August 22, 2005

Question: When my family doctor found that I’m hypothyroid, she referred me to an endocrinologist. When I saw him, he prescribed Synthroid. I asked him to prescribe Armour, but he snapped at me, saying he’s never prescribed anything but Synthroid, and since it works perfectly well, he’s not going to prescribe anything else. He was very intense about not prescribing Armour. I guess he was angry that I’d asked him twice for Armour instead of Synthroid because he looked like he was going to burst at the seams. He said, "Go ahead and get somebody else to prescribe Armour. The T3 in it will make your T3 blood level peak in a couple of hours, and then you’ll have heart palpitations, nervousness, and insomnia." Then he snapped at me: "When that happens, don’t come whining to me. Go back to whoever was stupid enough to prescribe the Armour for you." I was shocked at how rude he was. That was my first and last trip to his office. His rudeness aside, if the peak T3 level is really such a problem, why do so many people prefer Armour to Synthroid?

Dr. Lowe: The answer is that the endocrinologist is mistaken; the peak T3 level is not a problem. The only time Armour causes adverse effects is when a patient takes too much for her as an individual—just as when she takes too much of any other thyroid hormone product, including Synthroid.

We’ve observed many hundreds of patients taking products that contain T3. Despite our careful inquiries of many of these patients, we’ve never heard complaints of adverse effects that could credibly be ascribed to peak T3 blood level.

My impression is that most endocrinologists have had little-to-no clinical experience with T3-containing products. Perhaps because of that, they haven’t learned that the adverse effects from peak T3 levels that they so often warn against seldom if ever occur. Their false belief that adverse effects do occur, however, serves well the financial interests of corporations that market T4 products, such as Synthroid. Some endocrinologists may not be cognizant of it, but when they parrot this false belief, they’re taking part in their profession’s quid pro quo for the enormous financial and nonfinancial incentives that T4-marketing corporations lavish on their specialty. (I document this in my soon-to-be published book Tyranny of the TSH.)

What should a patient, such as you, do when an endocrinologist espouses the false belief and then refuses to prescribe a T4/T3 product such as Armour. She should insist that the endocrinologist back up the belief with scientific evidence. What she’ll get instead, however, is an authoritative pronouncement that the adverse effects do occur, which boils down to nothing more than thoughtless mouthing of a marketing script.

Incidentally, I regret that the endocrinologist was ill-mannered toward you. You’re now a member of the huge population of hypothyroid patients who’ve reported gratuitous rudeness by members of that specialty.

Perhaps many endocrinologists are rude to patients such as you because they feel vulnerable. After all, they really have no scientific defense for prescribing only T4 products, which are ineffective for and harmful to many patients. In general, their choice of Synthroid is not based on science; instead, it’s based on the flagrant conflict of interest between high-profile opinion-makers in their specialty and, in the US, Abbott Laboratories, which markets Synthroid.

Most endocrinologists restrict their hypothyroid patients to T4-replacement. But no hypothyroid patient today has to settle for this inferior and dangerous treatment. Thousands of doctors not on the take from Abbott now offer safer and more effective thyroid hormone therapies. For your own health and well-being, I encourage you to find one of these other doctors.

(I have elsewhere covered the false belief that peak T3 levels from the use of T3-containing products cause adverse effects. Please see sections in my critique of Dr. Richard Guttler's false and harmful beliefs about hypothyroidism, and my critique of recent T4 vs T4/T3 studies.)

November 27, 2004

Question: Six months ago, I was losing a lot of hair. I started studying hair loss and found out it might be caused by a thyroid problem. I went to see my doctor, and as it turned out, I was right. My TSH level was 20.8. My doctor said I'm hypothyroid and prescribed 75 mcg of Synthroid. Since I’ve been using the Synthroid, I’ve felt worse and worse, and my hair is still falling out. My doctor says that since my TSH is now 1.8, the Synthroid is working fine. After studying more, I found out that many hypothyroid people don’t do well with Synthroid but get better with Armour. My doctor has talked it down, saying that in lab test studies, Synthroid worked better. He said that if I take Armour, the T3 in my blood will peak, and that may cause me to have a heart attack. I don’t want to risk that. At 27 years old, I’m not ready to die. What are my other options? Is there some other treatment I can get, or am I doomed to stay on Synthroid, feel horrible, and lose all my hair?

