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Treatments for Thyroid Dysfunction

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Type of doctors who can prescribe thyroid medications

Integrative wellness treatments from physicians of all specialties.

The treatment of hypothyroidism has been traditionally managed by endocrinologists, internists, and primary care physicians. These doctors commonly prescribe levothyroxine monotherapy to restore thyroid hormones to physiologic levels. In recent years, a more progressive approach to treating hormone imbalance has attracted physicians of all specialties and academic backgrounds.

Integrative wellness is a term used to describe the practice of treating a patient through a comprehensive approach. It often includes hormone replacement therapies, nutritional support, and lifestyle modifications to help mitigate preventable disease and reverse symptoms from age related (or disease induced) hormone deficiencies. Some doctors focus on specific hormone types, most commonly sex hormones and pituitary secretagogues.

Many integrative/interventional doctors also address thyroid function and prescribe treatment for hypothyroidism. These doctors are most likely to be open to prescribing compounded thyroid combinations and desiccated thyroid as an alternative to levothyroxine alone. Although there are  few credible organizations providing CMEs to doctors, it is important to understand that doctors can also receive misinformation disseminated by un-accredited organizations that charge doctors for training that has not been validated.

Having a basic understanding of the symptoms, diagnosis, and available treatments for hypothyroidism will help patients select the right doctor and recognize the right approach. Most integrative doctors follow evidence-based protocols for the diagnosis and treatment of thyroid disorder, hypothyroidism, and thyroid optimization. These doctors come from all specialties, including urology, gynecology, general surgery, sports medicine, psychiatry, and general practitioner.

Available TREATMENTS

Pharmaceutical thyroid products in their different forms can be complicated and confusing to both prescribers and patients.

 

The primary treatment for thyroid disease today is levothyroxine (T4) monotherapy. However, many thyroid patients request alternative treatments, which can include a combination therapy of levothyroxine and liothyronine (T3), or supplementation with desiccated thyroid that contains small amounts of both liothyronine and levothyroxine.

According to published data, evidence does not show benefit to using combination therapies over levothyroxine monotherapy. Several studies show no change in measurements between combination therapies compared to levothyroxine monotherapy. 

However, other studies show that patients prefer combination therapy over levothyroxine monotherapy. In addition, patients experience an increase in neuropsychological function when liothyronine is added to levothyroxine treatment. Additional studies have shown improved quality of life and other benefits after patients switched to a liothyronine/levothyroxine combination therapy. 

Basically, some patients respond well to levothyroxine monotherapy, while others respond best with a combination therapy. It sometimes takes experimentation to see what's right for each particular patient.

Thyroid hormone drugs are naturally derived or synthetic preparations containing levothyroxine, liothyronine, or both.


Commercial levothyroxine tablets are contraindicated in patients with hypersensitivity to any of the inactive ingredients.* Patients with sensitivities may alternatively use a compounded thyroid medication. Compounded thyroid capsules usually only contain active ingredients with a cellulose (or alternative) filler inside a gelatin capsule. 

 

*Source: Unithroid-package insert. http://www.unithroid.com/assets/pdf/Unithroid_Gemini_PI.pdf

Levothyroxine Medication Options

Levothyroxine (T4) is available in the form of brand-name medications and compounded medications. 

