Dr. Friedman’s New Approach to Thyroid Medication Timing | Optimize Your Thyroid Health

Are you taking your thyroid medication at the wrong time without even realizing it? In this video, Dr. Friedman explains a new, research-backed approach to thyroid medication timing that could significantly improve your energy, metabolism, and overall hormone balance.
Many patients with hypothyroidism struggle with persistent symptoms despite “normal” lab results. The timing of your medication may be the missing piece. Learn how adjusting when you take your thyroid medication can enhance absorption, improve effectiveness, and help you feel your best.

In this video, you’ll discover:

• Can you now take thyroid medicine with food?
• Can you take thyroid medicine with other medicines?
• Do you have to adjust the dose of your thyroid medicine?
• Should you get your blood tests done before or after your thyroid dose?
• Can you take NDT or L-T3 containing medicines once a day
• Why is liposomal testosterone safe?
• How does it compare to testosterone cream?
• Can it be given to men and women?
  
  

If you’re dealing with fatigue, weight gain, brain fog, or other thyroid-related symptoms, this information could be a game changer.

🔗 Ready to take control of your thyroid health? Book an appointment here:
https://www.goodhormonehealth.com/app...
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#ThyroidHealth #Hypothyroidism #HormoneBalance #DrFriedman #ThyroidMedication #Endocrinology #HealthOptimization