Dr. Lowe: Your best options are to reeducate your doctor or find one who’s more knowledgeable about thyroid hormone therapy. I suspect that your doctor has been mislead by two groundless beliefs promulgated by the endocrinology specialty—beliefs with disastrous consequences for hypothyroid patients such as you. The beliefs are about potential harm from using thyroid hormone products, such as Armour, that contain T3 as well as T4.

The endocrinology specialty first promotes the belief that only a steady blood level of T3 is normal and healthy; it follows through with a second, corollary belief: that is, if the T3 blood level peaks briefly, as after taking Armour, the patient is in peril. He’ll probably have troubling heart palpitations, but worse, he may drop dead from a heart attack. The way around these potential problems, says the specialty, is to use T4 alone, as in Synthroid.

It is true that for some some patients, a brief peak T3 level is indeed dangerous. But these patients aren’t likely to walk into doctors’ offices and ask for Armour or T3. The reason is, they’re lying on their death beds in nursing homes, and a sip of coffee or tea might make their fragile hearts shutter and threaten to stop beating.

True, the hearts of these decrepit patients may not tolerate peak T3 levels well. This doesn’t mean, however, that the same is true of the hearts of all patients. But concluding that it is true of all is an absurdly invalid deduction the endocrinology specialty has made.

For most patients, the brief peak T3 level from T4/T3 or T3 products is entirely inconsequential. I have observed— scrutinized is more accurate—many hundreds of patients who were using Armour or plain T3. Not a single one complained of troublesome palpitations during the peak T3 level. And not one reported a symptom during that peak T3 time that intimated an impending heart attack. In fact, no patient reported a symptom that suggested even a mild heart dysfunction.

The belief that the peak T3 level is troubling or dangerous for most hypothyroid patients has no scientific grounds. But as a scare tactic, it is an excellent marketing strategy. The belief has undoubtedly frightened hundreds of thousands of doctors, such as yours, into prescribing Synthroid in lieu of Armour. And as a result, it’s led to the sustained suffering of millions of patients, such as you.

The solution to this problem—as with so many other health problems today—is to reeducate your doctor. Or, if his mind is closed, the solution is to find another one who already knows how to treat you safely and effectively. Best of luck at it.

More on the Endocrinology Specialty's Presumption that T3 Adversely Affects the Heart

February 10, 2004

Question: You read where you said that Forest Pharmaceuticals doesn’t actively market Armour Thyroid or go after those who bad mouth the product. Do you know why?

Dr. Lowe: A representative at Forest Pharmaceuticals told me that what seems like indifference by the company is strictly a business decision. Forest could pay for studies to show that Armour is as stable and effective as any other thyroid hormone product. But the studies could cost as much as three millions dollars, and this wouldn’t be cost effective for the company. The reason is that the projected increase in sales of Armour wouldn’t make the investment in the studies financially worth while. Besides, Armour Thyroid sells quite well based on its effectiveness compared to competitive products.

February 8, 2004

Question: A doctor told me that Armour Thyroid is named Armour because the shape of the thyroid gland is like a shield. Do you know if this is true?

Dr. Lowe: I doubt it, mainly because the gland is shaped more like a butterfly than a shield. Nonetheless, I’ve occasionally heard what the doctor told you about the origin of the name Armour Thyroid.

Until today, I had no idea whether or not it was true. I checked my dictionary to see if it contained any helpful information. I found that a meat-packing industrialist, who lived from 1832 to 1901, was named Philip Danforth Armour. This raised a question as to whether Armour Thyroid bears his name.

To find out, I contacted a representative of Forest Pharmaceuticals, the company that markets Armour. He told me that the origin of the name isn’t certain, but most likely, the first drug company to market the product named it after Armour Meat Company of St. Louis, Missouri. This was the company Philip Danforth Armour owned. The Forest representative said that slaughtering of animals at the meat-packing company made thyroid tissue available for medical use. 

