A Pharmacist’s Review of Medications for Hashimoto’s and Hypothyroidism

For those with Hashimoto’s, optimizing thyroid hormones is one of the keys to feeling our best, while we work to remove the underlying triggers (such as nutrient deficiencies, stress and infections) that caused and/or are worsening the autoimmune component of the condition.

The right thyroid hormone medication can reduce thyroid antibodies and slow down the progressive thyroid destruction, as well as provide the energy needed to continue to work towards one’s health. Thyroid hormone medications can also reduce the size of thyroid goiters and nodules, as well as reduce the likelihood of thyroid cancer.

That said, thyroid hormone medications are very individualized! What works for your friend may not be your best option, leaving you with lingering symptoms such as fatigue, anxiety, brain fog, and excess weight. And just because your doctor may be most familiar and comfortable with prescribing one particular type of thyroid hormone medication, doesn’t mean you should settle for his/her preferred medication if that particular prescription just isn’t working for you.

As a pharmacist, I want to empower you to be your own best thyroid advocate. Taking the right thyroid hormone medication for you can be a game changer for how you feel and progress. But how do you know which medication might be best for you?

Read on to learn more about:

• A review of the available thyroid hormone options
• How to get the best results from your current medications
• How to improve your T4 to T3 conversion
• How to switch medications, if you need to

Medications to Balance Thyroid Hormones

Choosing the best medications starts with an understanding of our symptoms and labs.

While our symptoms can provide a clue that something is off, our labs can tell us if the reason we’re feeling unwell could be due to our medications. Labs will provide information on whether we are absorbing our medications, whether we are on a correct dose of medications, as well as whether our body has issues converting T4 to T3 (meaning a T4-only medication may not be optimal and/or we may need to address the conversion issues — more on that in this article).

All too often, conventional doctors simply test one’s TSH (thyroid stimulating hormone) and T4 levels (the amount of thyroid hormone circulating in your blood). However, TSH is a pituitary hormone, and doesn’t tell us what level of hormones we have available to use within the rest of the body.

For this reason, it’s important to have a full thyroid panel done, which will also help you and your practitioner determine the appropriate medication for you.

A full thyroid panel checks one’s TSH, free T4, free T3, and thyroid antibody levels.

• TSH: The thyroid stimulating hormone, or TSH test, is used as a screening test for thyroid disease, as well as a test for monitoring the correct dose of medication needed for an individual. TSH is elevated in cases of hypothyroidism. While conventional practitioners may have lax reference ranges, functional medicine practitioners have further defined the optimal reference range in which most patients will feel their best.
  • Recommended test: TSH
  • Optimal reference range: between 0.5-2 μIU/mL

• Free T4 & Free T3: T4 (thyroxine) and T3 (triiodothyronine) are the two main thyroid hormones. Some clinicians may only test for T4, but both are important to test for and should be in the optimal ranges. If the T4 is optimal, but the T3 is out of the optimal range, you know that your body is not making enough T3 hormone from the T4. It is important to monitor your T4 and T3 levels when adjusting your thyroid medications.
  • Recommended test: Free T3 and Free T4
  • Optimal T4 reference range: 15-23 pmol/L
  • Optimal T3 reference range: 5-7 pmol/L

• Reverse T3: The reverse T3 (rT3) test measures how much of the free active T3 is able to bind at thyroid receptors. RT3 is produced in stressful situations and binds to thyroid receptors, but turns them off instead of activating them. The rT3 test is sometimes used to identify cases of poor T4 to T3 conversion, as well as thyroid symptoms that are due to adrenal stress, instead of thyroid malfunction or autoimmunity.
  • Recommended tests: Reverse T3 (rT3)
  • Optimal rT3 reference range: 11-18 ng/dl

• Thyroid Antibodies (TPO, TG): The presence of thyroid antibodies indicates that the thyroid gland has been recognized as a foreign invader by the immune system and that the thyroid gland is under attack. Up to 95 percent of people with Hashimoto’s will present with elevated thyroid antibodies. However, they can be reduced as we work to address the root causes of the autoimmunity behind Hashimoto’s.
  • Recommended tests: TPO, TG
  • Optimal TPO reference range: <2 IU/mL
  • Optimal TG reference range: <2 IU/mL

For a detailed discussion and guidance on understanding your thyroid labs, please visit my article Top 10 Thyroid Tests and How To Interpret Them.

Symptoms or Thyroid Hormone Medication Side Effects

I put symptoms and side effects for all thyroid medications in the same category. This is because side effects of most thyroid hormones are primarily due to overmedication or inadequate doses of medication. That said, some individuals can have additional reactions to the fillers in the various medications.

Overmedication can cause hyperthyroidism due to therapeutic overdose. (Symptoms may include rapid or irregular heartbeat, nervousness, irritability or mood swings, muscle weakness or tremors, diarrhea, menstrual irregularities, hair loss, weight loss, insomnia, chest pain, and excessive sweating.) The cardiovascular and central nervous system effects are particularly serious. It’s important when starting medications (and while your doctor is finding the right dose for you) that you report all symptoms and have your labs repeated every four to eight weeks, or more often, if you have any of the above symptoms.

When not enough hormone is provided, people may continue to experience symptoms of hypothyroidism such as heavy menses, hair loss, dry skin, loss of eyebrow hair, infertility, constipation, slowed digestion, joint pain, depression, brain fog, fatigue, weight gain, and even miscarriages.

See the image below for the consequences of hypothyroidism and hyperthyroidism.

Safety

Thyroid medications are generally well tolerated and safe for those with hypothyroidism. However, there are some precautions for certain populations.

First and foremost, thyroid hormones should only be used for those with hypothyroidism, not for people with normal thyroid function who are wanting to lose weight.

Additionally, those with adrenal insufficiency due to Addison’s disease, should not start thyroid hormones for hypothyroidism until their condition has been well controlled. People with Addison’s disease can have low levels of cortisol, and thyroid hormones can increase how quickly they are removed from the body, leading to a dangerous situation.

In older individuals and those with cardiac issues, thyroid hormones need to be started at a lower dose, and increased slowly, as well as monitored frequently.

All thyroid medications have precautions relating to many different underlying health conditions. You will want to review your particular health situation with your practitioner and have them review any potential concerns with you.

Additionally, most thyroid medications react with other medications and may require you to space them apart when taking them.

Thyroid medications are generally safe for most women during pregnancy and while breastfeeding (they are considered category A, which is the safest category). Taking them can help prevent miscarriage, infertility issues, and even developmental disabilities. (Note: Most women will need to increase their dosage in the first trimester. If you’re planning a pregnancy, you may also need to increase your dosage; you’ll want to have your labs rechecked and work with your doctor to determine what is best for you and your baby.)

Dosing Considerations

You’ll want to have your full thyroid panel measured before and during dose titration trials. While trying to get on the right dosage of medication, you will want to test your thyroid labs every four to six weeks. Once you’re symptom-free, and if you’re stabilized on your new thyroid medications, every three months to one year may then be appropriate for testing and monitoring your thyroid levels.

Generally, the rule of thumb I like to consider is that if your TSH is elevated, and you have thyroid symptoms, you may benefit from starting thyroid medications.

If you are already on thyroid medications, and have levels of TSH, T3 and/or T4 outside of the optimal ranges, you may benefit from further tweaking or optimizing how you take your medications, as well as considering a dose increase/decrease and/or medication change, depending on the circumstances.