Transcript

SPEAKER_01 0:03

Today's talk is entitled Dr. Friedman's New Approach to Thyroid Medicine Timing. I think you'll find this to be a fascinating talk, and I think this is going to change how we treat people with hypothyroidism. Prowling today is we're going to go over my new approach to thyroid medicine timing. It's going to be based on an article in the Journal of Clinical Endocrinology and Metabolism, JCEM, that discusses taking thyroid medicine on an empty stomach versus with food. So we'll talk about can you now take thyroid medicine with food? Should you take thyroid medicine with food? Can you take thyroid medicine with other medicines? Do you have to adjust the dose of your thyroid medicine if you're changing from without food to with food? Could you get your blood test done before or after your thyroid dose? And can you take non-desiccated thyroid or desiccated thyroid extract or levothyroxine, lyothyrinine-containing medicines once a day? The thyroid is in your center of your neck, as everybody knows. There's two lobes. It's a butterfly shape organ that's above your trachea. Thyroid hormone makes two active hormones, T4 or thyro thyroxine, and T3, which is triodothyrinine. It also makes what's called reverse T3, also, and it makes T2, which is inactive. We're going to mostly be talking about the making the synthesis and release of T4 and T3. There's feedback by the pituitary hormone TSH, so that when the T4 and T3 rises, TSH shuts down. And this can be somewhat transient that if it rises for a little time during the day, this can suppress the TSH. TSH intern feeds back and regulates the thyroid to make more T4 and T3. There are many options for thyroid hormone replacement. Many endocrinologists use levothhyroxin or LT4 alone. Some of the brands are generic levothyroxin, synthroid, levoxyl, pyrocint, and unithroid. There's gel capsules, tyrocint, generic tyrosint, and thyquidity. There's T3, cytomyl or lyothyroid alone. There's combinations of T4 and T3. There's desiccated thyroid. These uh is probably not available. It's unavailable for the last couple months, although some places, pharmacies may still have some. Armor, nature thyroid, WP thyroid is really also no longer made. ERFA is a product in Canada. These often come from pig thyroids. Around the world, there's other products. These are often called natural desiccated thyroid or NDT or desiccated thyroid extract DTE. Just usually call them desiccated thyroid. You can take desiccated thyroid plus levothyroxin, desiccated thyroid plus thyroidine. And in general, the proper treatment needs to be individualized. You don't have one blood pressure medicine. You need to individualize a treatment for hypothyroidism. Interesting, there's about multiple studies, including review articles, have shown a poor quality of life among patients, about 15 to 20 percent of them on levothyroxin alone, even though they have a normal TSH volume. A lot of studies trying to figure out why. Iron, calcium, vitamins that have iron or calcium, proton pump inhibitors such as endoprozol or mirazol, caraphate, oral bisphosphamates, of which they use free bone osteoporosis called phosphamax, or lostat, or cholesteromine. And it's unclear how long the separation period should be. Some studies have recommended, some guidelines recommend 30 minutes, others up to four hours. And you can imagine if you're taking a couple times a day the dose every and you have to separate it from food or medicine by four hours, it's going to really cramp your life. And many of my patients really have trouble following some of these guidelines. Um, there's little studies that have validated these, these, um, these, guy, these ranges and time to separate your medicine. Um, there was some studies that suggest taking it at night, so it doesn't interfere. Some of my patients wake up in the middle of the night, which I don't recommend, so it's separate. So I think there needs to be much more studies about this. And this paper seemed to answer some of those studies. Now, tyrosin, which is a gel capsule, there's both a liquid form and a gel capsule form. It seems to be better. There are some studies of tyrosin that it doesn't interfere, that food doesn't interfere with it, and it can be taken with food or with other medicines. Well, this is a paper published in Journal Clinical Androcology Metabolism, came out in the April issue, entitled Fasting versus Non-Fasting. Dose suggested levothyroxin ingestion and hypothyroidism or randomized clinical, and it's from the Netherlands. The introduction to the paper talked about that clinical guidelines recommended levothyroxin to be taken on an empty stomach between 30 and 60 minutes before breakfast and separated from medicines known to interfere with absorption. And this is to prevent reduced gastrointestinal uptake or uptake from your stomachs. This group did a questionnaire study in that 50% of people reported that delaying breakfast was Burdomson. One-third admitted not consistently adhering to the recommended timing, and some reported regularly forgetting to take their medication through the fast requirement. I think people are used to taking it when they wake up in the morning, and if they have to wait to take it, they often forget to take it. This contributes to suboptimal olivothoroxin therapy. Additionally, 25% of patients reported skipping breakfast altogether to meet these fasting conditions. And they referenced several papers, including some uh prominent review articles and a systematic review about uh lemotheroxin and error. Um there this led them to do the study that raised the by that these observations raised the question of whether routine coingestion of levothoroxin with breakfast could be a viable alternative to fasting, provided that the expected reduction in absorption is offset by increasing the dose. So the idea is if you're going to absorb a little less, you give a little bit higher dose. Therefore, they conducted a randomized, dividing the two people into two groups, clinical trial, comparing traditional fasting, levathyroxin intake, with levotheroxin intake along breakfast, accompanied by a 15% dose. So the people that took it with breakfast, they were given 15% extra. So if they're on 100 micrograms, they were given the equivalent of 115 micrograms. And they assessed whether this alternative regimen could maintain TSH stability. They didn't want the TSHs to either drop or rise, and improved patient satisfaction among individuals