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In Defense of Dr. Barry Peatfield |
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News
Fibromyalgia Research Foundation
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 Fibromyalgia Research Foundation A Nonprofit Organization for Research and Education April 17, 2001 Richard Clifford Dear Mr. Clifford: Preliminary Note: In this letter, I will refer repeatedly to the "mandates" of the conventional thyroid specialty. By mandates, I refer to four propositions that serve as guidelines to the diagnosis and treatment of hypothyroidism. The mandates are: (1) a deficiency of thyroid hormone is the only cause of symptoms and signs characteristic of hypothyroidism, (2) clinicians should not permit patients with "normal" thyroid test results to use thyroid hormone, (3) hypothyroid patients should use thyroid hormone only in "replacement dosages" (dosages that keep the TSH within its reference range), and (4) hypothyroid patients should only use thyroxine (T4). As I recently documented, each of these mandates is false.[1] I use the term "mandates" to refer to the propositions for a specific reason: because the punitive powers of regulatory agencies, such as the General Medical Council, subjugate physicians to them. The powers of regulatory agencies of conventional medicine can be invoked to force physicians to use the diagnostic and treatment protocol dictated by the mandates. Those powers force physicians to comply with the mandates, even when the protocol the mandates decree clearly fails to meet the needs of the physicians’ hypothyroid or thyroid hormone resistance patients. The powers can also be invoked to punish physicians who violate the mandates. The physicians may be punished even though violating the mandates was the only way to relieve the suffering of their patients. Some physicians, such as Dr. Barry Peatfield, have steadfastly persisted in violating the mandates. Their doing so has been an act of courage, for the risk they have faced on their patients’ behalf is suspension or revocation of the privilege to practice medicine. Comments on Dr. Barry
Peatfield’s Medical Practice Dr. Peatfield’s Knowledge
of the Field of Thyroidology I had the privilege of visiting Dr. Peatfield in England in October, 2000. I spent several days with him, intensely discussing thyroidology and fibromyalgia. During these discussions, we talked in great detail about his clinical practice. We spent considerable time discussing similarities and differences of his practice from those of other clinicians offering the public alternatives to the conventional medical treatment protocol for hypothyroid patients. From these extensive discussions with Dr. Peatfield, I know that he has read my textbook cover to cover—all 1260 pages. Having written the book, I can, of course, easily discern from discussions with individuals who have and have not read it. Dr. Peatfield has done so, through and through. This is an enormous feat, considering the size of the book. That he has read the entire book is substantial evidence that he is intensely dedicated to acquiring cutting-edge knowledge of thyroidology. From my discussions with him, I know that his motivation for such burdensome study is to provide his hypothyroid patients with the highest possible quality of care. During the past thirty years, the conventional thyroid specialty has succeeded in abbreviating most physicians’ knowledge of thyroidology to two false propositions. The first is that the TSH is the only test physicians need to identify and manage hypothyroid patients. The second is that the only thyroid hormone hypothyroid patients ever need to use is thyroxine. Dr. Peatfield is a stellar exception to this dwarfing of physicians’ knowledge of thyroidology. I consider him one of the rare physicians today with a vast, rational, and current-state-of-the-field knowledge of thyroidology. In my estimation, his knowledge of thyroidology far exceeds that of all but a few endocrinologists I have communicated with during the past 15 years. Moreover, from my lengthy discussions with Dr. Peatfield and two of his assistants, I learned that in his management of hypothyroid patients, his decisions are based on thoughtful consideration of his vast knowledge of thyroidology. What more can one ask of a medical practitioner caring for hypothyroid patients. Dr. Peatfield’s Choice
of Thyroid Hormone Preparations Use of Thyroxine. Dr. Anthony Toft recently wrote that most hypothyroid patients being treated with thyroxine "have no complaints about their medication."[18] He made a similar statement in an October, 2000 letter to Mrs. Linda Thipthorp of Truro, Cornwall, England: "The overwhelming majority of patients receiving thyroxine therapy for an underactive thyroid gland in whom blood tests are normal feel perfectly well."[19] Dr. Toft’s enthusiastic endorsement of thyroxine treatment drew a rebuttal from Mary Shomon (the world’s foremost advocate of patients dissatisfied with conventional medical treatment). "Toft’s opinion," she wrote, "actually directly contradicts the findings of informal research conducted by the Thyroid Foundation of America that showed that the majority of post-Graves’ disease hypothyroid patients still suffered a variety of symptoms when on levothyroxine."