  • Active Ingredient(s):
    • T3 stimulates protein synthesis. It also increases the rate of protein degradation, and, in excess, the rate of protein degradation exceeds the rate of protein synthesis causing loss of muscle tissue
  • Corresponding Hormone:
    • Thyroxine (T4); a synthetic levoisomer of thyroxine
  • Half-life:
    • 6-7 days. A single dose reaches its maximum effect in about 10 days (its binding to plasma proteins is strong as well as extensive) and passes off in 2–3 weeks (t½ 7 days in euthyroid, 14 days in hypothyroid and 3 days in hyperthyroid subjects).
  • Dosage Forms:
    • Compounded capsule; liquid-filled capsule; tablet; solution
  • Contraindications:
    • Levothyroxine is contraindicated in patients with untreated subclinical (suppressed serum TSH level with normal T3 and T4 levels) or overt thyrotoxicosis of any etiology and in patients with acute myocardial infarction. Levothyroxine is contraindicated in patients with uncorrected adrenal insufficiency since thyroid hormones may precipitate an acute adrenal crisis by increasing the metabolic clearance of glucocorticoids
  • Uses:
    • Levothyroxine is used in the treatment of primary, secondary (pituitary), and tertiary (hypothalamic) hypothyroidism. Levothyroxine will potently suppress thyrotropin secretion in the management of goiter and chronic lymphocytic thyroiditis, and it can be used in combination with antithyroid agents to prevent the abc development of hypothyroidism or goitrogenesis during the treatment of thyrotoxicosis. Intravenous levothyroxine is primarily used to treat myxedema coma or stupor. Levothyroxine therapy is preferred over thyroid and thyroglobulin because the hormonal content of levothyroxine is standardized, and the effects of the drug are more predictable. Levothyroxine provides only T4, of which roughly 80% is deiodinated to T3 and reverse T3. Since T3 is three times as potent as T4, virtually all of the activity of T4 can be ascribed to T3. Levothyroxine has been used clinically since the 1950s.
  • Description:
    • Levothyroxines long half-life makes it an ideal medication to restore thyroid hormones to stable, physiologic levels.

Brand-Name Levothyroxine Medications

  • Available Strengths: 25mcg; 50mcg; 75mcg; 88mcg; 100mcg; 112mcg; 125mcg; 137mcg; 150mcg; 175mcg; 200mcg; 300mcg
  • Dosage Form: Tablet (color, size, and shape depends on the strength)
  • Available Strengths: 25mcg; 50mcg; 75mcg; 88mcg; 100mcg; 112mcg; 125mcg; 137mcg; 150mcg; 175mcg; 200mcg; 300mcg
  • Dosage Form: Tablet (color, size, and shape depends on the strength)
  • Available Strengths: 25mcg; 50mcg; 75mcg; 88mcg; 100mcg; 112mcg; 125mcg; 137mcg; 150mcg; 175mcg; 200mcg; 300mcg
  • Dosage Form: Tablet (color, size, and shape depends on the strength)
  • Available Strengths: 13mcg; 25mcg; 50mcg; 75mcg; 88mcg; 100mcg; 112mcg; 125mcg; 137mcg; 150mcg; 175mcg; 200mcg
  • Dosage Form: Capsule (liquid filled)
  • Inactive Ingredients: gelatin, glycerine, water
  • Available Strengths: 25mcg; 50mcg; 75mcg; 88mcg; 100mcg; 112mcg; 125mcg; 137mcg; 150mcg; 175mcg; 200mcg; 300mcg
  • Dosage Form: Tablet
  • Inactive Ingredients:Colloidal silicon dioxide, lactose, magnesium stearate, microcrystalline cellulose, corn starch, acacia and sodium starch glycolate. The following are the coloring additives per tablet strength: http://www.unithroid.com/assets/pdf/
    Unithroid_Gemini_PI.pdf

Compounded Levothyroxine Medications

Compounding pharmacies that specialize in hormone products offer several thyroid options, including custom levothyroxine options. These options are most commonly available as Immediate Release or Sustained Release capsules.

Because the dosages can be customized by the prescribing provider, compounded medications can be made in dosages that are not available from commercial medications. Compounded levothyroxine can also be combined with liothyronine and other chemicals to create new combination products that are not available commercially. 