with well-controlled hypothermicism. They took people already on levotheroxin, well-controlled with a normal TSH. Eligible patients were randomly assigned to either the fasting group or to the breakfast group in a one-to-one ratio. This was an open-labeled trial. It wasn't blinded. The patients and the investigators knew what group they were allocated to. Fasting group was instructed to take their levotheroxin 30 to 60 minutes before breakfast. Breakfast group was instructed to take their levotheroxin with breakfast within empirically chosen 50%, 15% dose increase to compensate for the expected reduction in absorption of levotheroxin. The use of interferon drugs, including calcium, iron, magnesium containing supplements, vitamin supplements, potassium and phosphate binders, proton pump inhibitors, and H2 receptor antagonists, was allowed. However, they're instructed to maintain a four-hour interval between the lemotheroxin and these medications and to report any dose changes or new prescriptions. They then, after they finished the study, which I think was for six months, they then had a crossover period where the P patients in the fasting group could go into the breakfast group. They didn't have a daily round, they just had the fasting group and go into the breakfast group. They defined TSH stability as two consecutive TSH measurements remaining within the reference range and the change of one unit different from baseline. So the TSH was at four at three and baseline, they were allowed to go up to four or to two, but they couldn't go more than that. This is the results section. The TSH was stable in both groups without a significant. In the fasting groups, 74% of the patients had a stable TSH. Again, it didn't change much, 73%. And the breakfast group, this was non-significant. This is on the right, it shows a scatter plot of the mean change in TSH from baseline. Again, no significant change. And the breakfast group, there was seemed to be one patient at the bottom there that did change a lot, but that was just an out there. I think the rest were quite stable. They took the crossover group and of the crossover, 77.8% of the crossover patients, the one that switched from fasting to leaving with breakfast, they preferred the levathoroxyl with breakfast over fasting ingestions. This was actually the same patients. The other group, it was just um two different groups of patients. And the crossover, it was actually the same patients when they switched over, they preferred to eating it with breakfast. This is the results. On the left is the self-reported well-being. And you can see that the breakfast group, 33% had an improved sense of self-of well-being. 62% were stable and 4.4% decline. While in the fasting group, it was 16.3. So the amount that took it in the breakfast area, sense of satisfaction doubled, which I think is quite remarkable. The sense of well-being doubled. So they put they reported being felt better, they did better in the breakfast group. And um they whether they preferred taking the levotheroxin, the breakfast group, 76% preferred to take it in the breakfast group, while in the breakfast group, 76% preferred it to be non-fasting with no preference in 14. While in the fasting group, it was about evenly divided. So these are, I think some of these are the crossover group, but in general, patients preferred it to take it um with breakfast and um have to worry about fasting. Their conclusions in this randomized proof of concept trial in patients with well-controlled hypothyroidism, 15% dose-ingested levathyroxide medicine. Breakfast achieved a similar TSH stability compared to fasting and levothyroxide ingestion. Self-reported well-being tended to be higher in the breakfast group, with 88% opting to continue breakfast ingestion after study. So once they went on breakfast ingestion, non-fasting, they liked they don't want to stay on that. Patients who switched from fasting to breakfast ingestion reported improved well-being. And they didn't examine interfering drugs. My view of this paper was that it's an excellent, important, innovative paper. There were fairly small numbers in the group. They relied a lot on the crossover data, which I think had only like 14 patients or so, but that was a really important group because they were uh that group was on both treatments and they liked being on the uh eating with breakfast group. And I always thought that this timing from food was overstated, there was little data on it. And uh, in general, I always thought that I just their patients' dose based on their lab results. So as long as they're fairly consistent, you know, I look at their lab results, and if the thyroid tests are showing they need a higher dose, I would give them a higher dose as long as as long as the patient was on a fairly consistent dose and adjusting for the next time around as based on labs. In other words, if you take your thyroid medicine with food every day, your labs will reflect that and your dose can be adjusted. If you switch from fasting to taking it with breakfast, you may need a higher dose. And I think that's more important to take it daily, even if it's with food, they really have this restricted life than many of my patients report. Um, I think it's the same thing's gonna happen if you take it with interfering medicines. Um, but um we that that wasn't tested. And I think your patients can separate them for sure. It's easier to digest your medicines than ingest your food, I think. Most of my patients, I recommend taking the live thyroidine or the desiccated thyroid twice a day on a waking and mid-afternoon, which is waking is a little bit separate from food. But in general, I don't think you have to wait that long. So you wake, get up in the morning, pop your medicines right out. And as soon as you're out of bed, they're in your medicine cabinet, you get dressed, you're out of the bathroom, then it takes 15 or 20 minutes or half hour or so, 10 minutes. Um, and then you can eat your breakfast or drink your coffee. So again, I think based on this paper, you don't really have to wait that much time. Um, and it's the people did better if they ate it with uh with breakfast, but didn't fast. Now I'm gonna get into an interesting uh area about levels after eating it. Um, and some of these are AI generated, some of these are data generated. But when you take your medicines, your levotheroxin, for example, the dose goes up by about 12 to 14 percent. And there was a paper that I