New Research Questions Traditional Treatment Approaches for Hypothyroidism

November 29, 2017 1 Comment by Scott Isaacs, M.D.

There have been several new studies that question the traditional approach doctors have used to treat hypothyroidism. In the United States many people are treated with thyroid medication because their thyroid stimulating hormone (TSH) is elevated – or for nonspecific hypothyroid-type symptoms such as weight gain, cold intolerance, fatigue and depression. Sometimes these symptoms are related to the thyroid but there are many nonthyroidal causes of symptoms classically attributed to the thyroid.

A study published in the New England Journal of Medicine in June 2017 known as the TRUST study (Thyroid Hormone Replacement for Subclinical Hypothyroidism) was unable to show that the medication levothyroxine produced any measurable improvement in hypothyroid symptoms. The researchers found that there was a benefit in some symptoms, but this was no different than the improvement seen with a placebo. Patients reported improvement in thyroid-specific quality of life measures but the extent to which they improved was no different whether someone took a placebo pill or actual thyroid medication.

It is well known that the TSH level naturally rises as you get older, especially after the age of 65. A TSH level in the range of 5-10 mIU/L can be completely normal for someone over the age of 65 and is common for people over the age of 80. Treatment of the TSH in this range may not be helpful. Furthermore, studies have shown that people with a higher TSH level over the age of 65 tend to live longer. It is thought that people need less thyroid hormone as they get older and the elevation of TSH with age is not deleterious and may have a protective effect.

The author of the study, Dr. Douglas Bauer from the University of California, San Francisco stated “I would speculate that we’ve overestimated the benefit of thyroid hormone therapy on symptoms based on the fact that previous studies haven’t been blinded.” One flaw in Bauer’s study was that the thyroid hormone treatment may have not been aggressive enough to show a difference. The average TSH in the group treated with thyroid hormone was 3.6 mIU/L which is higher than the goal of 1-2 mIU/L used by most clinicians. It is possible that higher doses of thyroid hormone or using a combination of thyroid hormones could have produced better results.

However another study from the Thyroid and Parathyroid Center at Oregon Health & Science University which was recently presented at the 2017 American Thyroid Association found that a person’s perception of a higher levothyroxine dose may be more effective than the actual dose. In this study, both patients and researchers did not know the actual dose of thyroid medication they were taking. Hypothyroid symptoms such as mood, cognition and quality of life did not differ whether the levothyroxine dose was adjusted to achieve TSH levels in the low-normal, high-normal or mildly elevated range. But despite the lack of objective benefit, the vast majority of patients preferred the levothyroxine doses that they perceived to be higher – whether they actually were or not. In fact, patients with mildly abnormal thyroid levels felt better than those with normal thyroid levels as long as they thought they were taking a higher dose. Dr. Mary Samuels, the lead author of the study commented, “With these data, we believe that patients should be counseled that symptoms in these areas are not reliably related to levothyroxine doses or thyroid hormone levels.”

My take on this new research is that we have a lot more to learn about treating thyroid disease. Clearly there are some treatments that don’t seem to provide much benefit, or at least no more benefit than a placebo pill. But, my experience in treating patients in the real world is vastly different than in a research study. I have found that with careful adjustment of doses of levothyroxine, different brands or with trying different thyroid hormone preparations including liothyronine (Cytomel) and natural desiccated thyroid hormone (Armour thyroid, Nature-throid, NP Thyroid and others) most patients feel better. I don’t take a one size fits all approach as was done in these studies. How someone feels is just as important as their thyroid hormone dosage and their thyroid hormone levels. If you have normal thyroid levels but still have hypothyroid symptoms, something is wrong. Normal levels are not enough to say everything is fine.

by Scott Isaacs, MD

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One Comment

  1. Carla Jones says:
    Saturday, December 30, 2017 at 5:47pm

    I take WP thyroid, and read that it is best to have TSH blood work done prior to taking the med. is this true? If so, should the TSH results be higher or lower?

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