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Thyroid Optimization Quick Reference

Inner Circle Member Forum >> Iodine and Thyroid Health >> Thyroid Optimization Quick Reference

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Posted: 6/6/2018 9:07:01 AM
Edited: 1/25/2019 8:09:49 AM (10)
 
Thyroid Optimization Quick Reference

Thyroid Optimization Quick Reference

Contents

Overall context for this topic
General information
Program targets
Test Planning
Testing Considerations
Treatment considerations
Standard of Care cautions

Page edition: 2019-01-25

Context

NOTE:
In the interest of space, this is a two-part sticky article.
Thyroid status must include consideration of iodine consumption
Part 1: Iodine Quick Reference.

Unlike mineral and vitamin core supplements, thyroid optimization may not be simply a matter of dial-in the iodine and you’re done. Thyroid dysfunction, hypothyroid in particular, is pandemic in our modern experience, and does not always fully respond to a corrected metabolism and microbiome.

Due to several modern issues, hypo (low) thyroid function is pervasive, with hyper (excessive) thyroid function also a concern, but much less prevalent. The Standard of Care (see bottom of article) for thyroid too often amounts to dogmatic blundering (and that’s being charitable). Most people starting the Undoctored or Wheat Belly program have no real idea of their thyroid status. Many have been suffering, for years, perhaps decades, with undiagnosed hypo, or at the hands of misguided SoC treatment. Some have even had their thyroids destroyed or removed, perhaps needlessly.

The hypo/hyperthyroid pandemic seems to have multiple causes, including but not limited to:

  • iodine deficiency (covered in Part 1);
  • iodine out-competed by non-native halogen compound exposure;
  • other endocrine disruptors in diet altering thyroid needs,
  • dysbiosis that disrupts the role of bowel flora in thyroid hormone conversion,
  • thyroid being a common target in autoimmunity (itself a product of dysbiosis), and
  • other thyroid diseases, not all optional.

General Information

The need for optimizing thyroid has been part of the program, going back at least a decade, and is extensively discussed in all the books and program materials:
Book: Undoctored: starting page 284 of print edition
Blog: DIY Thyroid (Part 1 of 3, public)
Blog: DIY Thyroid, Part 2: Lab Interpretation (public)
Blog: DIY Thyroid, Part 3: Thyroid Hormone Replacement (public)
Video: Complete Thyroid Testing (members)
Video: Track Oral Temperature on Iodine (members)
Video: Iodine and Autoimmune Thyroid Conditions (members)

Program Thyroid Targets

You have probably had TSH tested at some time, and that number can provide a clue. If you have ever had a “full panel” run, there’s some risk that it was for markers (some not actually measured) that aren’t terribly useful, such as: FTI/T7, T3U/TU, TT3, TT4, TTSI, and additional synthetic markers calculated from those, such as SPINA-GT.

Here are the actually-measured markers found to be of most use.

Test Name Target Range Discussion
fT3: Free T3 or
Triiodothyronine, Free, Serum, CPT Code 84481
Upper half of Reference Range This is the active form of thyroid hormone. Low is hypothyroid (and pervasive). High is hyper. Why it might be out of range requires considering all the markers.
fT4: Free T4 or
Thyroxine, Free, Direct, CPT Code 84439
Upper half of Reference Range This is the storage form of thyroid hormone, theoretically converted to T3 as needed, but that conversion is often abnormal (and why T4-only monotherapy often fails).
TSH: Thyroid Stimulating Hormone (Thyrotropin), CPT Code 84443 0.2 to 1.5 µIU/mL This is actually a pituitary hormone test, but it’s what you usually get, often the only “thyroid” test you get. Consensus Reference Ranges typically run too high (allowing an upper limit of perhaps 2.5, more typically 4.5, but not uncommonly some ancient high number like 10 or 15). Many doctors won’t act until it’s over 10. If a TSH is all you have, and it’s outside the program range, it means you need actual thyroid testing. Note that being in-range for program is not dispositive. TSH can be optimal, yet other thyroid measures are out of range. Get a full panel at least once.
TGab: Thyroglobulin Antibody, CPT Code 86800 Within Reference Range
(and zero is fine)
Get two or more antibody tests at least once. If any are above the RR, that suggests that an autoimmune thyroid condition is active (and it may not be the only AI condition for which you are at risk). This situation needs to be treated as 3 or 4 separate problems:
1. stay at RDA for iodine until cautiously challenged
2. thyroid hormone imbalance
3. active autoimmunity
4. probable dysbiosis
The present page only addresses thyroid hormone re-balancing.
TPOab: Thyroid Peroxidase Antibody, CPT Code 86376
(TBII)/TRAb: TSH-Binding Inhibitor Immunoglobulin / TSH Receptor Antibody, CPT Codes 83520/83519
TSI: Thyroid Stimulating Immunoglobulin, CPT Code 84445
rT3: Reverse T3, CPT Code 84482 Lower half of Reference Range This can get complicated. fT4, when converted in the body, can become fT3 or rT3. When too much becomes rT3, it essentially blocks fT3. So you can have an in-range fT3, yet still have hypothyroid symptoms. The main value in running an rT3 is to discover just how skillful a healthcare provider you are going to need. The question of why your body is making excess rT3 needs investigation.
AM oral temp 97.3°F (36.3°C) or slightly higher. Take it immediately upon awakening, before even getting out of bed. If it’s consistently below this value, suspect hypothyroid. This simple at-home measure can be used to track trends between thyroid labs.