wasn't a co-author of, but I was involved in it when I was at the NIH in the 90s. That was one of the first papers to show that. So you take your values of you take your levathyroxin, you're measuring your free T4 afterwards, the dose is a little bit higher, up to uh 30 to 20 to 30 percent higher. And this shows compared to the trough levels, the trough levels before you take it, PFA levels after you take it. And you can see here that um the levels are higher. You can see the scale is up as high as 30%, as low as 10%. You know, within about two hours or so, they get higher, and then they come back down to normal. So if you again, if you get your blood test done after you take, even your T4, it's a little bit higher. Now, what about T3? T3 is even more dramatic. So here when you take your T3, it could be two to three times higher after um taking it uh, you know, within an hour, two hours after taking it, as shown in this figure here. So I think especially with the T3, it's important to do it to trough values before you eat. But even the T4, it's important to do it before you eat. And this is a um AI uh schematic that shows what happens. The levotheroxin uh peaks in two to three hours, the liocyramine peaks in three to four hours, and then they return to baseline. With food controversy food intake, especially high fiber food, reduces the bipolity and delays the peak concentration by 15 to 40 percent. Liquid T levotheroxin, such as tyros synth, it seems uh doesn't affect it, reducing the need for strict fasting. Pharmokinetics uh with fasting with levotheroxin peaks around two to three hours by a long half-life, a tail up to seven days. And with food, it's it's broader. It doesn't peak as much and it's shifted to later. So that's an important concept. When you take with food, you don't have this quick rapid increase, you have a broader increase, which I think is going to be beneficial. Well, then the next couple slides. But with T3, it's the same thing with food, it delays your absorption. Um, this uh AI area saw it was less dramatic than T4. I've seen other papers and suggestions that it's more dramatic, but in general, it's the same thing happens when you take it with food, you get less of a peak, it's a little broader, it's a little more um throughout the day. Oh, in general, with the T3, big increase after you eat, especially around two hours by followed by a decline. This is a paper, um, an article from a paper by um Bianco, Tony Bianco, and this shows um modeling of taking 50 micrograms levotheroxin three times a day in A, twice a day in B, or once a day in C. And you can see that when you take it three times a day, you still get a lot of jaggedness when you take it. That's the the time is in hours. And you can see every time you take it, you get a pulse and a trough, but it's more stable. It's not as dramatic as the once a day. So you can see the once a day, you're really up high and then down low. In the twice a day, you're uh still have a lot of um going up and going down. And then in the um, and then when you take it three times a day, again, it's still jagged, it's still not pointed, but it's more um, it's it's flatter. On the right side is somebody that's taking a levotheroxin dose of 112 micrograms being transitioned to a levotheroxin plus liothyrinine combination therapy. The first one is if you take 3.25 micrograms twice a day plus the levothoroxin. The second one is five micrograms twice a day plus the levotheroxin. And the third is 10 times 10 micrograms twice twice a day plus the levotheroxin. Here you can again see that if you take it um a couple three times a day, you're flatter, you're more human, but you still have pulses. If you take it twice a day, you're still a little flatter, you're you're a little less flat, but you still have pulses. If you take it once a day, twice a day, you're at a higher dose, and you have even more highs and lows. It really shows that you take the T3, your levels go up pretty dramatically after taking it. But what happens with food? Again, this is an AI-generated diagram, and you can see here that the green is fasting, the levotheroxin levels. The no, it's the let's do the blue first. The blue is the levotheroxin with fasting, and the orange is the levotheroxin with food. You can see it peaks a little later and it's a little bit more spread out with the food. So you don't have this big rise and then uh decline in the T4. But if you take T3, it's even the same thing, it's even more dramatic. The green is the T3 after taking free T3 after taking T3, it goes up really high and then comes down really rapidly. But with food, it again, it's more delayed. The food is gonna be the reddish color, but it's more delayed. And um, you get if you take it with food, and this is gonna be the same you'll see with lemothhyroxin, um, with desiccated thyroid in the next slide. All of them, you get a big increase, and then food delays the increase and makes it more flat, more even. When it's more even, you get less of a suppression of your TSH. And this accounts, I think, for why patients have a lower TSH on levothyroxin when they take on an empty stomach, than if they didn't. In other words, if a patient has a TSH of one, um, you say, well, this person is perfectly replaced, but they took on an empty stomach, it really may be a TSH of three, and they may feel a little hypothyroid. Maybe this explains why some of the people have a normal TSH and don't feel well because they're really on their TSH might be two points higher than what it looks like if you take it on, uh, would have taken it with food. I think there's advantages to taking a little bit of food, and I think that's possibly one of the reasons, besides the fact that it was just more convenient, why in the paper JC and M that people liked it better with food. Okay, so this is an AI-generated model with food, a little bit complicated, but I'll walk you through it here. So the blue is the levotheroxin level with food, with fasting, the blue, and the matched blues right here are the levotheroxin with food. So again, it's delayed, and then the free T3, the same thing. The green is the big peak fasting, and the um and the hyphenated green right here is the T3 with food. So again, it's delayed. And then this model looked at uh TSA suppression. So I think you don't want as much TSA suppression with the dose. So the top bar shows um the the top bar shows TSH that's with a dotted sort of orange color or reddish color, TSH that's