Thyroid hormones affect every organ, tissue, and cell in the body. Appropriate medication management will allow you to recover from the effects of hypothyroidism and will give you energy, vitality, and support to continue working on optimizing your health.
If you are currently taking thyroid medications and are still not feeling well, be sure to read this entire post for an overview of my top thyroid medication recommendations. For a deeper dive into optimizing your thyroid hormones to start feeling better, you can download my complete Optimizing Thyroid Medications eBook below, FREE for a limited time!
Conventional treatment guidelines state that there is no benefit from taking combination T3/T4 products, and that T4 products are superior. However, most of these claims are based on studies funded by pharmaceutical companies with a vested interest in promoting the use of their own products.
I believe that combination products may be advantageous for many patients with Hashimoto’s. Some Hashimoto’s patients are not able to properly and efficiently convert T4 to T3. For example, zinc is required to convert T4 to T3, and Hashimoto’s patients are often deficient in zinc.
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 is a dud that 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. Additionally, many patients report that they feel better taking a combination T4/T3 product.
11 Things You Need to Know About Thyroid Medications
1. Types of Thyroid Medications
Synthroid was the most commonly prescribed medication in the United States in 2013, but it isn’t the only thyroid medication. There are three types of medications that can be used to treat an underactive thyroid:
- T4-containing medications (include Synthroid, Levoxyl, Levothyroxine and Tirosint)
- T3-containing medications (Cytomel and compounded T3)
- Combination T4/T3 medications (Armour, Nature-Throid, WP Thyroid, compounded T4/T3 medications)
Some people with Hashimoto’s may not be able to properly convert levothyroxine (T4), the active ingredient in Synthroid, to liothyronine (T3), the more metabolically active thyroid hormone… leading to unresolved thyroid symptoms — including fatigue, depression, weight gain and hair loss, despite being on medications. (For more information on various thyroid medication options, read my article: Which Thyroid Medication is Best?.)
2. Medication Monitoring
Thyroid medications are “Goldilocks” hormones, which means that they have a narrow therapeutic index. They are dosed in micrograms (1/1000th of a milligram), and very slight changes in doses can lead to symptoms due to under-treatment or over-treatment. Common side effects of these medications, such as the ones listed in the package insert, are often due to overtreatment:
- Rapid or irregular heartbeat
- Chest pain
- Weight loss
- Excessive sweating
Undertreatment side effects include hair loss and fatigue. Careful dosage titration is necessary to avoid the consequences of over- or under-treatment.
In addition to tracking your symptoms, you should have the following tests done: TSH, Free T3, and Free T4, to monitor your response to medication.
While reference ranges of what’s “normal” may vary depending on the lab that produces the test reports, most thyroid patients feel best with a TSH between 0.5-2 μIU/mL, and with Free T3 and Free T4 in the top half of the reference range. For accurate blood test results, be sure to postpone your thyroid medications on the morning of the test, as some medications (especially T3-containing medications) may skew your numbers.
(For a symptom tracker and a letter to your doctor about medication adjustments, see my article: When Your TSH is Normal, But You Are Anything But.)
3. Switching Medications
Switching between brands of thyroid medications, though sometimes necessary, can mean that a person who was previously stable on a particular dose of medication, may require a higher or lower dose of the new brand. Retest your thyroid 4-8 weeks after switching from one brand of medication, or after increasing your dosage, to be sure you are dosed appropriately. (For more information, read this article: Switching Thyroid Medications.)
4. Thyroid Drug Interactions
Thyroid medications are notorious for drug interactions with other medications. This means that some medications can cause alterations in thyroid hormone levels and side effects — and in turn, thyroid medications can impact the effectiveness and toxicity profiles of other medications. Always be sure to check with your pharmacist when taking new medications or over-the-counter drugs. Ideally, you should fill all of your prescriptions at the same pharmacy so your pharmacist can do a check of your drug interactions every time you fill a prescription.