Choosing Your Best Medication 

Choosing your best medication also requires a little self-assessment.

1. Do you have food sensitivities to gluten, lactose or other ingredients such as corn or grains (which are often found in thyroid meds)?
2. Do you take medications for stomach acid issues (acid blockers don’t play well with many thyroid meds)? Do you have gastrointestinal or liver concerns?
3. Do you have a morning habit that prevents you from absorbing most thyroid medications? (Some medications need to be taken away from breakfast, other supplements and coffee. I’ve been personally guilty of the latter, courtesy of #mamalife, so no judgement here.) All of these can impact how well you consistently absorb your particular thyroid hormone medication, which will directly impact its effectiveness.
4. Do you have low ferritin, a selenium or zinc deficiency, or gene variations in your deiodinase genes that may prevent you from properly converting T4 to T3?

Overview of Thyroid Hormone Medication Options 

Medication options to balance thyroid hormones include:

• T4-only medications
  • Generic levothyroxine tablets
  • Synthroid tablets
  • Levoxyl tablets
  • Tirosint gel caps
  • Tirosint liquid (Tirosint SOL)
  • Compounded T4 medications
• T3-only medications
  • Liothyronine
  • Cytomel
  • Compounded T3 medications
• T4/T3 combination medications
  • WP Thyroid (Note: This medication has been unavailable since 2021, following a voluntary recall in 2020)
  • Nature-Throid (Note: This medication has been unavailable since 2021, following a voluntary recall in 2020)
  • Armour Thyroid
  • Compounded T4/T3 medications

To better understand the differences in these available thyroid medications, we need to briefly talk about a few of the thyroid hormones we have in our body. The three hormones I’ll primarily talk about in this article are T3, T4, and TSH.

Triiodothyronine (T3) is our primary biologically active thyroid hormone. About 20 percent of our T3 hormone comes from thyroid secretion directly, while the remaining 80 percent is produced when Thyroxine (T4) is naturally converted to T3 within our bodies. While T4 is 300 percent less biologically active than T3, it is critical to our body’s ability to produce adequate and healthy levels of the needed T3.

It is the low levels of T3 and T4 that signal the release of thyroid stimulating hormone (TSH). When TSH remains too high, we know we have hypothyroidism, and that is the conventional measure that many doctors solely look at.

On the opposite end of the spectrum, continued high levels of circulating T3 and T4 stop the release of TSH. When TSH remains too low, we suspect a hyperthyroid problem.

In people with normal thyroid function, TSH levels still often fluctuate (such as in cases of pregnancy, illness, diabetes, other underlying conditions, chronic stress, or nutrient deficiencies).

Most conventional doctors will prescribe synthetic T4 medications, so many people are only familiar with T4-containing thyroid medications tablets such as levothyroxine (generic), Synthroid®, Levoxyl®.

However, there are additional, lesser known T4 formulations such as Tirosint® gel caps, Tirosint®-SOL liquid and compounded T4 capsules, that may lead to better outcomes for some individuals.

Additionally, there are T3-only medications such as liothyronine (generic), Cytomel®, and compounded T3, which offer the more active thyroid hormone, T3, to be taken directly.

Last but not least, there are combination T4/T3 medications which can be naturally derived from the thyroid glands of animals, often referred to as Natural Desiccated Thyroid (NDT) medications (examples being Armour® Thyroid, Nature-Throid®, and WP Thyroid®), as well as versions of T4 and T3 that are compounded by compounding pharmacists. Thyrolar, a manufactured synthetic version of T4/T3, was previously available in the United States. However, it has been on long term back-order since 2013.

Let’s look at how these medications are different and who might be best served by the different types. We’ll start with one of the most prescribed drugs in the United States, the generic T4 medication levothyroxine.

T4 Medications (Levothyroxine)

As there are various manufacturers and dosage forms of T4 medications, I’m going to focus on the guidelines that apply to all T4 medications first, and then I will go into differences between the various versions of levothyroxine.

Description: Levothyroxine is the generic name of a synthetic version of the thyroid hormone Thyroxine, referred to as T4.

In an extensive survey done in 2014 (and published in 2018), it was the second most prescribed drug in the United States. It is among the most widely prescribed medications in the world.

When a drug becomes “generic,” this means that the pharmaceutical formulation has lost its patent, and this allows many manufacturers to make it, instead of just one pharmaceutical manufacturer having exclusive rights to it.

Various pharmaceutical companies offer their own versions of levothyroxine tablets under specific brand names, including: Synthroid®, Levothroid®, Levoxyl®, Unithroid® and Thyro-Tabs® (in the United States), Eltroxin® (in Canada), Euthyrox® (in the EU), and Oroxine® or Eutroxsig® (in Australia).

Levothyroxine is also available as Tirosint® gel caps, Tirosint®-SOL liquid, as well as compounded T4 capsules.

Dose: T4-containing medications are usually started at a dose of 25-50 mcg per day. The medications are then adjusted to the target dose by 25 mcg per day, every four to six weeks, depending on the person’s thyroid function tests and symp­toms.

The maximum recommended dose is 300 mcg/day. Most negative side effects have to do with incorrect dosage (this is true of all thyroid hormone meds, as I mentioned at the beginning of this article). It is important to start low and go slow for that reason. Your practitioner should work with you and adjust the starting dose to best fit your particular health profile.

Pros: As a well-established prescription medication that is off-patent, levothyroxine is a low cost option and is typically well tolerated by most patients. Most conventional doctors are most familiar with and will prescribe T4 medications, and many people will do well on them once they are on the correct dose.

Potential Cons: There is one main issue that applies to all types of T4-only medications (whether branded, generic, gel cap, or liquid), and this has to do with the fact that T4 is a prodrug, and needs to be converted to T3, the more active thyroid hormone in the body. This reaction doesn’t happen equally in every person, and thus some are not able to adequately convert T4 to T3 within their body. This can result in inadequate treatment and ongoing symptoms.

Some Patients Feel T4 Medications Often Result in Inadequate Treatment

While many people do very well on T4-containing medications once they are dosed appropriately and stabilized, a 2019 review of the research found that many people taking T4 medications simply aren’t happy with their results, and that more than a third of patients remain inadequately treated (based on labs and symptoms) despite levothyroxine therapy. In particular, 5-10 percent of people taking T4 replacement – even if they normalize their TSH level – are found to have impaired psychological well-being, anxiety, or depression.

As a pharmacist, I would ask the following questions in this situation.

1. Is your TSH normal, but not optimal? Most people feel best with a TSH between 0.5-2 μIU/mL, so you may need a dose adjustment.
2. Is your TSH inconsistent and/or fluctuating? If so, you may not be absorbing your medications due to fillers, GI issues, or interference from foods, medications, and supplements. (See below.)
3. Are your levels of T3 and reverse T3 optimal? If not, you may want to look at conversion issues. In those taking T4, we can work on optimizing your conversion and/or consider a therapy that includes both T3 and T4.
4. Do you have root causes (like adrenal issues!) that need to be addressed?