The representative wasn’t sure when the product was first marketed, but he thinks it goes back at least to 1940. I’ve often heard, without verification, that Armour has been on the market for a hundred years or so. He commented that there's a problem in knowing the product's true lineage: Forest is the 4th or 5th company to own the right to market Armour, and former companies usually don’t pass along to successive companies a detailed history of the product. He told me that Forest, which is based in St. Louis, acquired the right to market Armour from a French drug company, bringing it back to its geographic birthplace.

Dr. Lowe: Armour Thyroid is desiccated thyroid derived from pig thyroid gland tissue. Most of our hypothyroid patients use Armour, and they respond extremely well to high enough dosages.

Sales representatives from one particular drug company have deceptively misled doctors into believing that the animal source of Armour makes its thyroid hormone content unreliable. The product's potency, however, is as reliable as that of any synthetic product. For patients who don't want to ingest animal products, Thyrolar is an excellent synthetic alternative to Armour. Armour and Thyrolar have the same ratio of T4 to T3. They are equally reliable and effective when patients use high enough doses.

Armour and Thyrolar both contain 38 mcg of T4 and 9 mcg of T3. This is 4 parts T4 to 1 part T3 (the exact ratio is 4.22 to 1).

Some endocrinologists now advocate the use of products containing both T4 and T3, but they recommend a higher T4 to T3 ratio. They prefer a ratio 10 parts T4 to 1 part T3. The lower T3 content of such products renders them far less effective than Armour and Thyrolar. In our clinical experience, the treatment outcome is inferior for patients who use products with the lower T3 content.

The inferior treatment outcome is supported by two recent studies conducted by endocrinologists.[1][2] The studies showed that patients who added only a small amount of T3 to their T4 continued to suffer from symptoms, just as did patients who used T4 alone. The ratios of T4 to T3 the patients used varied, but most  used a higher T4 to T3 ration than in Armour and Thyrolar. Of course, the endocrinologists restricted the patients' dosages according to their TSH and thyroid hormone levels, and this almost guaranteed that the patients took too little thyroid hormone and continued to suffer from hypothyroid symptoms.

After four weeks, I called him and complained. I actually felt worse than before I started the Armour. He told me to come in and have blood work done, so I went in the next day. Two days later, his nurse called me with the results. My TSH 1.16 (it was 1.24 before I started the Armour), and my free T3 and free T4 were slightly above the middle mark. He told me my results were "textbook perfect," but I talked him into raising my dose to 90 mg.

I’ve been on the 90 mg for two weeks and my symptoms haven’t gotten any better. I do aerobic exercise and weight training every day except Sunday. I also stick to a low glycemic type diet. My lifestyle is good, and I don’t think it’s what’s holding me back from getting better. I’m getting frustrated and it’s hard to keep up the positive attitude. I'm slowly getting depressed about not getting better, but there’s not much more I can do. I already work my butt off. Should I press the endocrinologist to increase my dose further?

Dr. Lowe: It's good that you have an endocrinologist willing to prescribe Armour for you. Most endocrinologists are T4 bigots; yours isn’t, and that’s refreshing and fortunate for you.

Hopefully the endocrinologist won’t keep your Armour dose too low. He most likely will, however, if he adjusts your dose according to your TSH and thyroid hormone levels while ignoring your clinical response to a particular dose. To get well, some patients must use Armour doses that are high enough to produce TSH and thyroid hormone levels that upset endocrinologists. But the lab values are meaningless in themselves, as long as a patient isn’t overstimulated and has gotten well from her hypothyroid symptoms. What's truly harmful is for a doctor to keep a hypothyroid patient’s dose too low strictly for the sake of predetermined lab values.

You said that your endocrinologist scheduled you for a reevaluation ten weeks after you started using Armour. Two to four weeks is usually enough time to evaluate the benefits, if any, from a particular dose of Armour. I see no reason to wait ten weeks for a reevaluation.