[20,p.153] Indeed, contrary to Dr. Toft’s opinion, available evidence shows widespread dissatisfaction with conventional thyroid hormone therapy dictated by the mandates. The mandate that physicians permit patients to use only thyroxine has generated tremendous dissatisfaction. My website, <www.drlowe.com>, is visited almost exclusively by patients dissatisfied with conventional thyroid hormone treatment. The site now has between 13,000 and 16,000 different visitors per month. Even stronger evidence for dissatisfaction is Mary Shomon’s website, for hypothyroid patients displeased with their conventional treatment. Her site has an average of half a million visitors each months! Moreover, her book for hypothyroid patients dissatisfied with their conventional care, Living Well with Hypothyroidism,[20] was an instant bestseller. More than a year after its publication, its sales remain extremely high all across the English-speaking world. Perhaps when Dr. Toft made the statements I quoted above, he had not been privy to such evidence. Regardless, the available evidence shows that his statement about patient satisfaction with thyroxine is wrong. Dr. Peatfield is well aware of this evidence. And his awareness contributes to his prudent and responsible decision not to treat his hypothyroid patients with thyroxine alone, but, instead, to treat them with desiccated thyroid or T3 alone. I should mention that some researchers have concluded that treatment results with thyroxine are "superior" to those with desiccated thyroid.[31][32][33][34][35][36] In estimating which preparation was superior, some researchers mentioned the clinical status of patients in their studies. A thorough reading of the published papers, however, makes one thing clear: Most often, by "superior," the researchers have meant that thyroxine has provided free T3 levels more steadily within the reference range than has desiccated thyroid.[35] Hence, the researchers’ aim in treating patients with thyroid hormone has been to keep the TSH and thyroid hormone levels within their reference-ranges. The clinical and health status of patients has been of little or no concern. The results of these studies, therefore, should not be interpreted to mean that thyroxine is superior in eliminating patients’ hypothyroid symptoms and signs and returning them to a healthy status. Use of Desiccated Thyroid. Dr. Peatfield prescribes desiccated thyroid or T3 for hypothyroid patients. The choice he makes depends on his mindful consideration of the individual patient’s needs. His use of desiccated thyroid shows a freedom from the prejudicial and pejorative view of desiccated thyroid that predominates within the conventional thyroid specialty. Consider, for example, Dr. Anthony Toft’s recent statement, "Those who advocate the use of Armour thyroid do so on the basis of no evidence whatever . . ."[19] It is beyond my comprehension why anyone familiar with the thyroidology literature would make such an glaringly false statement. That desiccated thyroid, when used properly, is an effective and safe treatment for hypothyroidism is massively documented in the medical literature. In fact, through the first two thirds of the 20th century, most clinical studies within the field of thyroidology involved the use of desiccated thyroid. The published evidence that desiccated thyroid—in dosages twice to three times the equivalent amount of thyroxine prescribed nowadays by conventional physicians—is both safe and effective in the treatment of hypothyroidism is simply too massive to reference here. In the 1970s, some pharmaceutical companies that market brands of thyroxine began providing enormous financial incentives to the conventional thyroid specialty. Until then, desiccate thyroid was far more widely prescribed than was thyroxine. Financial incentives from these companies continues and is gargantuan. Synthroid, for example, is a brand of thyroxine marketed by Knoll Pharmaceutical Company. Synthroid is one of the most frequently prescribed medications in the United States. It is a fact of life that he who pays the Piper calls the tune. And when a corporation such as Knoll pharmaceutical Company donates a million dollars to the American Thyroid Society to fund thyroid research,[14] I am convinced that studies the Society funds with that money will be those whose outcomes are likely to be favorable to the financial interests of Knoll. This will ensure a continuing financial relationship between the Society, the funded researchers, and Knoll. Studies that would militate against the financial interests of the corporation are not likely to be funded. Similarly, when Knoll Pharmaceutical Company provides funding of the American Association of Clinical Endocrinologists (AACE) to develop practice guidelines,[15] those guidelines are likely to admonish physicians that the only form of thyroid hormone hypothyroid patients need is thyroxine. I must also mention here that the use of TSH assays is enormous, providing immense revenues for companies that market them. Bulusu, a consultant chemical pathologist in England, wrote in 2000, "Most laboratories in the country are experiencing an exponential increase in workload for these tests. It is worrying that clinical diagnosis has been relegated to history, and that assessment is based almost entirely on biochemical tests." He referred to the "huge increases in work load and cost of doing these tests."