  • Available strengths: Customized by prescriber; any strength not available commercially
  • Common dosage forms: Capsule; Sublingual tablet or troche; liquid suspension
  • Release: Available in Immediate and Sustained Release
  • Inactive Ingredients: cellulose; gelatin capsule
  • Active Ingredient(s):
    •  3,3',5-triiodo-L-thyronine
  • Corresponding Hormone:
    • Liothyronine (T3
  • Half-life:
    • 6-7 days. A single dose reaches its maximum effect in about 10 days (its binding to plasma proteins is strong as well as extensive) and passes off in 2–3 weeks (t½ 7 days in euthyroid, 14 days in hypothyroid and 3 days in hyperthyroid subjects).
  • Dosage Forms:
    • Compounded capsule; liquid-filled capsule; tablet; solution
  • Uses:
    • The oral tablet is indicated for use as replacement or supplemental therapy in the treatment of hypothyroidism of any etiology, except transient hypothyroidism during the recovery phase of subacute thyroiditis; as a pituitary thyroid-stimulating hormone (TSH) suppressant in the treatment or prevention of various types of euthyroid goiters; and as a diagnostic agent in T3 suppression tests. Liothyronine injection is indicated for intravenous use in the treatment of myxedema coma/precoma. Either form of liothyronine may be used for patients who are allergic to desiccated thyroid or thyroid extract derived from pork or beef. Supraphysiologic thyroid hormone concentrations may occur following orally administered liothyronine, but not after intravenous administration. Liothyronine is potentially more cardiotoxic than levothyroxine. However, due to the faster onset of action and the need to peripherally convert levothyroxine (T4) to the biologically active T3, liothyronine has been recommended for treatment of myxedema coma.
  • Adverse:
    • Adverse reactions, other than those indicative of hyperthyroidism because of therapeutic over dosage, either initially or during the maintenance period are rare
  • Description:
    • Liothyronine (L-triiodothyronine or L-T3) is a synthetic sodium salt of the endogenous thyroid hormone triiodothyronine (T3). There are no comparative studies available. Levothyroxine is generally considered the most appropriate of the thyroid replacement agents for long-term treatment of hypothyroidism. However, a small randomized clinical trial demonstrated improvement in mood and neuropsychological function of hypothyroid patients with partial substitution of liothyronine for levothyroxine. Liothyronine received approval for use by the FDA in 1954.
Liothyronine Medication Options

Liothyronine (T3) is available in the form of brand-name medications and compounded medications. 

Brand-Name Liothyronine Medications

  • Available Strengths: 5mcg; 25mcg; 50mcg
  • Dosage Form: Tablet
  • Inactive Ingredients: Calcium Sulfate; Gelatin; Starch; Stearic Acid; Sucrose; Talc

Compounded Liothyronine Medications

Compounding pharmacies that specialize in hormone products can compound liothyronine into different dosage forms, most commonly as a Sustained-Release capsule. Compounded liothyronine can be made into strengths not available in commercial products, allowing prescribers to personalize the prescription.

Compounded liothyronine can also be combined with other ingredients to create new combination products that are not available commercially. Liothyronine is often combined with levothyroxine (see combination therapy).

  • Available Strengths: Customized by prescriber; any strength not available commercially
  • Common Dosage Forms: Capsule; Sublingual tablet or troche; liquid suspension
  • Pharmacokinetics: Available as a Sustained Release capsule 
  • Inactive Ingredients: cellulose; gelatin capsule
Liothyronine and Levothyroxine Combination Therapies

Combination therapies of Liothyronine (T3) and Levothyroxine (T4) are available from compounding pharmacies, commercially, and as desiccated (dried) thyroid medications. 

Brand-Name Combination Medications

  • Active Ingredient(s): Triiodothyronine (liothyronine, T3) sodium and tetraiodothyronine (levothyroxine, T4) sodium in the amounts listed below.
  • Available Strengths: (t3/t4 per tablet) 3.1 mcg/12.5 mcg; 6.25 mcg/25 mcg; 12.5 mcg/50 mcg ; 25 mcg/100 mcg ; 37.5 mcg/150 mcg
  • Dosage Form: Tablet 
  • Release: Only available as an immediate release tablet 
  • Inactive Ingredients: calcium phosphate, colloidal silicon dioxide, corn starch, lactose, and magnesium stearate

Compounded Combination Medications

Compounding pharmacies that specialize in hormone products can combine liothyronine (T3) and levothyroxine (T4) into a single capsule. Strengths can be customized for each ingredient by the prescriber, and additional ingredients can be added, as well – creating a wide variety of options for the provider and patient. 

