Thyroid disease - how to persuade your GP to diagnose and treat
UNDERSTANDING THYROID DISORDERS by DR ANTHONY TOFT
Please note the points made by Dr Toft appeared in his first book and are detailed below. However in more recent editions he changed his advice, so you may not find the advice he gave below in more recent versions.
A Book Review - ISBN NO. 1-898205-92-2
This is a very useful book to buy if you have any kind of thyroid disorder because it specifically details the indications for treatment and exactly when to start treating, with which doses of thyroxine and how treatment should be monitored. It is a British Medical Association publication written by a Consultant Endocrinologist. Therefore you can show it to your GP to persuade him to use thyroid hormones correctly. Only too often the GP is only interested in the blood test, not the clinical situation, and even then most patients end up being under treated. As far as I am concerned the important aspects for management, which Toft makes very clearly are as follows:-
- To diagnose and monitor thyroid disease you need to check a free T4, a free T3 and a TSH (thyroid stimulating hormone).
- Diagnosis and monitoring is not just a biochemical decision, but also depends on how you feel. To get the dose right needs an assessment of both the blood tests and the clinical symptoms.
- Patients who have sub-clinical hypothyroidism should be treated sooner rather than later, partly because 20% go on to develop overt hypothyroidism in each following year and partly because Toft states that one should "nip things in the bud" by prescribing thyroxine sooner on the grounds that preventive medicine is better than cure.
- Toft states that T3 may have to be used if the sense of well being is not achieved.
- The correct dose of thyroxine is achieved when the T4 gets to the upper part of the normal range and the TSH to the lower part of the normal range. A typical result would be a Free T4 of 24 and a TSH of 0.2, but Toft points out that in some patients a sense of well being is only achieved when a Free T4 is raised for example to 30 pml/L and the TSH is low or undetectable. In these circumstances it is essential that the T3 level in the blood is normal in order to avoid hyperthyroidism.
I am particularly interested in Toft's point, which is that he sometimes increases the dose of T4 over and above the normal range in order that patients can feel better - certainly I find that the last 25μg dose often makes the world of difference to many patients. If however trying thyroid hormones does not help then one should reduce the dose down.
People are often concerned about taking "hormones for life". The point about thyroid hormones, which is true for any substance required by the body, is that one can have too much or too little. For all essential substances from water to sunshine this applies. With thyroid one also needs a correct amount and this is achieved by measuring blood levels, correcting with supplements and rechecking with blood tests. Doing it this way is therefore free from any long term unpleasant side effects.
In the USA, the normal range for TSH has been changed so that anyone with a TSH above 3.0 is put on thyroid hormones. The reason for this change of heart is that a TSH above 3.0 carries an increased risk of arterial disease.
One should also remember that one's personal normal range of thyroid hormone is not the same as the population reference range. We all have a narrow normal variation of thyroid hormones and for some people this sits right at the top of the population reference range.
Thyroid History is an excellent website with hundreds of experts from medical journals going back to the early 19th Century.
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