 u21f1_north_west_arrow_to_corner Return to ToC

Test planning

• Can you get your doctor to order the tests you need?
• Does your plan cover those tests?
• Will your doctor correctly interpret the results?
• If out of program range, can you get the treatment you need?
• If you can get an ideal treatment, does your plan cover it?
With far too many consensus doctors, the majority of endocrinologists, too many sickcare plans and drug formularies, the answers are often:
  no, no, no, no and no.

Getting more than a TSH often requires that an adverse diagnosis already be recorded. Treatments other than levothyroxine (T4 only) are often off-formulary for many plans.

If you need to obtain your own testing, is that even possible in your jurisdiction? In nanny states like New York, the answer is yet another:
 no.
It might require medical tourism to work around that.

You need to have a contingency plan for these situations. In particular, you do not want to fight to get a draw ordered, show up for it, and have the lab personnel inform you that one or more tests is not covered, and that there may be a $500 out-of-pocket charge.

On the up-side, if you have a medical set-aside plan, such as a health savings account, or flexible spending plan, you can usually use those funds for off-plan tests and off-formulary prescriptions. But even then, don’t spend more than necessary.

So do your homework before engaging the healthcare system. For example, you might have a doctor supportive of your self-directed healthcare, but who is constrained by policy in ordering tests, yet willing to prescribe optimal meds, but you’ll have to pay out of pocket for them. Prior to a consultation, get the needed tests run, and provide the doc with a copy.

For reference, in the U.S., a complete thyroid panel can be had from Life Extension for between $150 and $265 (depending on sales), with individual tests available for less. A TSH+fT3+fT4 is $56-$100 from L.E., useful as follow-up for dialing-in a treatment. These tests are ordered on-line, fully pre-paid, then scheduled on-line at any convenient LabCorp clinic (no additional charges). Results are emailed (PDF) (but also physically mailed, so be mindful of what address you use).

You may also be able to order tests (without a doctor’s order) directly from various walk-in labs, such as Direct Labs, LabCorp and Health Check USA. For a few thyroid tests, saliva sample-at-home/mail-away kits are available from ZRT Labs, and can be web-ordered from multiple re-sellers.

If your doctor is unsupportive of optimal thyroid health, it’s worth discovering that unhappy fact early in the process. Then see: Finding a Doctor (which includes a key screening question on thyroid).

In general, you can get thyroid testing on your own, if necessary. Precise thyroid diagnosis and effective treatment, on the other hand, requires engaging a healthcare provider with some skill or experience.u21f1_north_west_arrow_to_corner Return to ToC

Testing considerations

Be thoughtful about the time of day for the draw. Due to circadian variation, it helps to be consistent. 10:00 AM might be a reasonable choice, but probably any time near the daily average would do (because anyone looking at the results later is going to be comparing them to population averages).

If you are losing weight, expect thyroid hormone levels to be distorted (fT3 depression in particular). Be cautious about dosing and dose adjustments. It’s still worth getting a baseline assessment. Don’t assume a thyroid HRT dose is “final” until it’s been checked while weight has been stable for at least 30 days, and you’ve been on the program long enough to resolve any dysbiosis.

If you are just starting the Undoctored / Wheat Belly program, any autoimmunity is likely going to be more active now than later, and this could show up in thyroid AI measures. It is likewise still worth getting a baseline assessment. For example, if the AI (’ab) measures are in range, you have a free hand in iodine restoration.

If you are already on thyroid HRT, take your daily dose after the draw.

At least 36 hours before the test, discontinue any biotin supplement, and any multi-vitamin containing biotin, and any hair/nail-focus supplement that may contain undeclared biotin (or list it as vitamin B7, vitamin H, or coenzyme R) The usual assay methods involve biotin-streptavidin attraction, and the supplement can falsely inflate some results, and to a non-trivial extent.