  • Available Strengths: Customized by prescriber; commonly prescribed strengths include (Levothyroxine/Liothyronine): 25mcg/5mcg; 50mcg/5mcg; 75mcg/5mcg; 25mcg/10mcg; 50mcg/10mcg; 75mcg; 10mcg
  • Common Dosage Forms: Capsule
  • Release: Available in Immediate- or Sustained-Release
  • Inactive Ingredients: cellulose; gelatin capsule

Desiccated Thyroid Combination Medication

Desiccated (dried) thyroid, or thyroid extract, refers to porcine or bovine thyroid glands, which are dried and powdered for therapeutic use.

In the last few decades, pork alone has been the typical source. Desiccated thyroid is a combination of levothyroxine and liothyronine in a T4:T3 ratio of 4.22:1 per USP.

There are several commercial desiccated products available in addition to custom compounded options. Various thyroid extracts have received FDA approval since 1939.

Dessicated thyroid is indicated for the treatment of hypothyroidism, especially in improving the symptoms of thyroid deficiency such as lack of energy, weight gain, hair loss, dry skin, feeling cold, and goiter.

Desiccated Thyroid Medication Options

Desiccated thyroid is porcine- or bovine-derived thyroid gland, which is dried and powdered for use as a medication. Desiccated thyroid is available commercially and through compounding pharmacies.

Brand-Name Desiccated Thyroid Medications

  • Active Ingredient(s): The active ingredient (desiccated natural thyroid) in Armour® Thyroid (thyroid tablets, USP) is derived from porcine (pig) thyroid glands of pigs processed for human food consumption and is produced at a facility that also handles bovine (cow) tissues from animals processed for human food consumption. Each tablet provides 38 mcg levothyroxine (T4) and 9 mcg liothyronine (T3) per grain of thyroid.
  • Available Strengths: 15mg- ¼ grain; 30mg - ½ grain; 60mg- 1 grain; 90mg -1 ½ grains; 120mg -2 grains; 180mg -3grains; 240mg-4 grains; 300mg-5 grains
  • Dosage Form: Tablet
  • Inactive Ingredients: calcium stearate, dextrose, microcrystalline cellulose, sodium starch glycolate and opadry white
  • Active Ingredient(s): Nature-Throid® (Thyroid USP) Tablets, micro-coated with a reduced odor, for oral use are natural preparations derived from porcine thyroid glands. Each tablet provides 38 mcg levothyroxine (T4) and 9 mcg liothyronine (T3) for each 65 mg (1 Grain) of the labeled content of thyroid.
  • Available Strengths: 16.25 mg. (1/4 gr.); 32.5 mg. (1/2 gr.); 48.75 mg. (3/4 gr.); 65 mg. (1 gr.); 81.25 mg. (1 1/4 gr.) ; 97.5 mg. (1 1/2 gr.) ; 113.75 mg. (1 3/4 gr.); 130 mg. (2 gr.) ; 146.25 mg. (2 1/4 gr.) ; 162.5 mg. (2 1/2 gr.) ; 195 mg. (3 gr.) ; 260 mg. (4 gr.) ; 325 mg. (5 gr.)
  • Dosage Form: Tablet
  • Inactive Ingredients: Colloidal Silicon Dioxide, Dicalcium Phosphate, Lactose Monohydrate1, Magnesium Stearate, Microcrystalline Cellulose, Croscarmellose Sodium, Stearic Acid, Opadry II 85F19316 Clear

Also Known As: Westhroid Pure 

  • Active Ingredient(s): WP Thyroid® (Thyroid USP) Tablets, for oral use are natural preparations derived from porcine thyroid glands. Each tablet provides 38 mcg levothyroxine (T4) and 9 mcg liothyronine (T3) for each 65 mg (1 Grain) of the labeled content of thyroid.
  • Available Strengths: 16.25 mg. (1/4 gr.); 32.5 mg. (1/2 gr.); 48.75 mg. (3/4 gr.); 65 mg. (1 gr.); 81.25 mg. (1 1/4 gr.) ; 97.5 mg. (1 1/2 gr.) ; 113.75 mg. (1 3/4 gr.); 130 mg. (2 gr.) ; 146.25 mg. (2 1/4 gr.) ; 162.5 mg. (2 1/2 gr.) ; 195 mg. (3 gr.)
  • Dosage Form: Tablet
  • Inactive Ingredients: Inulin (from chicory root); Medium Chain Triglycerides (from coconut); Lactose Monohydrate (trace diluent); WP Thyroid is used as an alternative treatment in patients who are sensitive to the inactive ingredients found in other commercial brands

