In my past life, before I found my life’s calling of helping people with thyroid conditions take back their health as the “Thyroid Pharmacist”, I worked as a consultant pharmacist who was focused on optimizing medications for people with disabilities and the elderly. While my official job title was Consultant Pharmacist, I really felt that the most important part of my job was to help advocate for individuals who could not voice their health concerns. I ensured that they were getting the most benefit from their medications, that they were not over-medicated, that they had access to medications that could potentially help them, and that they received the proper care they deserved. I want to do the same for you.
There are quite a few options for thyroid medications for hypothyroidism. However, most people are only familiar with synthetic T4-containing thyroid medications.
Some people report feeling better on combination T4/T3 medications (like Armour®, compounded T4/T3 or Nature-Throid®). Others may feel better taking synthetic T4 medications (like Synthroid®, Tirosint® or Levoxyl®), while some patients may benefit from a synthetic T3 medication (like Cytomel®). Still, others feel best when on T4-containing medications made without fillers that they are sensitive to.
Of the readers I’ve surveyed, up to 59 percent have felt better taking a combination T4/T3 medication, while up to 43 percent have felt better on a synthetic T4 medication. While lab results seem to be most improved with Synthroid® (69 percent), mood and overall energy seem to improve more by switching to a combination medication like Nature-Throid® (63 percent).
Changing your thyroid medication may help you absorb thyroid hormone better, which may in turn result in a reduction in symptoms, and an increase in mood and energy levels!
Today, I’d like to help you explore the different options out there, so I’ll cover:
- Is levothyroxine beneficial for everyone?
- What are T3-containing hormones?
- The possible benefits of T4/T3 combination options
- Debunking myths regarding natural desiccated thyroid medications
- What are compounded T4/T3 medications?
Conventional Thyroid Medication Treatment: T4 Hormone Medications
The standard of care for Hashimoto’s is to utilize a synthetic thyroid hormone replacement medication. Levothyroxine, commonly sold as Synthroid® or under other brand names like Levoxyl®, Tirosint®, Euthyrox® (in the EU), Eltroxin® (in Canada), and Oroxine® or Eutroxsig® (in Australia), is a man-made T4 hormone. It’s the most commonly prescribed medication for Hashimoto’s once a person progresses into the advanced hypothyroid stage, and it is used as replacement or supplemental therapy for internally produced thyroid hormones when our own thyroid gland cannot make enough.
Many people do very well on T4-containing medications once they are dosed appropriately and stabilized. However, while these medications can be helpful for many people and their symptoms, levothyroxine does not address the underlying root causes of the condition.
Synthetic thyroid medications are also often dosed incorrectly by doctors, taken incorrectly by patients, and underutilized by our bodies. This is because levothyroxine contains the less-active but longer-acting T4 hormone. The T4 molecule is considered a pro-hormone, 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. The conversion from T4 to T3 can be impeded by numerous factors, including stress, nutrient deficiencies, and impaired liver and gut activity.
However, not everyone converts the T4 hormone to T3 properly. This is why many people continue to struggle with thyroid symptoms such as hair loss, brain fog, weight gain, depression and fatigue, even after they’ve started taking medication.
Furthermore, some people may be sensitive to certain fillers in their levothyroxine medication. Some common fillers found in T4-only medications include lactose, maize/corn starch, and even gluten! (Click here to read more about checking out whether your thyroid medication is gluten free.)
As I mention in my books Hashimoto’s: The Root Cause and Hashimoto’s Protocol, as well as on my blog, dairy, corn, and gluten are some of the most common food sensitivities in those with Hashimoto’s; and ingesting even small portions of them can exacerbate symptoms and prevent healing in some. Removing these food sensitivities may, however, reverse the autoimmune attack on the thyroid in some cases! You may wish to ask your doctor about Tirosint®, which is a hypoallergenic T4-only option for those with multiple intolerances.
Of the readers I have surveyed, those that switched to Tirosint® experienced a 68 percent improvement in labs, 50 percent improvement in mood, 62 percent improvement in energy levels, and 32 percent improvement in hair loss.