Fasting is usually not a material factor in thyroid testing (up to 18 hours or so), so handle fasting status based on any other tests also being run.

Dosing adjustment re-tests may not need to include the full panel. fT3, fT4 and TSH may suffice for routine testing, where AI is not on the table.

Suggested re-testing intervals vary by diagnosis, marker and treatment agent (as well as weight trend). This is a topic that you need to discuss with your enlightened care provider. It might be as short as 2 weeks for a Cytomel adjustment, or 6 months to see if an AI titer is receding.u21f1_north_west_arrow_to_corner Return to ToC

{Hypo}Thyroid HRT treatment considerations

Correct iodine first

If mild hypothyroid is indicated, and autoimmune thyroid is off the table, there’s some chance that it’s simply iodine deficiency, and that correcting iodine will optimize thyroid in a couple of months. This is always worth following through on before engaging on the challenge of thyroid hormone replacement therapy.

When more than just iodine is needed, it’s usually in the form of natural (animal-sourced) or synthetic thyroid T3 and/or T4 hormones. These are prescription agents in most places.

OTC supplements may be expected to not work

In the US, you can find many thyroid support formulations that hint about containing what you need to complement your endogenous deficiency, but they don’t. If they did, the FDA would require that they be prescription.

T4-only might work

If hypothyroid is frank, and/or did not respond to iodine restoration, your care provider is apt to suggest an initial treatment with levothyroxine (synthetic T4). For some 20% of people with hypo, this can work. This might include cases where both fT4 and fT3 are low. If fT4 was already in-range, however, adding more T4 may trigger side effects even if it does raise fT3 and lower TSH. Caution: if the doctor prescribes brand name Synthroid®, find out why. If generic levo isn’t working…

NDT is usually the answer

Natural Desiccated Thyroid is porcine (pig) or bovine (cow) thyroid extract. This was the go-to treatment historically, prior to the introduction of synthetic T4 (and drug industry promotion of that as “superior”). Apart from formulary issues, many doctors refuse to prescribe anything containing T3, due to lack of experience, and perhaps concerns about reactions and compliance (perhaps a reasonable concern with many non-empowered patients). If you, as an empowered patient, encounter such resistance, find a doctor who will be your advocate.

NDT has the advantage that it contains not just T3 and T4 in what may be nearly ideal proportions for most people, but also other minority forms of thyroid hormones, the value of which is not established. Ancestrally, hunter-gather humans would have consumed game thyroids, possibly deliberately (as is the case for other game organs).

Being animal-sourced is a problem for followers of certain philosophies, so another alternative for T3+T4 treatment is…

Synthetic T3 has its place

This is most commonly known as Cytomel®, liothyronine sodium, a salt of L-triiodothyronine. The ratios of T4:T3 are generally fixed for any particular NDT, so if, for example, T4 is not wanted to go any higher, but T3 is still depressed, adding straight T3 might be considered. Taking a compounded synthetic T4+T3 allows the ratio to be adjusted as required.

Careful dosing and monitoring is required, as T3 is rapidly absorbed, and can have severe side effects if overdosed. Dose adjustment for branded Cytomel®, for example, is to titer by no more than 5 µg every two weeks.

Dial-In and Vigilance

This page (and the Undoctored) program do not provide diagnosis, agent selection, dosing and dial-in details. Apart from regulatory concerns, there are too many diverse scenarios. You need to be working with a supportive healthcare provider with some experience in thyroid. But work to get the numbers optimized — not just “normal” — optimized.

However, don’t just get it dialed-in and then lock it down. Check periodically, particularly if the ailment is autoimmune thyroid (classically Hashimoto’s) and/or there is a dysbiosis situation that is being resolved. As these get resolved, your endogenous thyroid hormone production and conversion is apt to shift, even self-correct, and any thyroid HRT will need adjustment.

AI Thyroid in work

A major presentation of hypothyroid is autoimmune, most commonly Hashimoto’s Thyroiditis. As suggested in the testing table above, this probably needs to be treated as four separate problems:
1. stay at RDA for iodine until cautiously challenged
2. thyroid hormone imbalance
3. active autoimmunity
4. probable dysbiosis
Work on all of these at once. Get the thyroid hormones balanced. Employ existing and emerging program strategies to reverse AI generally. Employ existing and emerging program strategies to optimize gut flora, as the most likely root cause of the AI is a dysbiosis.

There are number of gurus who now specialize in claiming to arrest, if not reverse Hashis. The Undoctored program does not presently suggest that you might expect reversal. The #1-4 list above can be addressed, and the program here would be a solid baseline from which you might cautiously explore anyone else’s Hashi tweaks.

