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 Post subject: TRH stim tests??
PostPosted: Thu May 07, 2009 7:48 am 
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Q: Some holistic MD's will focus only on Free T3 and Free T4 as well as clinical findings in regulating thyroid replacement (virtually ignoring TSH). I'd be interested in opinions utilizing this method. I will push TSH down to 0.5 but have been apprehensive to go lower based on theoretical long term risks of cardiomyopathy and osteoporosis. If we follow this more traditional approach however, we miss a number of people who suffer with probable hypofunctioning pituitary or hypothalamus glands. Intuitively it would seem that if a patient were being overtreated, they would have side effects of hyperthyroidism. At times when I have inadvertently "overtreated" with thyroid, resulting in a low TSH found later, the patient would claim they felt much better. Should we be doing TRH stim tests?

Also, I cannot find toxicity with high dose K2. Why don't you come out with a 10 or 20mg size?

Steve Grable MD

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 Post subject: Re: TRH stim tests??
PostPosted: Thu May 07, 2009 7:48 am 
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A: Dear Dr Grable:

From my understanding that will not hasten the process; this seems to be a lifetime need. I believe nothing can beat my protocol with BC-I, HRT, Beyond Bone and Vit D 5000.
Thanks for checking.

Sincerely,

Garry F. Gordon MD,DO,MD(H)
President, Gordon Research Institute
http://www.gordonresearch.com

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 Post subject: Re: TRH stim tests??
PostPosted: Wed May 13, 2009 7:53 pm 
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A2: Dear Dr. Grable,

I have been working with thyroid issues for many years and would like to comment on your question regarding the TSH. First of all, I find the TSH to only be relevant in the 'pre' treatment evaluation, ie, before adding in exogenous hormone. Yes, when someone is clinically hyperthyroid, the TSH will be suppressed, but most importantly the actual thyroid hormones will be elevated. the actual cause of metabolic pathology (A-fib, osteoprosis, etc) is due to the excess of circulating thyroid hormones, not the TSH itself.

When, patients are treated with Synthroid or Armour, the TSH becomes much less accurate contrary to the way we have all been taught that the TSH is the "gold' standard. As you may already know the ranges on all of these tests are not established from looking at optimally fit people. Secondly, I have on numerous occasions seen quite variable TSH reading on patients on long standing stable doses of Synthroid to now convince me that the TSH is a big waste of time. (I only order them mostly because it is still the "standard" of care.) For example, I recently had a woman come in on Synthroid 75mcg QD who had a TSH of 1.7 with a Free T4 of 1.38 done on a Friday by her PCP. I drew labs on Monday and she had a TSH of 4.5, a Free T4 of 137, and a suboptimal
Free T3 of 2.3. She had hypothroid symptoms. So, which TSH to believe? I have even sent my own TFT's off to different labs and found the TSH levels to vary, yet the Free T4's and free T3's remain stable. (...and i'm not on thyroid hormone)

I have several patients on either Armour or just Synthroid or some other mix, who are clinically euthroid (subjectively they feel optimal -- not "high' or hyper or hypo), with optimal Free T4's and T3's, but with suppressed TSH levels. On physical exams they display NO hyper thyroid signs. Every time they have their doses decreased, they
begin to have hypothyroid symptoms return. So, how do we explain suppressed TSH levels when in fact the Labs (fT4/fT3) and the clinical examination reveal they are euthyroid?

These people are in fact, NOT hyperthyroid despite the suppressed TSH! Please do not treat them by this mediocre test. I think there is a phenomena of the pituitary regulation getting lazy when we take over the peripheral hormone control. (kind of like a driver's ed
situation where the passenger seat has an instructor who can take over the control of the car and the student drive just lays back....I'm trying to make an analogy here.)

I have had many patients for over 15 years in their middle age to elderly years with optimal fT4/fT3 labs, suppressed TSH levels < 0.1 and subjectively at optimal euthroid quality of life and NEVER had an incident of all the garbage fears the Endocrinologists tell you of such as, 'heart attacks", Atrial fib, osteoporosis, etc. Never!

I think the whole role of TSH needs to be revamped in our thinking. we need to go principally by clinical exam, listen to the patient, and use the actual free hormone measurements first.

Feel free to contact me if you have further questions.

yours,
Ron Manzanero, MD
http://www.aimmd.com
Austin,TX

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 Post subject: Re: TRH stim tests??
PostPosted: Wed May 13, 2009 7:54 pm 
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A3: Dr Gable,
I am following patient's clinical symptoms and basal temperature as my prime directive. The TSH goal is to be suppressed less than .5. If the T3 is too high then the patient should c/o tachy or feelings of hot flashes. I found mark Starr's hypothyroid book an excellent source for treating and being sensitive to subclinical hypothyroid.

osteoporosis needs to addressed separatedly esp for vit D level and estrogen dominance issue. hope this helps Curtis Takemoto-Gentile, MD

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 Post subject: Re: TRH stim tests??
PostPosted: Wed May 13, 2009 7:54 pm 
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A4: Dear dr. grable....everyone of us treating patients should be doing regular metabolic testing that amongst other things determines bmr...the bmr is the single most sensitive way to assess thyroid function....go to my web site http://www.antiagingmedicine.com and view the videos labeled, "health, disease, and aging - it's all about energy" parts 1-4...you will have a six hour seminar on metabolic testing and how you can use it to define and refine your preventive programs for every patient you see....this is the key to individualizing therapy, and also the key to individualizing thyroid therapy...thyroid blood tests (total t3, total t4, rt3, and tsh) are only helpful to determine if you are using the right ratio of t3 to t4 (in which case they can be very helpful)....but they are of no help at all in determining who needs therapy.....used to use trh stim tests almost thirty years ago...never found them to be helpful....all the best....

Frank shallenberger, md

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 Post subject: Re: TRH stim tests??
PostPosted: Wed May 13, 2009 7:55 pm 
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A5: As you know, TSH is a pituitary hormone. When it is low, it may be due to pituitary insufficiency, as you point out, or from full replacement of thyroid hormone, causing the pituitary to sense that stimulation of the thyroid is not necessary. Lack of TSH does not cause osteoporosis or heart problems/arrhythmias. Excess thyroid hormones do. Long term studies show that high t4 levels are related to increased bone loss but NOT with low TSH and normal T4 levels. I've treated clinicallly hypothryoid patients with TFT's within the reference ranges (note I did NOT say "normal" range) for over 24 years in my practice. I monitor them closely from a cardiac and bone density perspective and have never seen problems unless the T4 levels were elevated.

I used to do TRH stimulation tests in the office and did not feel that the results obtained gave me any greater information than a thorough history & physical would. TRH causes significant nausea so not a pleasant test for patients (or staff) to endure.

Best,
Robban A. Sica, MD Center for the Healing Arts, PC
370 Boston Post Road Orange, CT 06477
http://www.centerhealingarts.org

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