uh with food, you don't get that much TSH suppression. If you start having with levotheroxin. If you have the levotheroxin with fasting, it would be that little darker reddish color, you have more TSH suppression. And if you take the T3, you have even more TSH suppression if it's uh fasting and less if it's with food, but if the food is still more of a TSH suppression. So again, if you take TSH, your TSH gets suppressed, you have more effect on your your seeing like a lower TSH compared to your actual value. You want an even value, you don't want your TSH suppression. Okay, and this is desiccated thyroid extract. Again, this is a model. You can see the free T3 levels with desiccated thyroid extract are green. With fasting, they're high, with food, they're lower, and then the free T4 fasting. Is the blues here. And then over here is the desiccated thyroid of food. Again, it's flatter. And this shows the TSA suppression is more with fasting down in here than the sort of darker reddish color. The lighter reddish color shows with food less of a suppression. These are purely AI-generated models, but I think they're pretty accurate. So the question is, and people, patients always ask me this, and their endocrinologists don't really understand this. Is it okay that people on T4, T3 combinations or desiccated thyroid extract have a suppressed TSH? And I think the reason why they have a suppressed TSH is when they take their T3 in the morning and their desiccated thyroid extract in the morning that has T3 in it, at high dose suppresses their TSH. And that last suppression lasts throughout the day. While the rest of the day, they're probably okay. So I would say, yes, it's okay to have a TSH suppressed. You may not want it to be absolutely zero, but it's okay to be suppressed as long as your Free T4 and Free T3 levels are, you know, trough Free T4 and Free T3 levels are okay. As long as you don't have signs or symptoms of hyperthyroidism, as long as you don't have heart disease. And then I often look at a bone turnover marker called a urine tilopeptide. And as long as that's not high, I also feel pretty good that they're not over-treated. Should you get your blood test done before or after your morning, your morning thyroid dose? Before represents the trough, after represents the peak. And as I showed before here, you should get it, they're higher after you take your medicine. So you should try to get your labs done first and then take your morning dose. So you're in the trough area, otherwise they'll be falsely high. They found that TSH levels may be falsely suppressed for five hours after taking a T3 containing medication. TSH then begins to increase five hours after the dose and continues to rise until 13 hours after dose, which time it's stable. T3 levels are also affected, increasing after the dose is given, hitting a peak in four hours. This means if you take your one to take you to take your thyroid medicine within five hours of getting your blood test done, your lab toast might show you're overdosed, even when you're accurately dosed. Or they may show your labs to be within normal limits at which you're underdose. So thus it's best if you're taking thyroid medicines, even T4 alone, but I would say um desiccated thyroid or T4 T3, it's best to get your thyroid test done first thing in the morning, make an appointment in your lab, bring your medicines with you, and take them right after you have your thyroid test done to ensure you get accurate results. So I think with this in mind, um in general I try to give um patients desiccated thyroid. I always do it twice a day because of the T3. But I've seen in this, you know, you still have these peaks after taking it that can falsely suppress your TSH and lead to, you know, just a little bit of hyperthyroidism throughout the day. Um, so therefore, it might be reasonable for some people to go on three times a day thyroid medicine and a lower dose spread out. And I did that on a patient I talked to today. I put some patients on a T4, T3 combination, the both, and then the T3 has a short half-life. That means it beaks and then it's gone throughout your system. So if you take it once a day, desiccated thyroid T3, you're hyper after you take it and hypo in the evening. And by the next morning, you could be quite hypothyroid. Um so therefore, it does need to be at least twice a day, maybe three times a day. A desiccated thyroid has other proteins in it, which are sort of the same as food, it might delay some of the peak to the peaks. Um but it may it may not. But I think having the desiccated thyroid has an advantage over T3, and it's more likely to be stable throughout the day. I don't use that much of compound of T3, uh, but there may be some pluses of taking compound of once a day or twice a day compounded to again try to avoid those peaks after taking it. So the people paper answers these questions. Can you now take thyroid medicine with food? I think the answer is definitely yes. Should you take the thyroid medicine with food? I think there's pluses about that. I think you're gonna get a more even absorption and a flatter curve of your levels of T4 and T3, and you'll have less suppression of your TSH. And you take thyroid medicine with other thyroid medicine with other medicines. This was not looked at in the paper. My guess is probably gonna be the same thing. You probably will be able to when you need to adjust your dose. As long as you're consistent, you may need to adjust your dose. So if you're telling me you're gonna go from taking it with food, with fasting to taking it with food, I may give you a slightly higher dose, as this paper recommended. If you're on somewhat of a stable dose and you decide you're gonna just do a little bit, you know, spread it out a little less, you know, maybe um instead of waiting for four hours, you're gonna take one one hour, instead of waiting uh 30 minutes, you're gonna wait 15 minutes. You know, we may not need to change a dose, but the next time we'll be able to see that adjusted. Should you get your um blood test done before or after your thyroid dose? The answer is before. And can you take your NVT or levotheroxetating medicines once a day? No, you need to take them twice a day. Um, so I think this is a pretty uh short webinar. It was a half hour. And I will um post this on my website, my Facebook page. We'll have time for questions. Um it will be on our podcast, and you can go on our Facebook page or email us any question.