Unresolved Root Causes Can Keep Us Symptomatic

One reason we may not have a 100 percent response to levothyroxine is because levothyroxine does not address the underlying root causes of the condition, which can contribute to other remaining symptoms. I’ve written extensively about root causes in other articles, and the importance of not just taking medications but working on our overall health through lifestyle changes and root cause medicine, so to keep this article from being a whole ‘nother book, I’ll focus on the pharmacology related issues. 🙂

T4 to T3 Conversion Issues

An important reason why some individuals may not have a full therapeutic response to T4-only thyroid hormones (even when dosed and taken correctly), can be due to the person’s ability to convert T4 to T3, so let’s talk more about that. (This is not just specific to the generic version of levothyroxine, by the way. It applies to all T4 medications.)

This is because levothyroxine contains the less-active but longer-acting T4 hormone. The T4 molecule is considered a prohormone, as it is less physiologically active than T3 and needs to be converted to T3, the more active thyroid hormone, by our bodies. T3 is sometimes called our “go” hormone because it tells our body to boost metabolism, grow hair, and create more energy.

In 2014, Dr. Wilmar Wiersinga, a Dutch endocrinologist and top thyroid researcher, stated that: “Impaired psychological well-being, depression or anxiety are observed in 5-10 percent of hypothyroid patients receiving levothyroxine, despite normal TSH levels. Such complaints might hypothetically be related to increased free T4 and decreased free T3 serum concentrations, which result in the abnormally low free T4/free T3 ratios observed in 30 percent of patients on levothyroxine. Evidence is mounting that levothyroxine (T4) monotherapy cannot assure a euthyroid state in all tissues simultaneously, and that normal serum TSH levels in patients receiving levothyroxine reflect pituitary euthyroidism alone.” In other words, this study suggested that T4-only therapy might not be enough to address the symptoms of hypothyroid patients, especially those related to mental well-being.

Some people have challenges taking a T4 medication, as they aren’t able to properly convert T4 to T3. This improper conversion can result in lingering thyroid symptoms or even new ones. The conversion from T4 to T3 can be impeded by numerous factors, including nutrient deficiencies, stress, infections, and impaired liver and gut activity.

Furthermore, in recent years, pharmacogenomics (the study of how a person’s genes impacts their response to medications) has helped us determine which patients may best benefit from particular medication due to their unique genes. From a pharmacogenomic standpoint, polymorphisms (variations) in the DIO2 deiodinase gene, which codes for the deiodinase 2 enzyme (Thr92Ala), can also lead to inadequate conversion of T4 to T3.

The thyroid gland plays a minor role in the daily production of T3, with the bulk of it being produced by two deiodinase genes (D1 and D2) that convert T4 to T3 outside the thyroid tissue. Thus, variations in these genes can impact how well the body is able to produce T3. Studies have shown that hypothyroid patients maintained on levothyroxine, depend on D2 for more than 80 percent of all their T3 needs. Thus, they are at much greater risk to develop low serum T3 during caloric restriction when the body acts to limit caloric expenditure, and temporarily slows metabolic function.

In one study suggesting a genetic link to poor ability to convert T4 to T3, a polymorphism in the DIO2 gene was found to be linked to who will or won’t respond well to T4 therapy (due to how well their body converted T4 to T3). Findings, however, are still viewed as controversial, and more studies are required.

If you have challenges converting T4 to T3, you might want to consider a genetic test with Nutrition Genome.

Other potential factors impacting T4 to T3 conversion include:

• Aging
• Alcohol
• Chemotherapy
• Cigarettes
• Deiodinase gene variation
• Diabetes
• Fasting
• Growth hormone deficiency
• Heavy metals
• Iodine excess
• Kidney and liver disease
• Liver backlog
• Low ferritin
• Low progesterone
• Medications
• Nutrient depletions
• Obesity
• Pesticides
• Radiation
• Stress
• Soy
• Surgery

As you can see from the graphic, a lot of the reasons people have poor conversion are also common triggers for Hashimoto’s. I believe this is one reason many of my clients do not do well on T4-only medications.

How to Make Your T4 Medications Work for You

There are a few steps that you can take to ensure that you are getting the most out of your T4 thyroid medications so that they work optimally for you.

1. Ensure ferritin is optimized: As mentioned earlier, T3 is sometimes called our “go” hormone because it tells our body to boost metabolism, grow hair, and create more energy. Without proper levels of ferritin (the iron storage hormone), the conversion of T4 to T3 can be impeded.

2. Support your adrenals: Stress is another common cause of low T4 to T3 conversion. Under stressful situations, T4 gets converted to reverse T3 instead of T3. Reverse T3 is an inactive molecule related to T3, but without any physiological activity. (It essentially just takes up space!) In the case where a lot of reverse T3 is produced, adding a combination product that contains T3 will help ensure that the right hormone is getting to the right receptors.

3. Support your liver: Most T4 to T3 conversion takes place in the liver, and when the liver is impaired, usually due to an accumulation of toxins or lack of nutrient absorption, we are unable to complete the process. Oftentimes, focusing on a liver support protocol, which includes eliminating food sensitivities, removing environmental toxins, and adding in supportive nutrients, can improve T3 levels.

4. Consider supplementing with zinc and selenium, which support the conversion of T4 to T3. Thyroxine (T4) is produced by the thyroid gland in ample amounts, but is relatively biologically inactive. Therefore, triiodothyronine (T3), the biologically active thyroid hormone, must be produced by a hormone conversion process, converting T4 to T3. The antioxidant selenium is required during this conversion process, its role being to neutralize the toxic build-up of hydrogen peroxide (H2O2) which is produced as a by-product of the hormone conversion.

A depletion in zinc also prevents the conversion of the T4 hormone into the active T3 version. This could lead to symptoms like hair loss, fatigue, and weight gain, even while taking thyroid medications like Synthroid.

Check out the articles linked above to learn more about supplements to optimize selenium and zinc levels.

5. Consider taking probiotics. We know that everyone with Hashimoto’s (and autoimmune conditions in general) have some degree of intestinal permeability. Given that about 20 percent of the conversion of T4 to T3 takes place in the gut, improving gut health can help with the conversion process and improve T3 levels. For many, the problem lies in the imbalance of beneficial to opportunistic bacteria in the gut microbiome, and getting a quality probiotic on board can help improve gut health and increase T3 levels.

But what if you find yourself needing to tweak your T4 medication (multiple times!), or you continue to experience symptoms or poor lab results? You may want to consider adding a T3 medication or switching to a combination T4/T3 medication instead, to address the conversion issue.

This underlying conversion issue also points to why using only a person’s TSH level (the conventional measure typically used) to determine how well their medication is working for them, is not truly reflective of what is going on with their thyroid health. A full thyroid lab panel is needed. When lab results come back showing that free T3 is below or within the low end of the reference range, while free T4 is above the reference range or in the optimal upper part of the reference range, this suggests that the individual might be dealing with impaired conversion. It is so important to know.

Beyond optimizing conversion, some individuals may benefit from switching to T4/T3 medications. Of the readers I’ve surveyed, up to 60 percent have felt better taking a combination T4/T3 medication, while around 40 percent have felt better on a synthetic T4 medication.  I used to routinely recommend T4/T3 medications for my clients, however, three of the four available brands have recently been recalled in the United States. We will discuss T4/T3 medications later in this article, including the options that are still available.

Last but not least, people may have suboptimal results to T4 medications due to inconsistent absorption. Let’s talk about this next.

