Which Thyroid Medication Is Best?

DR. IZABELLA WENTZ / SEPTEMBER 6, 2018

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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®.

Controversy
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)