SPEAKER_00 27:42

Great, thank you, Dr. Friedman. Um, I have a few questions on Facebook that we can get started with. Um, James asks, when you say twice a day, what's optimal points in the day to take the second dose?

SPEAKER_01 27:57

I usually have people take it first thing in the morning and mid-afternoon about two, uh, two or three p.m.

SPEAKER_00 28:05

Gina asks, Dr. Freeman, how are the thyroid drugs absorbed differently in a patient with a post-Royun gastric bypass surgery patients? I definitely have trouble absorbing oral hydrocortisone, hydrocortisone and was curious. I am also on T3, T4 combination twice a day.

SPEAKER_01 28:27

Um, so the rule and why is a gastric bypass and it does affect absorption. So people potentially would absorb it poorer. Um, they may have um maybe more delayed response. But I think it's gonna be the same thing that will look at your levels next time, or your doctor, if you're not my patient, will look at your levels next time and adjust it based on what your levels are. But I think people have gas for the bite by worsening have delayed absorption.

SPEAKER_00 28:54

Okay. Um, Annette asks, is there any studies on dissolving meds under the tongue versus swallowing? Any significant difference? Thank you so much.

SPEAKER_01 29:06

Okay, yeah, I don't think there's any significant difference. But I think most of the studies are done by swallowing it. And I think, as I said, I think I like it um with food and swallowing it because then it's a little more of a delayed response. Well, if you take it under your tongue, it might be a more of a rapid response.

SPEAKER_00 29:24

Cindy asks, if you have thyroid nodules, how often should we get them looked at?

SPEAKER_01 29:30

Oh, I think thyroid nodules again, it's sort of a different topic, but thyroid nodules are almost always benign. Very few people die from thyroid cancer. Um, you don't certainly don't want to die from thyroid cancer, but very few people in general, the field is going to be more conservative on that. That if you have a big nodule, you should get a biopsy. There's something called a TRAD score, which looks at how the ultrasound, the report of the ultrasound, doesn't look like it's an aggressive thyroid nodule with a high TRAD score or an unaggressive one. And if it's a low score and if it's a smaller nodule, you may need to just have it monitored and check to get the ultrasound maybe just one time the first time. If it's a little bit bigger of a nodule with a higher T-red score, you may need to get one every year. And if it's a fairly high score, you may need a biopsy. So in general, we're moving to be less aggressive with thyroid nodules.

SPEAKER_00 30:22

Andrea asks, so will taking the thyroid medication with breakfast show on labs, or do you need more medication, or is it just optimal to take more in that scenario?

SPEAKER_01 30:33

Okay, so um, if you take it with breakfast and you weren't, you know, you may have me or your doctor give you a little higher dose to start with. Or you can just wait till your next labs and see what happens, and we'll adjust your labs next time and we'll give you a little bit more.

SPEAKER_00 30:50

Solome asks, I have a hard time going to the bathroom on levothyroxin. Any suggestion on that?

SPEAKER_01 30:58

Um, I don't know if that's uh bowel or or urine. Um, in general, levothyroxin, if you're under treated, if you're hypothyroid, you can get constipation. If you're properly treated, you shouldn't. But maybe um, if you are constipated, you might want to switch to a desiccated thyroid or T4, T3 combination. In terms of urination, I don't think it affects it.

SPEAKER_00 31:19

Okay. Move on to some Zoom questions. What are the advantages of taking desiccated thyroid three times daily? I have a low around 2 p.m. Currently taking it morning and late afternoon.

unknown 31:33

Right.

SPEAKER_01 31:34

So I think you might be an example of somebody that's metabolizing it quickly. It's out of your system by late afternoon. So you feel low in the early afternoon. So if you were to take it breakfast, lunch, and dinner, for example, that might be a little more even. You take it with food, it stays more in your system evenly and it's spread out throughout the day.

SPEAKER_00 31:53

Okay. Polly asks, what about new liposomal testosterone delivery options?

SPEAKER_01 32:00

Right. So I decided to not talk about that today. I thought there'd be enough to talk about with the um the thyroid extract, and I think I was correct. Um, but I hope to have that talk um and maybe my next one.

SPEAKER_00 32:12

Okay. Jen asks, do you ever prescribe just tyrosin to a patient who is hypothyroid?

SPEAKER_01 32:19

I do, yes. I lose a lot of tyrosine, I use a lot of thyrocin. I take tyrosin myself. Um, tyrosin is a gel capsule, it's very pure, it doesn't have any uh binders or fillers, and some people are very sensitive to the binders and fillers. I always say that, you know, we talked about the 20% or 15% of people on levothyroxid are not doing well. That means that the 80 to 85% are doing well. But for many patients, the T4 alone is a good option. It is advantageous to be given once a day. And of the T4 alone, then you can just take tyrosint. The disadvantage of that is that you know the T3 is like a faster acting um uh you know um hit. It gives you a little bit better energy. And it also there's a company, something called reverse T3, which I talked about in a prior webinar and have a paper on that. If you take T4 alone, sometimes your reverse T3 goes up and the T3 doesn't bind to the receptor. So I do try to individual my practice, and some patients I give um tyrosin, some people I give T4, T3, and some people I give desiccated thyroid.