Strict Adherence Required for Consistent Absorption and Effectiveness

Studies (and my own clinical observations) have found that many people don’t adhere to thyroid medication usage guidelines. They won’t take it on an empty stomach (an hour before breakfast), and they’ll take it with their morning coffee or their acid reflux medication, without the required wait time. All of this can impact their medication’s absorption and its effectiveness. If adherence is an issue for you, the best T4 medication might be the hypoallergenic T4 medication, Tirosint, which I’ll talk about in a moment.

I am always a bit dismayed to hear from people that they did not know about the impact on their medication’s effectiveness by not following these basic guidelines, but research has found that ingesting food with T4 medication (tablets) decreases its absorption from approximately 80 percent to 40 percent. Coffee impacts absorption, too. It’s all about the gastric pH level and how foods, drinks and medications (including acid reflux/acid blocking medications) reduce the acid levels within the gastrointestinal system. Without this acidity, tablets take longer to break down, and there are direct effects on absorption that occur.

Thyroid medications have a narrow therapeutic index, meaning that they are “goldilocks” hormones, and careful dose titration is needed to get things “just right.” Doses that are incorrect by just a tiny amount can result in symptoms from over-treatment or under-treatment. So the above issues (generics’ potency differences, fillers, drinking coffee when taking your medicine or popping meds for acid reflux) can all result in ineffective thyroid treatment.

In order to overcome the absorption issues, I recommend the following:

• Follow guidelines. Take your medication consistently at the same time each day with a glass of water, 30 minutes before having food, coffee and other medications or supplements. Avoid magnesium, calcium, and iron supplementation within four hours of taking thyroid medication. Taking your medication with lemon water may help with absorption.
• Consider Tirosint and Tirosint SOL — these formulations can be taken with food and even coffee! (More on Tirosint options further on in this article… keep reading!)

Adverse Reactions and Medication Ineffectiveness Due to Fillers

I have found that some of my clients experience sensitivities and adverse reactions to the many inactive ingredients or fillers found in their T4 medications. These are added as bulking agents used to stabilize the tablets, as coloring agents, as preservatives, or to aid in the manufacturing process in some way. Many have been shown to potentially cause adverse reactions, as well as affect the absorption rate and effectiveness of the very medication meant to help the thyroid.

Most generic levothyroxine products contain lactose (the generic manufactured by Mylan is, however, lactose-free) and not all are gluten-free (examples: Lannet does not contain gluten, per se, but the maker does not certify it as gluten-free; Mylan does certify their product as gluten-free).

Can small amounts of these types of fillers really be problematic? Yes! Many people with Hashimoto’s have sensitivities to these ingredients no matter how small the exposure. In my 2015 survey of 2,232 readers, 57 percent of respondents said they reacted to or avoided all dairy, and over 75 percent avoided gluten due to sensitivities and reactions. Other fillers that are commonly found in T4 medications may include confectioners’ sugar (contains corn starch, and corn is another food sensitivity for many people with Hashimoto’s), sucrose, talc, and dyes. Why would we want these inactive filler ingredients in our thyroid medication?

If you are following all of the “absorption rules” but still having fluctuations in your TSH and symptoms such as anxiety, you may be reacting to the fillers in your medications. Fillers can cause malabsorption of the medications as well as digestive symptoms. In my experience, reactions to fillers are more common in those with liver congestion, food sensitivities, celiac disease, H. pylori, SIBO, parasites, and other root causes. 

• You can look up the latest and greatest on medication fillers at glutenfreedrugs.com (this info actually changes frequently, so it is worth checking) to ensure that your medications are gluten-free and free of fillers that may be reactive for you.
• Alternately, consider switching to Tirosint and Tirosint SOL — these formulations have minimal fillers.

Potency and Ingredient Inconsistency with Generic T4 (Unbranded) Versions

While generic availability is a positive thing because it reduces the cost of most medications, with medications that have a narrow therapeutic index, like thyroid hormones, generic versions open up the door for inconsistent thyroid hormone levels with every refill.

This is because the dosages and fillers may vary ever so slightly between each manufacturer. Different pharmacies may dispense different manufacturers, and even the same pharmacy may switch between manufacturers from month to month. For patients taking generic thyroid hormones, it’s important to note the name of the manufacturer as well as request that their refills be filled with that particular manufacturer’s version of levothyroxine. While most pharmacists and physicians actually recommend keeping on T4 hormones made by the same manufacturers (instead of switching between brands), this doesn’t always happen in the real world.

Generic prescriptions suffer from a potential potency and ingredient inconsistency issue as a result of having multiple manufacturers providing the drug to the same pharmacy. The U.S. Food and Drug Administration (FDA) requires the potency of all thyroid hormone medications to fall within a range of 95 to 105 percent, but different manufacturers can pick what potency within that range they will provide. Different makers also include different fillers.

This can result in issues when it comes to taking a generic, as you don’t know which manufacturer (what potency and what inactive ingredients) you might be getting with each refill. With one refill, you may get a pill at 95 percent potency, and the next time, due to it originating from a different manufacturer, you might get pills at 105 percent potency. This can affect the consistency of how much thyroid hormone you are getting (and absorbing), which can affect both your symptoms and your labs. Additionally, with one refill, you may be getting a filler that is reactive in your body and prevents proper absorption. 

However, brand name prescriptions are manufactured by only the branded maker (like Synthroid), so you will always get the same potency and the same inactive ingredients with each refill of brand medication.

We know that even small differences in dose and absorption levels may lead to adverse reactions and even therapeutic failure. The American Association of Clinical Endocrinologists, the Endocrine Society, and the American Thyroid Association (ATA) recommend the consistent use of a single preparation of brand-name levothyroxine over generic preparations for this reason.

How to Overcome:

• One way to overcome this issue is to note the manufacturer of your levothyroxine and insist that your pharmacy only use this manufacturer for all of your refills. Then, verify that the correct manufacturer was indeed dispensed when you pick up your prescription. I generally recommend sticking to one pharmacy for all of your prescriptions, to ensure your drug interactions are properly monitored; and as long as your pharmacy is able to continue providing the same manufacturer of levothyroxine to you, you will want to continue getting your refills there.
• If needing to switch pharmacies, you will also need to inquire that the new pharmacy can order the levothyroxine made by the same manufacturer you have been using.

Branded Versions of Levothyroxine

There are various branded versions of levothyroxine tablets, and each one has slight differences in absorption and fillers. The main takeaway from this section is that if you feel well on one particular brand, you will want to stick with it. If you feel unwell on that brand, you may want to consider adjusting your dose or how you take the medicine, or consider switching to a different version of levothyroxine (which may be available in tablets, gel caps, or liquid formats).

Synthroid

Description: Synthroid is a branded version of levothyroxine and is the most common­ly prescribed medication for hypothyroidism. In 2013, Synthroid was the number one prescribed drug overall in the United States.

In my reader’s survey, some 43 percent of respondents said they felt better on Synthroid. Additionally, Synthroid results were the best (of other T4 medications) for improvements in labs, with 69 percent experiencing improvements in their labs when taking Synthroid. Another 52 percent saw improvements in energy, 27 percent saw improvements in hair loss, and 40 percent saw improvements in mood.

Differences between generic (levothyroxine) and Synthroid:

The earlier concerns relating to the issue with fillers, the need for adherence to usage guidelines, and the potential ineffectiveness due to poor T4/T3 conversion, apply to Synthroid as well. Conventional doctors will be very familiar with this top branded medication.