[17] O’Reilly[16] wrote in 2000 that 890,000 TSH tests were performed in Scottish hospital laboratories alone. (TSH tests performed by non-National Health Service laboratories and those performed for screening for congenital hypothyroidism were not included in the calculation.) O’Reilly also wrote that the market for TSH assays in the United Kingdom (population of 59 million) is currently estimated at 9-to-10 million per year. The large revenues from the marketing of thyroxine and TSH assays convince me that market forces powerfully dictate dynamics within conventional medicine so that the flow of money is stabilized. I raise this possibility to those within the General Medical Council because I believe it to be plausible, and if so, it seems to me a matter that must be investigated. Science and not financial incentives should be the basis of medical protocols that impact the lives of millions of human beings. Some will consider it noblesse oblige of me to bring these matters up here. My rejoinder is that it would be ethically derelict of me not to. It is hard for me to imagine that rational considerations account for the intransigence of the conventional thyroid specialty toward those of us who consider its mandates pernicious to the health and well-being of patients. My opinion is that something other than rationality must account for the rigid adherence of the conventional thyroid specialty to mandates that so conspicuously fail to serve the interests of hypothyroid patients. In my view, it is well within the realm of possibility that, as with the industrial/military complex, the issue of human suffering and preventable death as a trade off for huge financial profits is an irrelevancy to corporate entities and individuals who profit from sales of thyroxine and TSH assays. It therefore appears to me that financial incentives have been instrumental in shaping the conventional belief that thyroxine is "superior" to desiccated thyroid. Despite the advocacy of treatment with thyroxine, desiccated thyroid provided such satisfactory clinical results that physicians continued to prescribe it widely until the power of financial incentives changed the conventional medical preference to thyroxine. In addition, experimental studies comparing the effects of desiccated thyroid and thyroxine clearly demonstrate that desiccated thyroid is effective. Hence, I believe the conventional preference for treatment with thyroxine alone for the treatment of hypothyroidism has been financially rather than scientifically based. After years of systematic and meticulous record-keeping and analyses of our data, we no longer use thyroxine alone in the treatment of hypothyroid patients. Our data showed that thyroxine alone provided such overwhelmingly inferior clinical results that we no longer can ethically restrict our patients to it. With most hypothyroid patients, we use either a synthetic T4/T3 combination or desiccated thyroid. Some hypothyroid patients do not benefit from these preparations but improve or recover only when we switch them to T3 alone.[3] Also, we have found that most biochemically euthyroid patients (those with "normal" thyroid function test results) with symptoms and signs characteristic of hypothyroidism improve or recover only with the use of T3 alone. Use of T3. My research team has established that approximately 33% of fibromyalgia patients have laboratory-documented partial cellular resistance to thyroid hormone.[21][22] In addition, we have found in double-blind and case-control studies that the use of T3 therapy, within a context of a more comprehensive regimen of metabolic rehabilitation, is both safe and effective in enabling patients to markedly improve or fully recover from their hypothyroid-like symptoms and signs.[2][3][4][5][6][7][8][9] After having studied my research team’s published scientific papers and my textbook, The Metabolic Treatment of Fibromyalgia, Dr. Peatfield has astutely used T3 therapy for the benefit of some patients. A sterling example of one of his patients who has recovered with the use of T3 alone is Mrs. Linda Thipthorp of Truro, Cornwall, England, whom I reference at other points in this letter. Dr. Peatfield uses T3 therapy appropriately, within the context of a broad-spectrum metabolic rehabilitation regimen. Having discussed at great length with him the diagnostic and treatment protocol within which he uses T3 therapy, I am convinced that he uses this thyroid preparation in his practice in a responsible, safe, and effective fashion. Dr. Peatfield’s
Predominant Use of Patients’ Clinical