T3 and T3/T4 Combination Medications
Some people like to opt for another type of thyroid medication: T3 medications. These contain liothyronine and include the brand name Cytomel® and compounded T3 formulations. They offer the active albeit short-acting T3 thyroid hormone. (You can read more about thyroid hormones here.)
These medications are generally not recommended to be used as a sole therapy for hypothyroidism, as their short half-life may put a person on a thyroid hormone roller coaster. However, they can be used as an add-on to T4-only medications. T4/T3 combination medications offer the two main thyroid hormones in the same ratio that is present in our own bodies.
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% 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% 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.
Dr. Wiersinga suggests that people with specific genetic polymorphisms (certain gene mutations) that affect thyroid hormone transport may benefit from combination T4/T3 therapy, and that people who continue to have thyroid symptoms despite having normal TSH levels may benefit from a trial of T3 in addition to T4 medication.
Further studies are needed to answer the questions of whether or not T4 alone is sufficient. To date, studies have been inconclusive, yet the number of hypothyroid patients asking for T4/T3 combination therapy has multiplied in the last decade.
Interestingly, a new follow up to the 2014 Dr. Wiersinga study, published in 2017, claims that T3 therapy has still not been proven to be beneficial, but many patients are now asking their doctors to switch them to T4/T3 combination medications, as many have reported a reduction in their thyroid symptoms when T3 is added to their regimen.
T3 Medication Controversy
Physicians may worry about using T3-containing medications or increasing the doses of thyroid medications due to concerns about heart palpitations and increased risks of osteoporosis, which may result from a person who has excess levels of thyroid hormones.
According to Carter Black, RPh, who has been a practicing pharmacist since the 1970’s, the 80’s brought T3 medications into a negative light…
Weight loss clinics started prescribing Cytomel® along with amphetamines and liquid diets for people without thyroid disease. As you can imagine, this combination given to an overweight person with a normally functioning thyroid often created a dangerous situation. Patients were admitted into emergency rooms with life threatening symptoms of high fever, palpitations, labored breathing, dehydration, delirium, nausea, vomiting and even coma. This can be a very difficult clinical situation to manage, and death can result. People exposed to this cocktail were at risk for future problems of thyroid management (alternating hyperthyroid and hypothyroid states), cardiac damage, and severe depression.
Of course, as a pharmacist, I would like to point out that using thyroid medications to induce weight loss for people without thyroid disease is completely inappropriate.
Doctors were essentially inducing hyperthyroidism in people to induce weight loss. Since that time, the FDA has placed a “black box warning” (the strictest warning that can be placed in the labeling of prescription drugs when there is reasonable evidence of serious risks associated with the drug) on all thyroid medications, noting that they should not be used for obesity and weight loss in people with normal thyroid function, and that higher doses may cause life-threatening toxicity, especially when given with sympathomimetic medications.
Many of today’s practicing endocrinologists witnessed the effects of T3 for weight loss induction first hand as young residents and medical students early in their training. One can certainly understand a doctor’s aversion to T3 or T4/T3 combinations because of its history of inappropriate use in the past.
Most doctors truly care about your safety and want to do the best by their patients. However, in their effort to reduce the potential adverse reactions due to overtreatment, many individuals continue to experience thyroid symptoms because of undertreatment. Still, it’s important to understand why T3-containing medications can be beneficial to some patients.
Why T4/T3 Combinations May Help
Understanding thyroid physiology, I do believe that combination products may be advantageous for many patients with Hashimoto’s, as some Hashimoto’s patients are not able to properly and efficiently convert T4 to T3. This could be due to a congested liver or a deficiency in zinc, which is required to convert T4 to T3. Hashimoto’s patients are often deficient in zinc, and you can read more about that here.
There are also other factors that can inhibit the T4 to T3 conversion, including nutrient depletions and iodine excess, which are common root causes of Hashimoto’s. You can see the other possible factors below:
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.
Natural Desiccated Thyroid Medications
One T4/T3 medication option is Natural Desiccated Thyroid (NDT, sometimes called desiccated thyroid extract, or DTE) hormones. These medications are derived from the thyroid glands of pigs and are considered bio-identical to the hormones produced by our thyroid glands.