Pros:

• Branded drugs like Synthroid, unlike the generic levothyroxine, do not vary in potency or fillers, as they come from a single manufacturer.
• It appears to be gluten-free, according to the Gluten Free Drugs website.

Potential Cons:

• It is more expensive than the generic version.
• Synthroid’s fillers contain lactose, which may cause some people to experience absorption challenges (especially those with dairy sensitivities, lactose intolerance, or lactose allergies).
• Synthroid is not certified as gluten-free. I have heard from multiple patients with Hashimoto’s and/or celiac disease, who were adhering to a gluten-free diet, that they have had simi­lar symptoms to gluten exposure when taking Synthroid. I actually put in a request to the maker of Synthroid (Abbvie) to resolve this issue back in 2016.
• Synthroid does contain other fillers (on top of lactose) which may trigger a negative response, including confectioners’ sugar (contains corn starch), magnesium stearate, talc, povidone, and color additives.

Levoxyl

Description: Levoxyl is another branded version of levothyroxine.

In my reader’s survey, 25 percent of respondents said they felt better on Levoxyl, with 63 percent experiencing improvements in their labs. Another 55 percent saw improvements in energy, 27 percent improvements in hair loss, and 42 percent improvements in mood.

Differences between generic (levothyroxine) and Levoxyl:

The earlier concerns relating to the issue with fillers, the need for adherence to usage guidelines, and the potential ineffectiveness due to poor T4/T3 conversion, apply to this branded drug as well. Conventional docs will be familiar with this branded medication.

Pros:

• Unlike the generic levothyroxine, branded drugs like Levoxyl do not vary in potency or fillers, as they come from a single manufacturer .
• Levoxyl is lactose-free.
• It is gluten-free (but not certified).

Potential Cons:

• It is more expensive than the generic version.
• Levoxyl contains five inactive ingredients, including an antacid (which we know can impact the medication’s absorption!). Any of these fillers can cause adverse reactions in people who are sensitive.
• It is not certified as being gluten-free.

Tirosint – Levothyroxine Gel Caps

Description: Tirosint is a newer thyroid medication that is a hypo-allergenic version of levothyroxine. I recently wrote an entire article focused on Tirosint. In my survey, 26 percent of respondents said they felt better taking Tirosint. Out of those that switched to Tirosint gel caps (this was the only form available in 2015; recently, the maker introduced a liquid version as well, which contains just three hypoallergenic ingredients: levothyroxine, glycerol, and water), 68 percent saw an improvement in their labs, 62 percent saw an improvement in energy levels, 32 percent an improvement in hair loss, and 50 percent saw an improvement in mood.

Because of how quickly and consistently Tirosint is absorbed, it has also been found to be a better option for people who have certain gastrointestinal challenges (including infections like H. pylori and SIBO, both common triggers for people with Hashimoto’s), who are taking antacids/acid blockers/PPIs, or who are otherwise experiencing low stomach acid.

Dose: Tirosint gel caps are available in 12 different dosage strengths, ranging from a 13 mcg dose to a 200 mcg dose. Because this medication is more readily absorbed than other forms of levothyroxine, some people may find that they require a smaller dosage of Tirosint to keep thyroid hormones within optimal range.

Pros:

• As a branded medication, there are no potency or filler variations.
• Tirosint contains no gluten, lactose, or reactive fillers.
• It has been shown to be consistently absorbed by people with co-occurring digestive and gastrointestinal conditions (including H. pylori infections, celiac disease, other gastric pH-related issues, and malabsorption issues such as IBS), with patients gaining significant symptom improvements.
• Tirosint minimizes negative absorption effects relating to a person taking medications such as PPIs for GERD/acid reflux, even with their thyroid medication.
• It may be better absorbed, even when taken with a morning cup of coffee. Studies have shown that Tirosint is better absorbed with coffee compared to other forms of T4. In fact, new research has found that gel caps and liquid forms are unaffected when taken with coffee (unlike tablet formulations). For some people, it may be better absorbed than other forms of levothyroxine when taken with breakfast.

Potential Cons:

Just like with all T4 medications, the effectiveness of Tirosint may be impacted if a given individual is experiencing poor T4/T3 conversion. Here are some additional things to consider:

• As a newer and branded drug, it carries a higher cost, which means some insurance companies may penalize patients with a higher copay, while others may not pay for it at all (although the manufacturer offers a variety of programs to help with that — read more about that here).
• Conventional doctors may not be familiar with or have limited experience prescribing Tirosint, and may be reluctant to do so.

Tirosint-SOL – Levothyroxine Liquid

Description: Tirosint-SOL is a liquid form of Tirosint gel caps and only contains two inactive ingredients (glycerol and water). While the original Tirosint formula is considered to be hypoallergenic, having even fewer ingredients makes for a great T4-only option for those who may have difficulty swallowing pills or who may be allergic to the porcine in the gel caps.

Dose: Tirosint-SOL is packaged in monodose ampules in 12 different dosage strengths, including a 13 mcg/mL dose. It can be administered either directly into the mouth or diluted in a glass of water.

Pros: As a branded medication, there are no potency or filler variations.

• Tirosint-SOL contains the fewest fillers of all thyroid medications on the market.
• It has been shown to be consistently absorbed by people with co-occurring digestive and gastrointestinal conditions (including H. pylori infections, celiac disease, other gastric pH-related issues, and malabsorption issues such as IBS), with patients gaining significant symptom improvements.
• Tirosint-SOL minimizes negative absorption effects relating to a person taking medications such as PPIs for GERD/acid reflux, even with their thyroid medication.
• It may be better absorbed, even when taken with a morning cup of coffee. Studies have shown that Tirosint is better absorbed with coffee compared to other forms of T4. In fact, new research has found that gel caps and liquid forms are unaffected when taken with coffee (unlike tablet formulations). For some people, it may be better absorbed than other forms of levothyroxine when taken with breakfast.

Potential Cons: Just like with all T4 medications, the effectiveness of Tirosint-SOL may be impacted if a given individual is experiencing poor T4/T3 conversion. Here are some additional considerations:

• As a newer and branded drug, it carries a higher cost, which means some insurance companies may penalize patients with a higher copay, while others may not pay for it at all (although the manufacturer offers a variety of programs to help with that — read more about that here).
• Conventional doctors may not be familiar with or have limited experience prescribing Tirosint, and may be reluctant to do so.

T3 Medications

Having an impaired gut, stress, and/or any of other reasons shown in the earlier T4 to T3 conversion graphic, can make a T4-only medication ineffective. We can see signs of poor conversion happening when we look at a full thyroid lab panel, as mentioned earlier.

The reverse T3 (rT3) test measures how much of the active free T3 is able to bind at thyroid receptors. RT3 is produced in stressful situations and binds to thyroid receptors, but turns them off instead of activating them. (Stress is a common cause of low T4 to T3 conversion. Under stressful situations, T4 gets converted to reverse T3 instead of T3. Reverse T3 is an inactive molecule related to T3, but without any physiological activity.)

The rT3 test is sometimes used to identify cases of poor T4 to T3 conversion, as well as thyroid symptoms that are due to adrenal stress, instead of thyroid malfunction or autoimmunity. In cases where a lot of reverse T3 is produced, adding a thyroid medication that contains T3, ensures that the right hormone is getting to the right receptors.

In my practice, we have clients routinely plot their lab results on thyroid gradients, which provide great visuals to assess conversion and general thyroid health. We can easily see when it might be time to add in a T3 medication, or switch out a T4-only medication to some kind of combination therapy.