Results of studies of the use of clinical indices by other groups, such as Johansen et al.,[30] are consistent with those of Fraser et al. Moreover, studies by Skinner et al.[12][13] and my research team[2][3][4][5][6][7][8][9] support the findings of Fisher et al and Johansen et al. As a result of such studies and his own research and clinical experiences, Derry has recommended that the use of the TSH test be abandoned.[26][27] Despite this experimental support published in the medical literature, regulatory agencies—probably at the behest of the conventional thyroid specialty—continue to threaten or actually impose punishments on physicians, such as Dr. Peatfield, who heed the message of these scientific studies and use clinical indices in lieu of laboratory test values in their practices. Despite the results of such studies, the conventional thyroid specialty has continued to promote the use of laboratory test values in lieu of clinical indices. The available evidence indicates that conventional physicians’ dismissal of patients’ continuing symptoms and signs from the under-treatment or absence of treatment of hypothyroidism or thyroid hormone resistance has given rise to the "new diseases." These include fibromyalgia, chronic fatigue syndrome, and myalgic encephalomyelitis. An almost exclusive focus on the results of thyroid function test results, and neglect of the clinical and health status of hypothyroid patients, has become the standard of practice in conventional medicine. Some conventional thyroid specialists deny this. For example, Toft and Beckett wrote, "Dr. O’Reilly . . . overstates his view that the clinical aspects of thyroid disease have been remarkably downgraded." They wrote further, "The correct diagnosis will usually be made on the basis of both clinical examination and the results of appropriate thyroid function tests."[10] Similarly, endocrinologist Kendall-Taylor, reacted to complaints that conventional thyroid specialists ignore patients’ symptoms and signs. He protested, "The statement that ‘the clinical features of hypothyroidism . . . have been relegated to the status of historical curiosities’ is manifestly absurd: What the clinician aims to do is not simply categorize a patient into ‘hyperthyroidism’ or the subclinical variants, but rather to make a full diagnostic assessment, for which the thyroid function tests are one important facet."[28] Seemingly verifying these defenses of the conventional medical protocol, endocrinologist Cassar recommended that patients not be permitted to use thyroid hormone unless the TSH is 10 mU/L or there is "a compelling clinical indication."[9] (Italics mine.) His use of the words "a compelling clinical indication" suggests that physicians should consider patients’ symptoms and signs. The fact is, however, that such recommendations by conventional thyroid specialists are more academic and theoretical than real. I say this because conventional thyroid specialists have provided themselves with a rationale for disregarding symptoms and signs typical of hypothyroidism when these are inconsistent with the results of a patient’s TSH level. In the face of such an inconsistency, the rationale is distinctly dismissive of patients’ symptoms and signs. To wit: "Notwithstanding the physician’s assurance that the T4 dose is optimal, and the demonstration that serum TSH has decreased into the normal range, these patients may ask for a larger dose or take a larger dose on their own initiative. In this setting, the patient should be reassured that the T4 dose prescribed is appropriate, and other causes of the patient’s complaints must be investigated."[11] (Italics mine.) (This statement is excerpted from Surks’ chapter titled "Treatment of Hypothyroidism" in a major textbook on thyroidology, the 6th edition of Werner’s The Thyroid: A Fundamental and Clinical Text, published in 1991.) Surks’ advice to reassure patients that their dose "is appropriate" presumes that the patient’s T4 dose is adequate for the patient’s individual needs. His advice that "other causes of the patient’s complaints" be investigated shows a preconceived notion that replacement dosages of T4 are infallibly effective. In addition, his advice implies that if the patient is taking a replacement dose of T4 and is continuing to have symptoms typical of hypothyroidism, these must be caused by some other disorder. It is precisely this rationale of conventional thyroid specialists that has given rise to the supposed "new diseases" of the past 30 years: fibromyalgia, chronic fatigue syndrome, myalgic encephalomyelitis, and others—all largely the result of untreated or under-treated hypothyroidism or partial cellular resistance to thyroid hormone.[1][12][13][26][27] As Dr. Gina Honeyman-Lowe and I have argued with substantial documentary evidence,[21][22] the disorder underlying most patients’ fibromyalgia is inadequate thyroid hormone tissue regulation. Our data indicate that the fibromyalgia symptoms and signs of approximately 90% of patients are features of hypothyroidism and/or thyroid hormone resistance complicated by low physical fitness levels, nutritional deficiencies, the dysglycemic effects of poor diet, and adverse metabolic effects of various medications prescribed to control various symptoms of hypothyroidism and/or thyroid hormone resistance. Many researchers have concluded that fibromyalgia and chronic fatigue syndrome are one and the same disorder.[23] Based on their comparative studies, it is highly probably that the etiology is the same as that of fibromyalgia—inadequate thyroid hormone tissue regulation. Other researchers who concur that fibromyalgia and chronic fatigue syndrome are features of untreated or under-treated inadequate thyroid hormone regulation include Dr. David Derry, former Scholar of the Medical Research Council of Canada,[26][27] and Dr. Gordon Skinner and Dr. Afshan Ahmad of Birmingham, Warwick, England.