SPEAKER_00 33:21

Frederick, which NDT to you do you prefer?

SPEAKER_01 33:25

I prefer um NP thyroid. Um I think it's a little better formulated than armor with a little better binders or fillers. I find um that T armor thyroid had a little too much, a little too much T3 and not enough T4 in it. And I think uh NP thyroid is a little more balanced on that, and that has a better ratio of the two.

SPEAKER_00 33:48

Okay. Did you say we cannot get desiccated thyroid anymore, or is that a particular brand?

SPEAKER_01 33:55

Right. So um this one is a changing story, and I did have an article that went on that. Um, in uh maybe in the fall of last year, the FDA had concerns about desiccated thyroid, the fact that it wasn't um FDA approved and there wasn't any clinical trials showing that it's effective. There was a lot of pushback, and the FDA, especially uh FDA director, Dr. Makari, wanted to keep giving it, and the FDA announced recently that they're gonna keep allowing it to be given. Um in terms so it I expect it to stay available, and I expect companies that are working on it, especially the Acella that makes empty thyroid, they are gonna have clinical trials that are gonna show it's effective and it is eventually gonna get FDA approved. Um, the second question is about insurance coverage of it. Uh, CAREMARC in 2019 made up that there was a shortage of backlog of desiccated of MP thyroid when there wasn't. I think this was a purely political situation. And then, you know, after a couple months, they allowed, um, they started giving their members MP thyroid. Now they're saying that they don't want to cover it and that you have to go on T4 to get it covered. I think this is a purely uh financial decision on their part. But it turns out that the insurance doesn't cover it that well, anyways. And there are things like such as good RX and different pharmacies that give it to you about the same price as the insurance, anyways. But I still do recommend taking uh desiccated thyroid. I think it's going to continue to be available for the patients.

SPEAKER_00 35:33

Amy asks, when I take my T3 two times daily, I get too hot. So I take my T4 and T3 replacement in the morning fasting with flutocortisone and sub-Q solucortef injections. Is this okay? I have gastroparesis.

SPEAKER_01 35:51

Yeah, it sounds like it's okay. So you might want again take it, you might want to go on a desiccated thyroid extract, might be better for you than the T3 because the desiccated thyroid extract is a little longer, or you might want to take your T3 three times a day. You can make an appointment with me and we can discuss that, or you can talk to your doctor.

SPEAKER_00 36:11

Pat says, I didn't see NP thyroid listed. Is it still a recommended manufacturer?

SPEAKER_01 36:16

Yes, I don't know if I wasn't there. I just missed it, but it's definitely available.

SPEAKER_00 36:20

Great. How space apart should a person with secondary Addison's disease take hydrocortisone and their NP thyroid, which is taken with food three times a day?

SPEAKER_01 36:32

So the hydrocortisone, first of all, is a myth. It doesn't need to be taken with food. Um, it's really, especially in sort of the physiological doses, it's perfectly fine on the stomach and doesn't need to be taken with food. So definitely you can take your NP thyroid and your hydrocortisone together. There's no problem with that. And third, as I sort of said in this talk here, you can take both of them with food if you want, and there's no problem with that.

SPEAKER_00 36:55

Shelly says, for those, oh, um, yeah, for those that have had um thyroidectomy, the peaks and valleys feel more exaggerated. So taking with food and doing two times a day or three times a day will help even it out. Or would the dosage throughout even start higher and reduce throughout the day?

SPEAKER_01 37:17

Oh, yeah, I think you can consider taking it. Uh you definitely should take it um if it's T3 twice a day. Um I think um if you take, I think the T4, at least right now, most people are okay with taking it once a day, but the T3 and the desiccated thyroid at least twice a day, and sometimes three times a day. Um then I think we would adjust your dose in your next labs.

SPEAKER_00 37:41

Amy has a question and also said that you are my doctor and you can't retire.

SPEAKER_01 37:46

I ain't no problem. We're planning on retiring. Uh thank you.

SPEAKER_00 37:50

She says my TSH is suppressed and is due to both T3 and steroid replacement. Why? Why don't most endos know that TSH will be suppressed on T3 and steroid replacement for adrenal insufficient? Why do physicians think that just testing TH TSH will tell them if the patient's FT4, FT3, and RT3 are normal or off? Can you explain why testing TH TSH is not beneficial when one is on T3 and steroid replacement, please?