T3-only medications are typically used as an add-on to T4-only medications, to address this issue. T3 medications have a short half-life and can pack a punch, so they must be dosed by a practitioner who is familiar with them. I’ll talk briefly about the generic, liothyronine, as well as the more commonly prescribed branded option in the U.S., Cytomel.

Liothyronine

Description: Liothyronine is the generic of the synthetic version of the thyroid hormone triiodothyronine, referred to as T3. The branded version of T3 available in the U.S. is Cytomel.

Dose: Liothyronine and T3-only medications are usually start­ed at 25 mcg by mouth daily, increasing by 12.5-25 mcg/day over the course of 1-2 weeks. Doctors may choose to increase this by a lower dose of 5 mcg every 1-2 weeks, for elderly individuals.

Most negative side effects have to do with incorrect dosage. T3 is absorbed very rapidly (it’s considered a “fast release” medication versus “sustained” or “slow” release). This may cause hyperthyroidism and even cardio symptoms such as palpitations in some patients. A good practitioner should work with you and adjust the starting dose to best fit your particular health profile (underlying health issues, age, etc.).

Pros: As a generic prescription, liothyronine is a low cost alternative.

Potential Cons: There are five potential areas of concern; the first one is applicable to the generic only, the other four for the branded version Cytomel as well.

1. Potency and ingredient inconsistency due to it being a generic
2. Adverse reactions and medication ineffectiveness due to fillers
3. Strict adherence required for consistent absorption and effectiveness
4. Lack of practitioner familiarity and expertise
5.  “Fast release” and rapid absorption can cause significant effects in some people

1. Adverse Reactions and Medication Ineffectiveness Due to Fillers

While Mylan’s branded generic offering is gluten-free and lactose-free, it does contain corn starch. Other makers of the generic, such as Paddock, are not certified gluten-free, although they don’t contain gluten in their ingredients list.

2. Lack of Practitioner Familiarity and Expertise

Probably the biggest potential con is that most conventional doctors may not be familiar or experienced with adding a T3 medication to a T4-only prescription (or switching to a T3-only medication). This inexperience may lead to a prescription resulting in incorrect dose ratios, or in patients not being effectively monitored for dose-related complications.

Some practitioners may even have an extreme aversion to prescribing T3 or combination therapies, given their knowledge of the inappropriate abuse of T3 medications in the 80s. Back then it was often – and inappropriately (and dangerously!) – prescribed as a weight loss medication (sometimes along with amphetamines!) by weight loss clinics. People were admitted to emergency rooms with serious cardio symptoms, some even in a coma. Some practitioners may have witnessed this, or had at least heard of it, so they’ve perhaps shied away from learning more. You can read more about this as well as other reasons practitioners may find it challenging to prescribe anything beyond T4 medications.

Having said that, it has now been shown in the (previously mentioned) research that a subset of hypothyroid patients just don’t do well on T4 medication alone, and that some people do better with T3/T4 combination therapy. Both the American Thyroid Association (ATA) and the European Thyroid Association (ETA) guidelines on thyroid hormone therapy do suggest that in certain such cases, a trial of T3 therapy including T4 can be considered.

In the 2014 ATA guidelines, it was pointed out that previously in a 2013 survey of specialist members of The American Thyroid Association, The Endocrine Society, and The American Association of Clinical Endocrinologists, only 3.6 percent of the 880 respondents would trial adding T3 to T4 given a hypothyroid patient with continuing symptoms, despite a TSH within the target range.

Fortunately, I think we’ve made some progress since 2013, and many more practitioners are opening up to the idea of using T3 medications.

In a more recent survey of clinicians, at least 58 percent said they would prescribe a trial of combination therapy for cases where T4-treated patients with normal serum TSH exhibited residual symptoms. Another found that up to 47 percent would add T3 therapy while reducing the T4 dose.

You may, however, need to find a doctor who is more familiar and willing. Here’s a link to a database of practitioners who would be more familiar with T3 and combination therapies.

3. “Fast Release” and Rapid Absorption Can Cause Significant Effects in Some People

When T3 is given in conventional tablet form, it’s absorbed and metabolized very rapidly, causing spikes in serum blood levels that may result in heart palpitations, sweating, tightness in the chest, and anxiety in some people. There is typically a peak of serum T3 about three hours after dosing, which is followed by a relatively fast decline. This is in contrast with the relative stability of T3 levels in individuals with healthy hormone levels. For this reason, manufacturers are looking at new delivery strategies such as liquid formulations and slow release tablets.

Researchers have been using laboratory rats to test a synthetic compound made up of zinc bound to three different T3 molecules, which is delivered in a capsule that is coated to prevent its breakdown in the stomach. The capsule is able to make its way to the small intestine where the zinc facilitates a slow release of the hormone.

Cytomel

Description: Cytomel is the branded version of the synthetic thyroid hormone T3, available in the U.S. In my survey, 52 percent of respondents said they felt better after taking Cytomel. The results relating to Cytomel also showed improvement in labs for 54 percent of respondents, improvements in energy for 73 percent, improvements in mood for 55 percent, and improvements in hair loss for 26 percent.

Pros:

• Unlike the generic, branded drugs like Cytomel do not vary in potency or fillers, as they come from a single manufacturer.
• Cytomel does not contain gluten (however, it is not certified gluten-free).

Potential Cons:

• Cytomel contains corn starch and lactose.
• Fast release and rapid absorption can cause significant effects in some people.

How to Overcome:

With T3 medications, I recommend starting with a low dose and slowly increasing it. Some individuals may also consider sustained release, compounded versions of T3.

Natural Desiccated Thyroid (T4/T3 Combination Therapy)

T4/T3 medications mimic the natural biological ratio of our hormones, with a ratio of 80 percent T4 to 20 percent of the more active T3 (4:1). In many cases, I recommend natural desiccated thyroid (NDT) medications (also referred to as desiccated thyroid extract or DTE). Natural desiccated thyroid medications are isolated from the thyroid glands of pigs and are bioidentical to what we would normally produce in our own bodies. Armour Thyroid, Nature-Throid, and WP Thyroid are three examples of natural desiccated thyroid medications.

Many patients who do not feel well on conventional T4 treatments, have reported feeling much better after switching to a T4/T3 option such as NDT.

If you are someone who is not able to tolerate NDT, or if you have an ethical or religious reason (since it is animal derived) why you’re not able to take the hormone, there are also compounded versions of T4 and T3 (I’ll talk about those in a moment; these are customized synthetic, not animal derived, medications that are tailored for a given individual).

Conventional doctors may not be supportive of NDT prescriptions due to their knowledge of past issues with quality control (relating to how dosage was determined, causing inconsistencies in hormone dose). Those issues are historical and dosing is now very consistent. You can read more about the history of NDT medications here.

However, there have been recent recalls on NP Thyroid, Nature-Throid and WP-Thyroid, due to certain lots being found to be sub-potent. This means that the affected medications may have too little thyroid hormone in them. Therefore, it is important to check with manufacturers to stay informed of any recalls or potency issues. (Please contact their manufacturers and your local pharmacist directly if you have any questions or concerns.)

There are proponents of NDT medications that feel that this bioidentical version is the best option for most people (and that the trace amounts of other hormones found in this natural hormone therapy, such as T1 and T2, may in fact have undiscovered biological benefits).