[12][13] Epidemiological studies indicate that the incidence of fibromyalgia in different countries ranges from 2% to 13% of the populations.[24][25] If we are correct that the main underlying mechanism of fibromyalgia is inadequate thyroid hormone regulation of tissues, then the incidence of the fibromyalgic clinical phenotype alone in industrialized countries suggests that the mandates of the conventional thyroid specialty have caused a major public health crisis. When we include other clinical phenotypes (such has dyslipidemia and cardiovascular disease, depression, and chronic fatigue syndrome) in the calculation, the number of affected people totals scores of millions. This staggering figure suggests a shocking tragedy—that by imposing the mandates on physicians and their patients, the conventional thyroid specialty has caused the most colossal public health disaster in the history of medicine. It is my conclusion that this is precisely the legacy of the conventional thyroid specialty of the past thirty years. The conventional thyroid specialty proclaims that it has established the "gold standard" for the diagnosis and treatment of hypothyroidism, expressed in their four mandates. Solving the problem of hypothyroidism by defining patients as "well" when their TSH and thyroid hormone levels are within the reference ranges, despite their continued suffering from hypothyroid-like symptoms and signs, is nothing more than a linguistic solution. The mandates, by dictating the choices of conventional physicians, have ruined the quality of life of millions of hypothyroid and thyroid hormone resistance patients. The mandates have also consigned uncountable numbers of people to premature death. It is noteworthy that Dr. Peatfield recognizes the pernicious effects of the mandates on hypothyroid patients, and that he has courageously chosen, on his patients’ behalf, to practice in violation of the mandates. I am convinced that the widespread use of clinical indices in the diagnosis and treatment of hypothyroid and thyroid hormone resistance patients would, with a few years, largely eliminate the putative "new diseases." But this rescue of millions of patients can occur only if physicians are permitted, with impunity, to conduct medical practices exemplified by that of Dr. Peatfield. Dr. Peatfield’s
Patient Education Program Dr. Honeyman-Lowe and I left England feeling that this aspect of Dr. Peatfield’s clinical practice is exemplary, and that other physicians’ patients would benefit from modeling his example. Having been particularly impressed with this aspect of Dr. Peatfield’s practice, I am perplexed about the accusation that he has not adequately informed his patients about relevant aspects of hydrocortisone treatment. The accusation starkly contrasts with our observations. One complaint against Dr. Peatfield apparently is that he has not informed patients of the need to gradually withdraw patients from physiologic doses of hydrocortisone. In general, I do not believe there is any indication to do so. The purpose of physiologic dosages of hydrocortisone is to compensate temporarily for decreased adrenal reserve, and a rebound deficiency upon abrupt withdrawal would be extraordinarily unlikely. This is especially so in that during the time Dr. Peatfield has patients taking physiologic dosages of hydrocortisone, the patients are also undergoing thyroid hormone therapy. If a patient, before beginning treatment with Dr. Peatfield, had decreased adrenocortical function due to inadequate thyroid hormone regulation, the thyroid hormone therapy will have increased adrenocortical function. As a result, when the patient stops taking the physiologic dosage of hydrocortisone, his or her adrenal cortices should be able to synthesize and secrete sufficient amounts of cortisol. Thus, in general, the results are distinctly different from that in patients taking pharmacologic dosages of hydrocortisone. Dr. William McK. Jefferies has championed the safe uses of cortisol.[37] Dr. Peatfield’s use of this therapeutic agent is vindicated by Jefferies research and other explorations of this subject. Conclusion Physicians such as Dr. Barry Peatfield are doing their small part to rectify the damage by violating the mandates in their clinical practices. To do so, they courageously risk punishment by regulatory agencies such as the General Medical Council. Rather than being punished, however, these physicians should be honored by medical societies for their courage and humanitarian efforts. In addition, regulatory agencies should take it upon themselves to recognize the human suffering and premature death caused by the mandates of the conventional thyroid specialty, and they should call that specialty to account for its horrifying legacy of the past thirty years. I will be happy to elaborate, in writing or in person, any of the viewpoints I have expressed in this letter. The public health ramifications of the mandates of the conventional thyroid specialty are gravely serious. Because of this, I urge the General Medical Council to both exonerate Dr. Peatfield, and to address the pernicious impact of the mandates on the health and well-being of citizens of the United Kingdom. Best regards, cc: Barry Durrant-Peatfield, M.B. Follow
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