist won't believe it because it's not what they were taught in med school.  If they don't look for it they will never see it, so why should they believe that it exists?  If no one else will treat this condition, and this condition is the major cause of the treatment resistant depression, anxiety, and insomnia in my clients, then it falls within my scope of practice to do what is best for my clients.

The bigger issue with the medical community not treating T3 lies in the fact that Medical Standards for treating thyroid conditions involves only measurement of TSH.  For a health care provider to practice outside of this standard is very risky on a malpractice level.  Also, for a health care provider to treat outside of the standard would relegate them to the ranks of Alternative Medicine, which would destroy a medical practice.

In September 2009 I learned that the range of T3 really between 2.3 and 6.0.  This information came from a fibromyalgia clinic in Orem, Utah run by ARNPs, and from a medical clinic in Tulare California that deals exclusively with endocrine disorders.  I also found confirmation in Wikipedia where I found one graphic that put the normal range between 2.0 and 5.0.  It is interesting to me that the local medical laboratory shows the range for children to be 2.3 to 6.0, but for adults it is 2.3 to 4.2.

All of my clients, except a handful, have freeT3's below 3.5.  That is not only for my current clientele, but for all of my clients during the past 12 years.  This represents at least 500 or more people that I have evaluated.  In that 12 years period only a dozen or so have had a freeT3 above 4.0.  There were so few that I thought they were hyperthyroid without symptoms. To my surprise, my discovery in in September of 2009 show that, all but those few clients that were were normal, don't have enough T3.  They are all sick and treatment resistant and until the T3 is normalized I don't know what symptoms are caused by a co-morbid depression or anxiety disorder.

Significance:  T3 regulates how much ATP is made.  ATP is the power that runs all the cells in the body.  If T3 is low then ATP produced will be low.  Result is low or no energy.  The only way to get energy is either with use of stimulants or triggering the stress response to activate adrenaline. All of my clients have very little energy and what energy they do have is supplemented with Adrenaline.  Adrenaline comes with Cortisol (natural steroid).  Chronic use of Adrenaline and Cortisol cause diseases that rob a person of health and quality of life.  Furthermore, the use of other medications to treat the symptoms caused by overuse of adrenaline (or in this case low T3) are costly and cause further adverse reactions.

Problem:  To get adrenaline you must trigger the fight/flight response and requires one of the following:  exercise, positive mental attitude, worry, anger, procrastination, and risky behaviors. 
Forget using the pep rally in your head or exercising if you are depressed.  That leaves the depressed person with the last four.  Worry produces energy but it also produces anxiety.  Anger gets a lot of adrenaline very fast.  Procrastination is the only way to get important tasks done (need to be in crisis mode before your energy level is high enough).  Risky behaviors can generate tremendous levels of energy, but only for the time you are participating in the behaviors which doesn't help get important work completed.

Results:  If you don't trigger any adrenaline, you are a couch potato or sleep all day.  You are a bad person, lazy, worthless.  If you trigger the adrenaline you either become a: worry wart, a person needing anger management, poor time manager, or you are an adrenaline junky.  All of these are thought of as bad behaviors.  You are in a Catch 22.  Either way you go you are a bad person.  If you don't realize that the 'bad behavior' is your survival and to stop using it will lead to your demise, you will endlessly try to change but eventually will slip back into one of these 'bad behaviors' and thus you are incorrigible. That translates into: personality disorder, treatment resistant, non-compliant, or high consumer of health care resources. 

Solution:  If this is a low T3 problem, then simply increasing the T3 resolves the problem.  However, if your thyroid is perfectly healthy and is working just the way it is suppose to, or your sick thyroid is normalized with the use of Levothyroxine (T4), you won't find many mainstream health practitioners that will treat the low T3. If you do find someone that is skilled at treating low T3, treatment may include both Levothyroxine (T4) and Liothyronine (T3) at a 4:1 ratio (four parts of T4 to one part T3).  My clinical experience is that using Liothyronine draws a lot of criticism and there are several of my clients who have not tolerated the addition of T3.  Therefore, treating with T4 alone can be done.  Since T4 is biologically inert (as far as the BMR), serum levels above the reference range do not pose a health problem.

Roadblocks:  Even though use of T4 and/or T3 is a well accepted augmentation to treatment resistant major depression and has always been in the scope of practice for psychiatry,  treatment of thyroid by a psychiatric nurse practitioner is seen as practicing outside of the scope of practice and meddling with the treatment done by the PCP.  Very few medical practitioners understand this simple solution.  Further there is an overwhelming resistance by the medical community to even test for freeT3 let alone prescribing enough  T4 to treat it.  Those that practice evaluation and treatment of low T3 are relegated to the corps of Alternative Medicine and esteemed as quacks.

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