There are also those that feel that for some patients, NDT medications may actually be perpetuating the autoimmune attack due to the fact that they contain thyroglobulin and TPO antibodies (since they are formulated from animal thyroids).

The bottom line is that different people will do best on different medications. A practitioner must monitor a medication’s effectiveness, checking labs and symptoms. If someone starts feeling worse on NDT medications or has an increase in thyroid antibodies, I’d then recommend they switch to a compounded T4/T3 medication (using synthetic hormones).

So let’s talk a bit about three of the NDT medications.

Armour Thyroid

Description: Armour Thyroid is a natural (bioidentical) version of combined T4 and T3 hormones. In my survey, 59 percent of respondents said they felt better using Armour Thyroid, and 73 percent had more energy.

Dose: General guidelines start at 30 mg and increase the dosage by 15 mg every 6 weeks. Your practitioner should work with you and adjust the starting dose to best fit your particular health profile (underlying health issues, age, etc.).

Most negative side effects have to do with incorrect dosage. T3 is absorbed very rapidly (it’s considered a “fast release” medication versus “sustained” or “slow” release). This may cause hyperthyroidism, and even cardio symptoms such as palpitations, in some patients. I have found that “fast release,” however, is better for people with Hashimoto’s given that they typically have gut issues that affect absorption.

Pros:

• No potency or filler variation
• Gluten-free but not certified
• “Fast release” and rapid absorption of T3

Potential Cons:

• Higher cost in most cases
• Adverse reactions and medication ineffectiveness due to fillers (contains several inactive ingredients including dextrose, calcium stearate, sodium starch glycolate, microcrystalline cellulose, and opadry white)
• Animal derived (if that is a problem for you)
• Strict adherence required for consistent absorption and effectiveness
• Practitioner may be unfamiliar with working with Armour

Nature-Throid

Description: Nature-Throid is a natural (bioidentical) version of combined T4 and T3 hormones. In my survey, 56 percent of respondents said they felt better using Nature-Throid.

Dose: General guidelines start at 30 mg and increase the dosage by 15 mg every 6 weeks. Your practitioner should work with you and adjust the starting dose to best fit your particular health profile (underlying health issues, age, etc.).

Most negative side effects have to do with incorrect dosage. T3 is absorbed very rapidly (it’s considered a “fast release” medication versus “sustained” or “slow” release). This may cause hyperthyroidism, and even cardio symptoms such as palpitations, in some patients.

Pros:

• No potency or filler variation
• Hypoallergenic
• “Fast release” and rapid absorption of T3

Potential Cons:

• Higher cost in most cases
• Animal derived (if that is a problem for you)
• Strict adherence required for consistent absorption and effectiveness
• Lack of practitioner familiarity and expertise
• Currently under recall — see my note below on switching meds!

WP Thyroid

Description: WP Thyroid is a natural (bioidentical) version of combined T4 and T3 hormones. In my survey, 32 percent of respondents said they felt better using WP Thyroid.

Dose: General guidelines start at 30 mg and increase the dosage by 15 mg every 6 weeks. Your practitioner should work with you and adjust the starting dose to best fit your particular health profile (underlying health issues, age, etc.).

Most negative side effects have to do with incorrect dosage. T3 is absorbed very rapidly (it’s considered a “fast release” medication versus “sustained” or “slow” release). This may cause hyperthyroidism, and even cardio symptoms such as palpitations, in some patients.

Pros:

•  No potency or filler variation
•  Hypoallergenic
• “Fast release” and rapid absorption of T3

Potential Cons:

• Higher cost in most cases
• Animal derived (if that is a problem for you)
• Strict adherence required for consistent absorption and effectiveness
• Lack of practitioner familiarity and expertise
• Currently under recall — see my note below on switching meds!

Compounded T4/T3

If NDT medications do not seem like a good fit for you, compounded T4/T3 products offer another alternative. These medications also offer the advantage of being made devoid of any fillers that people may not tolerate, such as lactose or gluten, which are present in some thyroid medications and can be problematic for thyroid patients. Furthermore, these medications do not increase autoimmunity.

However, compounded T4/T3 products need to be prepared by specially trained compounding pharmacists. These compounds are usually much more expensive and may need to be refrigerated to preserve activity.

Thyroid compounds are usually prepared in the same physiological ratio that is found in NDT products. However, physicians can elect to change the amount of T3 and T4, as compounding pharmacists must make the medications from scratch. This can be a huge advantage for patients who did not feel well on conventional treatments or natural desiccated thyroid treatments.

Most T4/T3 compounds, like NDT products, are immediate release versions, which means they’re formulated to release the active medication immediately after oral administration. However, compounding pharmacists can also make sustained release versions.

While there has been some concern expressed about the potential side effects of fast release thyroid medications (such as Cytomel), I have found that slow-release products don’t tend to work as well for my clients with Hashimoto’s.

Slow-release products may be more difficult to absorb, as many people with Hashimoto’s have gut issues (leaky gut). Methocel is the name of the slow-release formulation that compounding pharmacists will use.

For my clients, I usually recommend a fast release/immediate release T4/T3 formulation, which utilizes Avicel as the filler. I’ve seen quite a few times where people have gotten suspended release or slow release compounded thyroid hormones… and all of a sudden, their TSH went from 1 to 3 μIU/mL, to 8 or 10 μIU/mL, or even to 15-20 μIU/mL! As such, when people say, “I tried compounded medications and they didn’t work for me!”, the very first question I ask is: “Okay. Was it a slow-release form?”

In other words, we do not want slow-release if we have Hashimoto’s and any kind of gut issue.

Pros: 

• Medications can be customized for your ideal ratio of T4/T3 and with filler ingredients that you are not sensitive to
• Can be made as fast or slow release versions

Cons:

• Not all doctors are familiar with prescribing T3/T4 meds
• A compounding pharmacist may not be available in your area
• You may need to pay out of pocket for them

Considerations:
Compounding pharmacies need to be high quality and meticulous due to the tiny amounts of drugs they work with; any errors can be magnified. I maintain a list of recommended compounding pharmacies for that reason. I look for compounding pharmacies that offer PCCA dilutions. PCCA is an association for pharmacists that helps them create more effective and more standardized compounds.

I recommend asking the following questions when considering a compounding pharmacist:

• What types of fillers are used?
• What is the source of the materials?
• Is the compound slow-release or immediate release?

Now that we’ve gone over the available thyroid hormone medications out there, let’s review the side effects and general precautions for thyroid hormone medications.

Switching Medications

While dose conversions from different medications are readily available, there may still be some discrepancies in the dose you receive and how you absorb the medications, so carefully monitor your symptoms and repeat your labs four to six weeks after switching, to make sure your body is adjusting properly.

While the conversion chart below is a great place to start, please note that NDT may be more bioactive, and thus physicians may elect to initiate with slightly lower doses when switching from levothyroxine to NDT. Furthermore, Tirosint may be better absorbed compared to other forms of levothyroxine. Thus, physicians may elect to initiate with slightly lower doses when switching from levothyroxine to Tirosint.

If you want more information on adjusting or switching your thyroid medication, I have written a short eBook called Optimizing Thyroid Medications, that you can download for free for a limited time. This eBook talks more about the types of thyroid medications and medication protocols out there, as well as medication titration, the issue with fillers, case studies to help show the benefits of different medications, and much more.