 

Combination Desiccated Thyroid Medications

Compounding pharmacies that specialize in hormone products can sometimes compound desiccated thyroid products into different dosage forms, strengths, and combinations. Compounded desiccated thyroid can be made into strengths not available in commercial products, allowing providers to personalize the prescription. Compounded desiccated thyroid provides an important alternative for providers and patients when commercial products are on back order or otherwise unavailable.

Desiccated thyroid can be combined with other ingredients to create new combination products that are not available commercially. Most compounding pharmacies use porcine-derived desiccated thyroid, which is the same source commercial manufacturers use. 

However, it is good to confirm with the compounding pharmacy that they are using porcine-derived thyroid since pharmacies are also able to source other types of desiccated thyroid including bovine-derived thyroid.

Compounded thyroid products are usually lower cost to the patient than commercial products.

  • Active Ingredients: Desiccated thyroid is a naturally occurring thyroid hormone derived from porcine thyroid glands
  • Available Strengths: Customized by prescriber; any strength not available commercially
  • Common Dosage Forms: Capsule
  • Release: Available as a Sustained-Release capsule
  • Inactive Ingredients: cellulose; gelatin capsule. Provides an alternative for patients who are sensitive to the inactive ingredients found in commercial products

Over-the-Counter Thyroid Supplements

It's important to use caution with thyroid supplements. 

Thyroid supplements might contain desiccated thyroid extracts (including bovine or porcine) with hormone concentrations that are unknown or not verified. Dessiccated thyroid extracts should only be supplemented using pharmaceutical products that have been validated for source and potency.

 Risks of self-administrated thyroid supplementation include: 
  • Negative feedback that disrupts healthy thyroid function.

  • A higher risk of exogenous thyroid induced hypothyroid or hyperthyroid.

  • There is little to no evidence supporting the efficacy of many thyroid products that are available online and in retail stores. 

  • Using herbal, mineral, or vitamin based supplements will not reverse true hypothyroidism.

  • Vitamin supplementation will only help when hypothyroidism is the result of vitamin deficiency.

  • Several OTC supplements list hormone metabolite 3,5-diiodothyronine (T2) as an ingredient. T2 will cause negative feedback resulting in decreased levels of T4 and T3. Little is known about effects and associated T2 dosages.

Optimal thyroid support should be maintained with a healthy diet containing food sources of iodine. Lifestyle changes including smoking cessation, stress reduction, and improved sleep can make a positive impact, as well. Patients should work with a physician to determine thyroid treatment protocol, including supplementation if applicable. 

 

1) LEVOXYL- package insert. Pfizer Laboratories Div Pfizer Inc
2) LEVOTHROID- package insert. Forest Laboratories, Inc.
3) Thyroid hormones, antithyroid drugs
4) Diana C. Brown, in Clinical Pharmacology (Eleventh Edition), 2012 (chapter 37)
5) SYNTHROID- package insert. Abbvie
6) TIROSINT- package insert. Mist Pharmaceuticals, LLC.
7) UNITHROID- package insert. Gemini Laboratories.
8) CYTOMEL- package insert. Pfizer
9) Compounded liothyronine SR capsule- Empower Pharmacy (compounded products).
10) Bunevicius R, Kazanavicius G. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism. N Engl J Med Gericke KR. Possible interaction between warfarin and fluconazole. Pharmacotherapy 1993;13:508—9.9;340:424-9.
11) ARMOUR THYROID- package insert. Allergan
12) NATURE-THROID (THYROID)- Full Prescribing Information. RLC Labs
13) WP THYROID- package insert. RLC Labs.