What about Hyperthyroid, thyroidectomy, nodules and cancer?

Graves Disease, nodules, untreated cancer, and other thyroid conditions present wider challenges. Often, TSH will be off-scale low, and fT3/4 off-scale high. The markers could even be erratic and brittle (due to flares). Adding thyroid hormone might well be completely contraindicated in such cases. Thyroid function might even need to be suppressed for a time with agents like PTU.

But the key hormone levels still need to be brought into range. The Undoctored program may resolve the underlying provocations over time. Keep checking. If not, thyroid function may eventually become nil (surely so, if thyroidectomy or radioactive iodine treatment was/is applied). Permanent thyroid HRT will then be necessary.

HRT dose timing

Follow the instructions for the preparation, which might include taking it at least 20 minutes before a meal (Dr. Davis suggests 1 hour, which also generally eliminates supplement interactions as a concern). Mind drug interaction advisories.

Generally, take at the same time of day each day. On arising each day might be ideal.

Some people take some preparations sub-lingually for better absorption.

Some people use a pill splitter and take half in the morning and half in the afternoon.

Dose adjustment

Because thyroid HRT can provoke strong reactions, it is not uncommon to start on a low dose, then adjust it every 6 weeks or so.

This program cannot provide dosing guidance, because individual cases vary so much, and IU/mg response rates don’t appear to be well established. Also, dosing and dosing increments vary by preparation.

Prognosis

Will you need to take thyroid hormone indefinitely? Perhaps not (for example, if the problem was simple iodine deficiency). For other scenarios, forum members can consider the conjectures in comments later in this thread.u21f1_north_west_arrow_to_corner Return to ToC


Standard of Don’t Care in Thyroid

This is not some obscure worst-case-scenario that you need be on watch for when the diplomas in the waiting room are obviously forged. This is the all-too-common consensus scenario, still playing out, every day, in the offices of PCPs and supposed specialists. This scandal gave rise to web sites like StopTheThyroidMadness (circa 2002, and see footnote), and continues to provoke about one new thyroid outrage book per year, written by both healthcare professionals and lay people who finally got fed up.

The point of including it here is not so that you expect it, but so that you are not shocked into despondency and inaction if it happens. For forum members, the first reply comment on this thread includes additional known work-arounds where your SoC situation is found to be completely hostile.

  1. Expect the PCP to fail to proactively look for or inquire about strongly suggestive symptoms of thyroid disorder, until they become flagrant.
  2. Don’t expect thyroid testing per se. Pituitary testing (TSH) is likely to be all that’s offered (or covered). If you ask for additional tests, don’t be surprised to be demeaned and have rank pulled (EBM: eminence based medicine).
  3. If you manage to get a “full panel”, don’t be surprised if it’s FTI, T3U, TT3, TT4 and TTSI, instead of the informative fT3, fT4, rT3, TPOab and TGab.
  4. Expect your TSH to be assessed per outdated guidelines for upper TSH limit, perhaps as high as 10µIU/mL. Don’t be surprised by a pronouncement of “normal” when well above the program target, if not actually above whatever limit was used.
  5. If you insist on treatment, expect T4 only, perhaps, suspiciously, even brand name Synthroid®.
  6. Expect dose adjustment based on TSH, perhaps TT4, but possibly fT4. Either of the T4 tests will conveniently measure only what’s being prescribed, and not the downstream fT3 and rT3 that actually matter.
  7. When multiple rounds of fruitless T4 dose adjustments result in zero progress, then physical and psychological misery, and this is not hyperbole, expect a prescription for a mood-altering medication. Plan to need to treat a whole new set of side effects from that.
  8. If this looks like zero net progress on your thyroid, and a net regression of overall health, that’s because that’s exactly what it is.

The above is for typical hypothyroid. Hyperthyroid has its own horror scenarios, often leading to your thyroid being literally nuked, or surgically extracted — too often needlessly — after which expect the T4-only trap.u21f1_north_west_arrow_to_corner Return to ToC


STTM: This site contains a wealth of useful thyroid information (mostly hypo), but that may not include their advice on iodine intake, which tends toward megadose.

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Bob Niland

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Posted: 6/6/2018 9:07:32 AM
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Posted: 6/6/2018 1:34:40 PM
 
Would it be too much to ask what are any obvious symptoms of thyroid issues, outside of the labs?
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Posted: 6/6/2018 1:55:22 PM
 
Bob:

Great job on your thyroid/iodine guides.
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Bob Niland

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Posted: 6/14/2018 2:03:42 PM
 
That’s great, Bob! 

And there’s always International Antiaging Systems that carries both Armour thyroid and Naturethroid available without prescription. 


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