.png){kind=small}
.png){kind=small}
BackTable / ENT / Article
Hashimoto’s Treatment: Hormone Replacement & Lifestyle Modifications
Julia Casazza • Updated Jul 10, 2024 • 35 hits
When caring for patients with Hashimoto’s thyroiditis, a two-pronged approach that addresses thyroid hormone replacement and lifestyle modifications is often most effective. Exogenous thyroid hormone is necessary for hypothyroid patients to restore normal metabolic function while lifestyle changes help reduce the inflammation driving disease symptoms.
Interested in learning more? Keep reading for valuable insights and practical advice on how to treat Hashimoto’s thyroiditis. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Not all patients with Hashimoto’s are hypothyroid, but those that are should be treated with a combination of thyroid hormone replacement and lifestyle modifications.
• Thyroid hormone replacement can involve levothyroxine (T4), liothyronine (T3), or both. Since T3 is the metabolically active form of thyroid hormone, treating patients with it can produce better symptom relief.
• The half-life of T3 is six hours, so patients taking this medication commit to thrice-daily dosing.
• Instructing patients to get their thyroid labs drawn at a consistent time of day (such as halfway between thyroid replacement doses) enables fair comparison between draws on different dates.
• Reducing simple carbohydrate intake and increasing antioxidant consumption can counter the inflammation that drives Hashimoto’s symptoms.
Table of Contents
(1) Thyroid Hormone Replacement in Hashimoto’s Disease
(2) Monitoring Thyroid Hormone Replacement in Hashimoto’s Disease
(3) The Importance of Diet & Exercise in Hashimoto’s Treatment
Thyroid Hormone Replacement in Hashimoto’s Disease
In Dr. Gibbs’ experience, treating hypothyroid patients with a combination of liothyronine (T3) and levothyroxine (T4) leaves them feeling better than levothyroxine treatment alone. This approach requires two prescriptions and thrice-daily dosing of T3 (as its half-life is six hours), but her patients report better energy levels on this regimen. She adjusts the T3:T4 ratio based on their levels of T3, rT3, and T4.
[Dr. Ashley Agan]
Let's say you've seen somebody and their T3, reverse T3 ratio is low and you say, "Okay, we're going to start you on some T3," and that the brand is Armour Thyroid? Is that the same thing?
[Dr. Dana Gibbs]
No. Armour Thyroid is natural desiccated thyroid. Armour is one brand name of natural desiccated thyroid, which is made from animal thyroid glands. It has T4 and T3 in it at a ratio of about 4:1. It's 38 micrograms of T4 for every 9 micrograms of T3. I generally don't recommend that for Hashimoto's patients because it also has the support proteins in it. It has thyroglobulin in it. It has thyroid peroxidase in it. I don't want to give that to somebody who's got Hashimoto's antibodies against those proteins and potentially reactivate their disease if they're in remission. I don't use that.
I use Synthroid and then I use liothyronine, and that way I can change the ratio. That 4:1 ratio may be okay for somebody, but the thyroid medicine that I take is more like a 2:1 ratio of T3 to T4. Somebody else might need a 5:1 ratio. I gain that by giving them two separate prescriptions. Yes, it's fussy. Yes, it's a pain in the butt, but it's much better than potentially triggering them to reactivate their autoimmune disease.
[Dr. Ashley Agan]
Okay. I'm glad I asked that.
[Dr. Dana Gibbs]
For a lot of patients, Armour Thyroid is great. It's a lot better than what they had before. If they go from just taking levothyroxine to taking Armour Thyroid, they're going to feel better.
[Dr. Ashley Agan]
Is that because there's some T3 in there?
[Dr. Dana Gibbs]
Because there's T3 in it. T3 is a funny thing because the FDA doesn't pay a lot of attention to T3. You could go online and buy an over-the-counter supplement that's laced with T3, and it's like, "What?" You don't know how many milligrams is in it. You don't even know it's there, actually. You just say, "Oh, thyroid support. Yes, this sounds good. I'll take it." Thinking that it's got iodine and selenium and some other minerals in there that'll help you, but you've got to be very, very careful and cautious with supplements, because there's a lot of people out there selling snake oil and stuff that'll actually harm you.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Monitoring Thyroid Hormone Replacement in Hashimoto’s Disease
Regular monitoring of thyroid hormone levels enables appropriate medication dosing. Dr. Gibbs checks labs (including T3, T4, and rT3) six weeks after initiating thyroid hormone replacement or changing doses. For her patients on a stable dose of thyroid hormone, she checks labs once a year. Since hormone levels change based on time from the last dose, Dr. Gibbs instructs her patients to consistently have labs drawn at the midpoint between two doses. This means that she always compares troughs to troughs.