In light of the recalls of several NDT thyroid medications over the past few years (NP Thyroid, Nature-Throid and WP-Thyroid), I’ve had a lot of questions about what replacement options people have. So, I wanted to take a moment to list some different options for when these medications aren’t available.

My top choices for replacement medications are:

1. Armour: It is the most similar to other NDT options, but some people have issues with corn as a filler ingredient, and some have reported this medication actually raising their TPO antibody level. The theory is that it may contain some thyroglobulin due to the manufacturing process, but I am not 100 percent sure if this is the case. That said, many people do well with this medication, and I have previously taken it myself with great results.
2. Compounded T4/T3: These are medications tailor made by compounding pharmacists. Ask for the immediate release version, as sustained release versions may not be absorbed properly by people with Hashimoto’s and gut issues like intestinal permeability (leaky gut).
3. Tirosint and Tirosint SOL: These are T4-only options in highly absorbable formulations that can withstand food and coffee. Of all of the T4 medication options, these have the best absorbability and the fewest fillers. For those who have issues with converting T4 to T3, another version of T3 can be added, such as Cytomel, liothyronine or compounded T3.
4. Synthroid or Levoxyl: These can also be combined with Cytomel or liothyronine for a T4/T3 combo medication.
5. Generic levothyroxine: This can also be combined with Cytomel or liothyronine for a T4/T3 combo medication.

The Takeaway

I hope this article gave you a good overview of the various types of thyroid medications that are available to you. Just like there is no diet that is perfect for everyone, there is no “one size fits all” when it comes to thyroid hormones. In many cases, it will take some trial and error to find the right medication and dosage that reduce your symptoms and help you feel your best. I do recommend working with a practitioner who is open to exploring the different options out there, so that you are not limited in your choices and can find the right fit for your situation.

Beyond thyroid hormone replacement therapy, there are also lifestyle changes I recommend to ensure that you feel your best and are not just addressing the hormone imbalances that result from Hashimoto’s, but the underlying root causes.

Did you find this article helpful? Let me know your experience with thyroid medications in the comments, or join me over on Facebook or Instagram!

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Don’t forget to download my free eBook on optimizing your thyroid medications as well!

References

1. Fuentes AV, Pineda MD, Venkata KCN. Comprehension of Top 200 Prescribed Drugs in the US as a Resource for Pharmacy Teaching, Training and Practice. Pharmacy (Basel). 2018;6(2):43.
2. Chiovato L, Magri F, Carlé A. Hypothyroidism in Context: Where We’ve Been and Where We’re Going. Adv Ther. 2019;36(Suppl 2):47‐58.
3. Chiovato L, Magri F, Carlé A. Hypothyroidism in Context: Where We’ve Been and Where We’re Going. Adv Ther. 2019;36(Suppl 2):47‐58.
4. Chiovato L, Magri F, Carlé A. Hypothyroidism in Context: Where We’ve Been and Where We’re Going. Adv Ther. 2019;36(Suppl 2):47‐58.
5. Taylor PN, Eligar V, Muller I, Scholz A, Dayan C, Okosieme O. Combination Thyroid Hormone Replacement; Knowns and Unknowns. Front Endocrinol (Lausanne). 2019;10:706.
6. Dayan C, Panicker V. Management of hypothyroidism with combination thyroxine (T4) and triiodothyronine (T3) hormone replacement in clinical practice: a review of suggested guidance. Thyroid Res. 2018;11:1.
7. Fallahi P, Ferrari SM, Ruffilli I, et al. Advancements in the treatment of hypothyroidism with L-T4 liquid formulation or soft gel capsule: an update. Expert Opin Drug Deliv. 2017 May;14(5):647-655.
8. Vita R, Saraceno G, Trimarchi F, et al. A novel formulation of l-thyroxine (l-T4) reduces the problem of l-T4 malabsorption by coffee observed with traditional tablet formulations. Endocrine. 2013;43(1):154–160.
9. Cappelli C, Pirola I, Gandossi E, et al. Oral liquid levothyroxine treatment at breakfast: a mistake? Eur J Endocrinol. 2013 Nov 22;170(1):95-9.
10. Vita R, Saraceno G, Trimarchi F, et al. A novel formulation of l-thyroxine (l-T4) reduces the problem of l-T4 malabsorption by coffee observed with traditional tablet formulations. Endocrine. 2013;43:154–160.
11. Cappelli C, Pirola I, Daffini L, et al. A double-blind placebo-controlled trial of liquid thyroxine ingested at breakfast: results of the TICO study. Thyroid. 2016;26:197–202. 10.1089/thy.2015.0422.
12. Pirola I, Gandossi E, Brancato D, et al. TSH evaluation in hypothyroid patients assuming liquid levothyroxine at breakfast or 30 min before breakfast. J Endocrinol Invest. 2018;41:1301–6. 10.1007/s40618-018-0867-3.
13. Benvenga S, Ducharme MP. Comparison of the intestinal absorption of levothyroxine (LT4): Tablet vs. soft gel capsule formulation. Endocr. Rev. 2011;32:3–625.
14. Vita R, Saraceno G, Trimarchi F,, et al. A novel formulation of l-thyroxine (l-T4) reduces the problem of l-T4 malabsorption by coffee observed with traditional tablet formulations. Endocrine. 2013;43:154–160.
15. Saraceno G, Vita R, Trimarchi F, et al. Two novel formulations of l-T4 (oral solution and soft gel capsule) are refractory to the coffee-induced intestinal malabsorption of tablet l-T4. Eur. Thyroid J. 2013;2:P132–P145.
16. Virili C, Giovanella L, Fallahi P, et al. Levothyroxine therapy: changes of TSH Levels by switching patients from tablet to liquid formulation. A systematic Review and meta-analysis. Front Endocrinol (Lausanne). 2018;9:10.
17. Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014;24(12):1670‐1751.
18. Dayan C, Panicker V. Management of hypothyroidism with combination thyroxine (T4) and triiodothyronine (T3) hormone replacement in clinical practice: a review of suggested guidance. Thyroid Res. 2018;11:1.
19. Burch HB, Burman KD, Cooper DS, et al. A 2013 survey of clinical practice patterns in the management of primary hypothyroidism. The Journal of Clinical Endocrinology & Metabolism. 2014;99(6):P2077–2085.
20. Jonklaas J, Tefera E, Shara N. Short-Term time trends in prescribing therapy for hypothyroidism: results of a survey of American Thyroid Association Members. Front Endocrinol (Lausanne). 2019;10:31.
21. McAninch EA, Bianco AC. The swinging pendulum in Treatment for hypothyroidism: from (and toward?) combination therapy. Front Endocrinol (Lausanne). 2019;10:446.
22. Idrees T, Price JD, Piccariello T, et al. Sustained release T3 therapy: animal models and translational Applications. Front Endocrinol (Lausanne). 2019;10:544.
23. Rush University Medical Center. Potential therapy for treatment-resistant hypothyroidism proves effective in lab study: Novel coordination of thyroid hormone with zinc promotes slow release of active hormone to supplement standard therapy. ScienceDaily. www.sciencedaily.com/releases/2018/10/181012135315.htm. Accessed May 29, 2020.
24. BiancoLab. http://deiodinase.org/2013/05/06/nutrient-availability-and-thyroid-hormone-activation-2/. Accessed October 12, 2020.