NDT medications also contain the thyroid hormones T1 and T2, which may have some physiological activity as well. Many patients who did not feel well on conventional treatments have reported feeling much better after switching to a NDT medication like Armour®, Nature-Throid® or WP Thyroid®. (Note: While Armour does not have any gluten-containing ingredients, it is not tested for gluten content, and as such, is not “certified gluten free.”)
When surveying my readers, I discovered that 59 percent did feel better after switching to Armour®, 57 percent felt better on Nature-Throid®, and 32 percent reported improvement with WP Thyroid®.
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 products.
When NDT hormones were first isolated from the thyroid glands of animals, manufacturers would measure how active the hormones were by measuring the iodine content within the substance. Of course, iodine levels would vary from animal to animal, so this proved to be an inaccurate way of measuring hormone levels.
It was later discovered that different batches of NDT would have varying levels of thyroid hormones.
In the past two decades, however, the technology used for manufacturing NDT has much improved. Manufacturers of natural desiccated thyroid now utilize specific kinds of chemical tests to identify the exact amounts of thyroid hormones in their product, ensuring an accurate and consistent dose.
Now, it seems, you can actually trust the dosage of T4 and T3 in NDT, whereas 30 years ago, that wasn’t the case. Doctors who have been in practice for quite some time and are not integrative-minded, might still be resistant to the use of NDT, as they remember the problems associated with the inconsistent product in its early years.
The National Institute of Health, a government agency (not funded by pharmaceutical grants) conducted a clinical trial to see if desiccated thyroid therapy is advantageous to T4 alone. The authors of the study concluded: “DTE (Desiccated Thyroid Extract) therapy did not result in a significant improvement in quality of life; however, DTE caused modest weight loss and nearly half (48.6%) of the study patients expressed preference for DTE over l-T4 (Levothyroxine). DTE therapy may be relevant for some hypothyroid patients.”
A doctor who is familiar with clinical trials that have shown T3 and NDT can be safe and effective when used appropriately, is more likely to feel comfortable with prescribing these medications. However, your doctor may not be aware of this research, and sometimes, it may help for you to make them aware of the latest news in thyroid care.
Other Controversies in Natural Desiccated Thyroid
Some proponents of natural thyroid medications, including Dr. Alan Christianson (author of Healing Hashimoto’s), advise that the desiccated glands of animals may be the best option as they also have trace amounts of T1 and T2, which may have undiscovered biological functions.
In contrast, Dr. Alexander Haskell (author of Hope for Hashimoto’s) and Dr. Mark Starr (author of Hypothyroidism Type II), report that for some patients, natural thyroid formulations from animal thyroids, such as Armour®, may perpetuate the autoimmune attack due to them containing thyroglobulin and thyroid peroxidase, and they only recommend compounded and synthetic thyroid medications for people with Hashimoto’s. Nonetheless, some people report that desiccated thyroid products, especially when given at a suppressive level, will reduce thyroid antibodies. A suppressive dose essentially puts our own thyroid to sleep, and all of the required hormones are obtained from the medication.
That said, some patients may have ethical objections to using animal-derived natural desiccated products.
Compounded T4/T3 Medications
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 the 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. Some professionals recommend sustained release formulations so that the hormone is released continuously throughout the day. However, these types of formulations may not be absorbed properly by people with Hashimoto’s and gut issues like intestinal permeability, or leaky gut. This is why many people say: “I tried compounded medications and they didn’t work for me.”
I’ve seen quite a few instances where people with optimal TSH levels (between 1 to 3 μIU/mL) started suspended release or slow release compounded thyroid hormones and, all of a sudden, their TSH jumped to 8, 10 or even 20 μIU/mL!
This is why many people with Hashimoto’s avoid sustained release formulations like Methocel, and instead opt for Avicel, the immediate release formulation that is better absorbed by their body.
If you’re considering trying T4/T3 medications, please note that specially trained compounding pharmacists are needed to make T4/T3 compounds, and they do take some time to prepare. Additionally, not all compounding pharmacies are equal, and a specialized process is required to prepare an accurate dose of compounded thyroid medications. Thus, patients might have to travel out of their way to find a compounding pharmacy.