5. Addison’s Disease and Thyroid Disease
Testing for Addison’s disease involves sodium, potassium, cortisol, and ACTH blood tests. However, these tests will be NORMAL until 90 percent of your adrenal glands have been destroyed by the immune system! Testing for 21-hydroxylase antibodies, which are antibodies against the adrenal glands, can tell you if you have Addison’s disease — up to a decade before the traditional tests for Addison’s reveal that diagnosis — and may prevent a life-threatening adrenal crisis. As most thyroid conditions are autoimmune in nature, and autoimmune conditions tend to go hand-in-hand, I recommend adrenal antibody testing for all thyroid patients!
6. Pregnancy and Thyroid Disease
Thyroid medications are Pregnancy Category A, which means that they are considered to be safe medications for use during pregnancy. Being on a correct dose of thyroid medication can actually help women conceive, as well as prevent miscarriage. If you get pregnant while taking thyroid hormones, be sure to see your doctor ASAP to test your levels. You will very likely need to increase your dose, as pregnancy increases the requirement of thyroid hormones. If you are thinking about pregnancy, be sure to read this guest post: Hashimoto’s and Pregnancy, as well as my article Best Advice for Hashimamas.
7. Fillers in Medications
Some people may react to fillers in Synthroid (corn starch, confectioners sugar, lactose, magnesium stearate, povidone, talc and color additives). People who are lactose intolerant, in particular, may have trouble absorbing many of the thyroid hormones that contain lactose.
Tirosint is a new thyroid medication that does not contain lactose and may prove to be a better option for those with lactose intolerance. Tirosint SOL is also available as a liquid version which only contains glycerol and water as inactive ingredients. You may want to read my article here for more information.
8. Absorption (External Factors)
Thyroid medication absorption can be impacted by many things, including food, other medications, and supplements.
- Thyroid medication should be taken on an empty stomach.
- Take medication 30 minutes to one hour before eating, taking other medications, taking supplements, or drinking coffee, to ensure optimal absorption.
- Antacids such as Tums, iron supplements, and calcium supplements can impair the absorption of thyroid medications.
- You need to have at least 4 hours of time in between your thyroid medications and these agents.
9. Absorption (Internal Factors)
Thyroid hormones are absorbed in the small intestine. Conditions like untreated celiac disease, lactose intolerance, malabsorption, and infections in the small intestine may prevent proper thyroid hormone absorption. A person who is not responsive to the usual doses of thyroid replacement hormone should be investigated and treated for the above-listed conditions. Once someone addresses these conditions, she/he may need to have a dose reduction in medication.
Read more about gluten and optimizing your diet in my article on the best diet for Hashimoto’s.
Thyroid medications are considered lifelong for most cases of hypothyroidism, but spontaneous remission has been reported to occur in up to 20 percent of patients. That said, addressing root causes can help increase the rates of remission. If you do not address the underlying root causes of your condition, your own thyroid hormone production may deteriorate over time, meaning that you may require dose increases over time.
Symptoms of worsening thyroid function can sometimes be subtle:
- Gaining a little extra weight every year
- Being just a tad bit more tired
You will need to test your thyroid function labs at least every 6-12 months to monitor your thyroid hormone levels. For more information, see the following articles: 6 Hashimoto’s Root Causes & Are Thyroid Medications Lifelong?
11. Beyond Medications
There’s a lot more to healing thyroid disease than simply taking medications. Most causes of thyroid disease are due to autoimmune conditions, including Hashimoto’s and Graves’ disease. These conditions result from the immune system attacking the thyroid because the immune system is out of balance. Even when the thyroid is taken out surgically or treated with radioactive iodine, the autoimmunity persists in most cases.
People with thyroid disorders are at greater risk to develop new autoimmune disorders if they do not treat the underlying cause of the immune imbalance. Most times, it’s a combination of adrenal dysfunction, food sensitivities, nutrient deficiencies, impaired gut function, infections and toxins that lead to the development of autoimmune disease.
The Bottom Line
There are many options for thyroid hormone treatment. Thyroid hormone therapy should be individualized with the patient in mind. Each person should work with a physician who is willing to find the thyroid medication that works best for him/her.
Overcoming Hashimoto’s can seem like a lot of moving pieces… but optimizing medication will help you start feeling better quickly. If you’ve done all of the above and your medications are still not optimal, then I highly suggest you check out my free eBook on Optimizing Thyroid Medications. I’m offering this eBook for free, for a limited time, so be sure to take advantage of it!
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