Glad you clarified about slow release T3 as an alternative. No problem with that.
Peak and blood draw.
So SRT3 is not absorbed in a uniform manner over the whole 8-12 hours. As shown in the paper you mentioned, SRT3 just does not peak at quite as high a level as plain T3.
Regarding the cost of SRT3
That is always possible; however, the AACE and ATA are so erroneously adamant about T4 being the only thyroid med required that it would take a lot to get that changed so that pharmaceutical companies might become interested.
Perhaps a significant benefit from SRT3 might be that the lower peak level would have less effect on TSH levels. Doctors are generally unaware that suppression is a common occurrence for many hypo patients and does not mean hyperthyroidism unless there are hyper symptoms due to excessive levels of Free T4 and Free T3. So anything that minimizes the possibility of an erroneous diagnosis of hyperthyroidism based only on TSH, with attendant reduction of thyroid med, would be helpful for those patients.
Thanks for your comment on the paper. We tried very hard to give patients concise information that could be easily utilized in discussions with doctors, and also provide enough analysis and scientific evidence that would hopefully convince doctors to make changes in their testing, diagnosis and treatment of hypothyroid patients. One thing I have always firmly believed is that everyone is entitled to their own opinion, but not their own facts. So we wanted to make sure we presented plenty of scientific evidence.
Daily Hormone Production
Thanks for helping clear up the quoted info. I also knew that the ratio of T4 to T3 from the thyroid gland is approximately 13 to 1. The numbers in the quote I previously used was obviously not production but the product of production plus conversion. I have no problem with using that knowledge to develop target doses, from which to adjust as needed to relieve symptoms. We discuss that in article 11 on p. 13 of the paper. However, the amount of thyroid medication required daily to relieve hypo symptoms has to take into consideration that each person may have different thyroid hormone levels that meet his needs, the variation in conversion rate of T4 to T3, and also that their may be different absorption rates of the med. Also, serum thyroid levels may not accurately reflect tissue thyroid levels, plus there are numerous variables affecting tissue thyroid effects. So in the words of an excellent thyroid doctor, medication dosage should be adjusted as needed to eliminate signs/symptoms of hypothyroidism without creating signs/symptoms of hyperthyroidism.
Circadian Rhythm
I have no problem with taking thyroid med at night or whenever it works best for the patient overall.
Slow Release
I was fully aware of the compounding of slow release thyroid meds. I am not fully confident that results from the process, as practiced by so many different compounding pharmacies, is consistently effective. I have seen one scientific study where the researchers showed the value of using a slow release form they had compounded that was reportedly effective and they planned to push forward with the concept. I have seen nothing further. If someone comes up with such a product, in the right T4/T3 portions, I would be all for it. But even then I can envision that individuals might get different results from variability in conversion, and other confounding variables, and might require a separate dose of T3.
The Ultimate Goal of thyroid hormone replacement
I am not convinced that we need to add "long term" to the goal of "relief of thyroid symptoms". I am not sure that new thyroid patients are typically younger and more adaptive. Many young hypo patients are not adequately tested and diagnosed for some time. In addition, many people, especially women seem to develop hypothyroidism later in life. Also I don't expect initially successful thyroid hormone therapy to last a lifetime. As shown in Fig. 1 in our paper there are many variables that can affect tissue thyroid effects. These variables are not static throughout our lifetime. For that reason hypo patients may find that conditions changed and they have become hypo and in need of followup testing and med/supplement adjustment. True that some symptoms are non-specific in nature, but there are a number that occur much more frequently in hypothyroid patients than in other patients. So those are the key ones to assess along with levels of Free T4, Free T3, Reverse T3, cortisol, Vitamin D, B12, ferritin, etc.
The road to the Goal
On this subject I refer you to article 11, p. 13 of the paper. "The aim of dose determination for a patient should be to get the patient on the required or optimum dose as quickly as possible. ....Some sets of rules have been proposed which may serve as an initial crude estimate to predict the final dose, which would equal the starting dose in unproblematic situations. Dose adequacy should then be assessed and adjusted as needed, with relief of symptoms being the main concern."
With that goal in mind that is why we suggest the tests on p.2 of the paper should be done up front. There is no advantage to delaying testing for cortisol, Vitamin D, iron, etc. That will identify and start supplementation quicker for any identified deficiencies.
No question about value of the ratio of Free T3 to Free T4. It is also mentioned in the paper. There are some people who are more susceptible to AF than others. If raising your thyroid hormone causes AF, then it is best to reduce the dose. From what I have read, there are also other variables that can cause reactions when raising thyroid med dosage, including low ferritin and low cortisol. Have you been tested for those, and if so, are they adequate? Also, if no other option available some people have used beta blockers to control the AF, in order to get the needed thyroid med dosage.
Thanks for your comments and your participation on the Forum.