On the other hand, I hope you don’t allow yourself to sink into depression because you haven’t gotten any better after two weeks on 90 mg of Armour. Impatience is understandable since you’ve suffered from hypothyroid symptoms for years. But a little more patience is necessary to find your optimal dose. Armour contains both T4 and T3. The benefits you’ll eventually get from the product will be a combined effect of the T4 and T3. If you increase your dose of Armour, and the increased dose contains enough T3 to benefit you, you’re likely to see the benefit within a few days to a week. But you may not benefit from the T4 for one to four weeks. To see how you benefit from both the T3 and T4 in the Armour, you must wait out the lag time of up to four weeks. Hopefully you’ll wait patiently; otherwise, you’re likely compound the frustration you must already feel.

If a new dose of Armour contains too little T4 and T3 to benefit you, you’ll have to go through another evaluation period. And you’ll have to do this again and again until you find what I call your "therapeutic window"—a small dosage range that optimally benefits you without overstimulating you. That optimal dosage range is highly individual, but historically, the typical patient’s therapeutic window has been somewhere between 120 to 240 mg (2 to 4 grains). There’s no way to accurately predict what your therapeutic window is. Until you find it, you may not improve much from the Armour. But once you do, you’re likely to feel that the wait was well worth it.

Dr. Lowe: No—Armour is not dangerous when patients use it properly, and it's not about to be taken off the market.

When most hypothyroid patients first consult us at our Center for Metabolic Health, they’re using Synthroid. Some of them have been using it for only six months; others have used it for as long as thirty years.

These hypothyroid patients consult us mainly for one of two reasons. First, some have suffered from the same hypothyroid symptoms at the same intensity for so long—despite their use of Synthroid—that they're weary of it. Other patients’ hypothyroid symptoms have gradually worsened to an intolerable degree, despite their continued use of Synthroid.

After we've evaluated these hypothyroid patients, a prescribing doctor on our treatment and research team switches them to Armour Thyroid—the product with which all our hypothyroid patients begin metabolic rehab. We then guide the patients through rehab. Within one-to-three months, virtually every one of the patients fully recovers her health—that is, she becomes completely free of hypothyroid symptoms.

Despite your doctor's opinion, none of these patients are harmed in any way by using Armour. Our treatment protocol includes painstaking monitoring for possible adverse effects from thyroid hormone. Our safety monitoring over many years has given us ample objective evidence that our hypothyroid patients' use of Armour is entirely safe. And our record of Armour’s safety is consistent with that in the published research literature; that literature contains no evidence whatever of a danger in the use of Armour.

The long history of patients’ safe use of Armour makes clear the professionally responsible course of action for your doctor: First, she should educate herself about Armour’s safety record. Second, she should seriously contemplate the harm she's likely to do to patients by restricting them to chronic hypometabolism through her exclusive use of Synthroid.

Some of our hypothyroid patients who recover with Armour subsequently become extremely angry. Some were ill with hypothyroid symptoms for decades, while their endocrinologists or other conventional doctors forced them to use the most expensive thyroid hormone product, Synthroid. Then they’re well after only a couple month's use of the least expensive thyroid product, Armour. To me, their anger at and contempt for their former doctors is quite understandable.

Some doctors, such as yours, have recently spread gossip about Armour Thyroid being removed from the market. I've just now spoken by telephone with an official at Forest Pharmaceuticals, the company that produces and markets Armour. She was firm that the company has no intention of ceasing to produce and market Armour. Its sales are stable. They’re stable despite unscrupulous marketing methods—such as spreading malicious gossip about Armour—by some of Forest's competitors in the drug industry, and by some endocrinologists who are complicitous with those competitors.

Hence, you can disregard your doctor's opinion as false. Patients have safely used Armour for a hundred years, and it will continue to be prescribed by doctors who are committed to getting their hypothyroid patients well. These doctors will be able to continue prescribing Armour because Forest Pharmaceuticals has every intention of keeping this excellent product on the market.

I wish you the best in finding a doctor who'll switch you to Armour. After the switch, I trust that you'll—like so many of our patients—recover from any hypothyroid symptoms the Synthroid has left you with.