SPEAKER_01 38:26

Okay, so a lot of questions there. Um, so as I said here, when you have your T4 desiccated, T3 or desiccated thyroid, you get a fairly big dose after you take it. And that suppresses your TSH, even if it's just high for a couple hours. That leads to the suppressed TSH that endocrinologists know about, and I know about it, but many doctors don't. In general, the steroids, if you're in a physiological replacement, if you're on like a high dose of pretazone, it's going to replace it. But if you're on maintenance dose of hydrocortisone, it's under 15 to 20 milligrams a day, it shouldn't affect your TSH basically. Um, and then um why do physicians think just testing your TSH? Well, tell them. Um, so if you are one of these patients, the 80% of the patients that are on levothoroxin only, you're doing pretty well, you don't have any other problems, you don't need to see a specialist, it's probably okay to just test your TSH. So can I have my counting job? I have thousands of patients on levothoroxin, they're doing fine. I basically check their TSH most of the time. Occasionally I get patients that aren't doing that well, and I would check their pre-T4 and Free T3, and rarely I would check the reverse T3. But, you know, then you have the 20% or 15% of patients that aren't doing well. And those you need to see a specialist like me, you need a comprehensive evaluation with total levels, and um, you need to uh adjust accordingly. And I and I still I always still get the TSH. You know, I like to see sort of where it is, even though I really base my guidelines on 3T4 and 3 T3 and reverse D3.

SPEAKER_00 39:57

Awesome. Gina said on Facebook, um, Dr. Freeman, we hope to see you at the Magic Foundation Adult Conference soon.

SPEAKER_01 40:05

Totally. It'll be in Denver. Awesome. Yeah, I can see I can see Tiffy and I can see uh she's still there and I can go to the conference. Yes.

SPEAKER_00 40:14

Yay. Um Janet said, is your RT3 article on your website? Yes.

SPEAKER_01 40:20

Yes, absolutely. And also we did a webinar on RT3 that you can listen to.

SPEAKER_00 40:24

Awesome. We'll take a few more questions. Tori asks, I just I feel just fine throughout the day taking armor once a day in the morning. It would double the cost if I took it twice a day. Is that okay?

SPEAKER_01 40:37

Um so what you can do, I mean, if you feel fine, that's fine. You know, it's okay. Um, most of the patients that come to see me don't feel fine. That's why they came to see me. Um, but I would probably still try it to just cut your pill, cut it in half, and take it twice, a half a pill twice a day, and it's the same cost. My guess is you'll feel a little bit better on that than you would be otherwise. But you can try that first and try it for yourself.

SPEAKER_00 41:02

Dr. Amy, would it be better to take NP thyroid with food with meals spaced evenly hours apart as I work in the evening and at night, or just stay, say typically it 8 a.m., 1 p.m., and 6 p.m. I think I'm overthinking this. Looks like we have two Amy's on here that never want Dr. Freeman to retire.

SPEAKER_01 41:22

Right. So Dr. Amy Hoffman, I don't want to retire. Um, we talked to you today. Um, you know, I think for now, most people can take it sort of like around breakfast, lunch, and dinner. You know, I think that's a good question. You know, what happens overnight? Like not taking the dip a little low, but I think for most patients, taking it uh two or three times a day with meals is okay. It's probably okay to take your second dose mid-afternoon. I think the morning one is sort of the key one that people are focusing on right now.

SPEAKER_00 41:54

We have one more question. Pat asks, MP Thyroid has very reasonable pricing directly for the manufacturer. At this point, they're not licensed for mail order in California. Is there a possibility of someone such as yourself encouraging them to get the license?

SPEAKER_01 42:10

I think there's a they work with a lot of pharmacies that are licensed in different states. There's one called Delta, there's one called Highlands. So I think in general, most of my patients are able to get it without any problem. And it doesn't seem to be too expensive either through Good Rx or through Delta or through Highland Pharmacy. Awesome.

SPEAKER_00 42:29

Where's the best place to get MP thyroid?

SPEAKER_01 42:31

So, you know, again, most people can just get it from the regular pharmacy. I think if it's an insurance issue, they're not covering it, then you may have to go through the Delta or the Highland pharmacies or good RX, and you may need to shop around for your source. Um, it's pretty readily available. You know, I think a while ago there's some shortages, but it doesn't seem to be any shortages now.

SPEAKER_00 42:53

All right, awesome. Well, I think we're good on questions here, unless anyone has any last words. Okay.

SPEAKER_01 43:06

Thank you so much. So we'll try to there's another couple thanks here. So we'll try to maybe talk about the um testosterone delivery and then come and uh talk. But hope everybody enjoyed this and it should be posted on my website shortly. Thanks everybody so much.