[Dr. Ashley Agan]
Yes. That makes sense. How often are you checking labs? I feel like from what I remember, we wait three months before we check TSH when we've started somebody on Synthroid. Is that—
[Dr. Dana Gibbs]
Yes. I'm a little faster than that. I tend to do the first check when I've changed somebody's dose or started somebody on new at about six weeks. After that, it stretches out. The smaller the change I've made, the longer I'll let them go between rechecks until somebody's really stable and then they can just go once a year. I always tell them, "Look, if something changes, get your butt back in here and let's do it," because everything that is fatigue is not thyroid, and people get really hyper focused, patients especially are going to get hyper focused on thyroid because I don't know if it's just sexy or whatever, it's just something they've heard about, but there's so many—
Like you said, anemia, you mentioned anemia when you were in residency making you tired. There's anemia, there's insulin resistance. There's other horrible things. There's tumors. You might've got developed cancer. Oh my goodness. Let's get you in and do a physical exam and figure out what the other symptoms are and figure out what's wrong.
[Dr. Ashley Agan]
Yes. Not all fatigue is thyroid.
[Dr. Dana Gibbs]
Not all fatigue is thyroid.
[Dr. Ashley Agan]
For your blood draws, does it have to be at a certain time of day? Is it more finicky because of the medications?
[Dr. Dana Gibbs]
One of the big complaints that I get from patients who have been on thyroid medicine with other doctors and then come to me is my numbers are all over the place. First they're high, then they're low, then they're high, then they're low. I'm like, "Well, do you go to the lab at the same time every time?" They're like, "Well, no, I go when I go to the doctor's office." I'm like, "Oh, well, there's part of your problem because if you get a peak dose--" Say you get up at six and take your thyroid medicine and then you go to the lab at 8:00. You're going to get a peak because two hours is a pretty good time when you're going to be at a peak level.
Most endocrinologists, you not take your thyroid medicine that morning, go to the lab first thing and then take your thyroid pills so they're getting a trough. If you're just checking a peak, then you're missing all the people that are low later in the day. If you're just getting a trough, you're missing all the people that are too high. What I tend to do is a mid dose. If you get up and take your thyroid medicine at 6:00, then you're going to take it again approximately 12 hours later, then go halfway between, go at noon to the lab.
I push them, I say, "Go as close as possible to exactly six hours after you took your morning dose or when you regularly take your morning dose." I ask them too the night before, make sure you took your evening dose 12 hours before you're going to take your morning dose because I want it to be as exact as possible. I tell them, "Look, make an appointment, get to the lab early, and then sit there in the chair and go, "Okay, I'm looking at my watch. Oh, oh, now stick me." Try to get it as close on that six hours as they possibly can. The closer they can get it, the easier it is for me to tell whether they're too high, too low, or just right.
[Dr. Ashley Agan]
By timing it like that, you're going to better be able to appreciate trends rather than it just being all over the place because you're checking different times of day.
[Dr. Dana Gibbs]
Correct. Here's the thing, the reverse T3 trend is not as finicky, but when I'm trying to figure out, okay, exactly how much T3 do I need to be giving a person, because that half life is so short, I really do want that mid dose as close as I can get it. If they're taking it three times a day, then I'll have them do it four hours after. If they're taking it two times a day, it'll be six hours. Halfway in between.
The Importance of Diet & Exercise in Hashimoto’s Treatment
While medication replaces thyroid function, lifestyle modifications can counter systemic inflammation responsible for symptom burden. Dietary changes that counter inflammation include reduced simple carbohydrate intake, increased antioxidant intake, and increased B vitamin intake. Habit-based changes that counter inflammation include effective stress management strategies and regular exercise.
[Dr. Ashley Agan]
With your T3 and T4 that you're prescribing, obviously that's going to help them with the symptoms that we talked about, the fatigue, hair loss, being cold, all these things. Does it do anything to the natural progression of the disease of Hashimoto's? Does it change what's happening from an autoimmune standpoint, or is it mostly just helping with the symptoms that are related to that?
[Dr. Dana Gibbs]
That's a really good question. Once you've got a patient feeling better and they trust you, then you can recommend other things like, "Here, I really think you ought to be taking these B vitamins. Here, I really think you ought to pay more attention to the standard American diet that you're eating that is destroying your pancreas. Here, I really do think you ought to start exercising. I really do think that you ought to start meditating. Here's how I think you ought to do it," blah, blah, blah.
Those are the things. Anything that reduces inflammation, reduces stress, is going to help that person reduce their tendency for high antibody levels. Antioxidants, all the things that lifestyle medicine doctors do to try to help their patients feel better also work on hypothyroid or Hashimoto's patients because that disease, it doesn't exist in a vacuum.
Podcast Contributors
Dr. Dana Gibbs
Dr. Dana Gibbs is an otolaryngologist specializing in thyroid, hormone, and metabolism conditions in Arlington, Texas.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2024, May 28). Ep. 173 – Hypothyroidism Unmasked: The ENT’s Diagnostic Journey [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