As a Thyroid Pharmacist, I’ve organized a directory of Recommended Compounding Pharmacies to help you discover local compounding pharmacies near you.
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?
The Takeaway and Next Steps
The bottom line is that there are many options for thyroid hormone treatment, and you should work with your healthcare provider to find the one that works best for you.
The thyroid medications brands available by category are:
- T4: Levothyroxine (generic), Tirosint, Synthroid, Levothroid, Levoxyl, Thyro-Tabs, Unithroid
- T3 (to be used in combination with T4 medications): Liothyronine (generic), Cytomel
- Natural Desiccated Thyroid (T4/T3) medications: Armour Thyroid, Nature-Throid, WP Thyroid, NP Thyroid
- Compounded T4/T3 medications: Created by compounding pharmacists (opt for immediate release formulations)
Please note, sometimes medications may go on backorder. If this happens to you, here are some resources to find out what’s in stock. You can try any of the mail-order pharmacies listed on their website; they should have available strengths stocked: Get Real About Hypothyroidism: Find a Pharmacy.
Thyroid hormone therapy should be individualized with the patient in mind. You should work with an open-minded physician to find the thyroid medication that works best for you.
You may find that, depending on your body and the type of medication you use, you may need to go higher or lower on the medication depending on how your body reacts to it. The key is not just to switch and move on with your life. Once you switch your thyroid medications, you need to retest in four to six weeks to see where your levels are and to see if you need to adjust your dosage any further.
I always advise testing thyroid antibodies before and after starting new thyroid medications. For example, if someone starts feeling worse after initially feeling better on NDT or has an increase in thyroid peroxidase antibodies after starting NDT, switching to a compounded T4/T3 medication may be helpful.
Ready to start? Download my eBook, Optimizing Thyroid Medications, free for a limited time. It contains key information, strategies and resources to help you get the most out of your thyroid medication, including a chart to help you convert your thyroid medication doses if you’re switching medications.
When you’re on the right medication and the proper dosage for you, you may experience a reduction in symptoms, and you may begin to feel better.
I hope this helps you find the right medication and dosage that work for you!
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The medical information in on this blog is provided as an educational resource only and is not intended to be used or relied upon for any diagnostic or treatment purposes. This information should not be used as a substitute for professional diagnosis and treatment.
Please consult your health-care provider before making any healthcare decisions or for guidance about a specific medical condition.
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- Jonklaas J, Talbert RL. Chapter 84. Thyroid Disorders. In: Talbert RL, DiPiro JT, Matzke GR, Posey LM, Wells BG, Yee GC, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. New York: McGraw-Hill; 2011.
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- Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2013 Jan-Feb;19(1):175.
- McDermott M, Ridgway E. Subclinical Hypothyroidism Is Mild Thyroid Failure and Should be Treated. The Journal of Clinical Endocrinology & Metabolism. 2001;86(10):4585-4590. doi:10.1210/jcem.86.10.7959.
- NP Thyroid. Acella Pharmaceuticals LLC Website. http://www.npthyroid.com. Accessed June 11, 2018.
- Hoang T, Olsen C, Mai V, Clyde P, Shakir M. Desiccated Thyroid Extract Compared With Levothyroxine in the Treatment of Hypothyroidism: A Randomized, Double-Blind, Crossover Study. The Journal of Clinical Endocrinology & Metabolism. 2013;98(5):1982-1990. doi:10.1210/jc.2012-4107.
- McAninch EA, Bianco AC. The History and Future of Treatment of Hypothyroidism. Ann Intern Med. 2016 Jan 5;164(1):50–56. doi: 10.7326/M15-1799.
- Wiersinga WM. Paradigm shifts in thyroid hormone replacement therapies for hypothyroidism. Nat Rev Endocrinol. 2014 Mar;10(3):164-74. doi: 10.1038/nrendo.2013.258.
- Wiersinga WM. THERAPY OF ENDOCRINE DISEASE: T4 + T3 combination therapy: is there a true effect? Eur J Endocrinol. 2017 Dec;177(6):R287-R296. doi: 10.1530/EJE-17-0645.
Note: Originally published in February 2015, this article has been revised and updated for accuracy and thoroughness.