From a front lines clinical perspective, what does the treatment roadmap for combination T3/T4 therapy look like? What approach to combination therapy do you recommend for the primary care, internal medicine, and/or women’s health specialist?
So when we decide to place a patient on combination therapy uh we we have a couple of options. We have just prescribing that patient side normal. And believe that the rocks in sodom. L. Being the sodium T. Three that's uh sold or a lot of physicians put place patients on desiccated thyroid extract D. T. That has a multiple different brands. So D. T. As I mentioned before historically it was the first form of treatment of hypothyroidism and that it has it was used for uh 90 100 years before it was almost replaced by live attire. Oxen. DT is just thyroid extract from pigs. Uh It used to be that it could be done from different animals. However uh today in the United States all D. T. Is produced based on thyroid that has been removed from pigs from slaughterhouses. So uh Chicago was the birthplace of D. T. Here with with slaughterhouse armor and swift. They had so many thyroid glands because they were killing all those uh animals that they developed this uh armour thyroid for example. It comes from the arm or slaughterhouse. So D. T. Contains T. four and T. three. If it's from pig it's in a ratio of 4 to 1. So there are four molecules of T. Four and one molecule of the three DT pills are measured in grains The old way of measuring this. But it's equivalent to 65 mg. so one grain is equivalent to 65 mg of extract In 65 mg of the extract. You will have 38 micrograms of level of T. Four and nine micrograms of T. Three. And all of them should have those numbers because that established by the United States pharma copia. So uh to produce the T. Uh laboratory needs to follow those standards form the United States Pharmacopeia which says 39 micrograms of 38 micrograms of tire oxen and nine micrograms of T. Three. Uh They allow you to have about plus minus 10%. So there's a small range around the 38 a small range about the nine uh micrograms. But that's sort of standard. Now Uh if you start a patient only with Iraq's and as I mentioned you would give about 1.5 microgram of liver Derakhshan per day per kilo for G. T. E. Uh I actually looked at several studies and it seems that the dose that will provide replacement for a hyper thyroid patient is between one grain and two grains about 100 and 20 milligrams of GT per day. But again this is just like little tire oxen. It depends on the absorption rate efficiency and it again depends on TSH so how are you going to monitor that first? You should start with the small dose. You should never go and give a full blast of D. T. Because it does contain T. Three and you want to avoid that. Remember level to Iraq's is very safe because it does not contain 23 D. D. Does contain 23 So I would start with half or even less of half of D. G. After those. And then build your way up. Now what should you be measuring? You should be measuring TSH free T. Four and T. Three. Why you measure T. Three? Because you're giving T. Three. You want to know what what are you doing to the T. Three levels of that patient? If you are not giving T. Three it wouldn't be helpful. But you are giving T. Three. So when do you measure this? Because the three has the issue of rapid absorption and a rapid half life. You need to measure fasting Before the patient takes the pill. So, you know how much the tree is coming from the previous pill that that patient received and three hours after the patient took the pill. Because then you know how high 33 and the circulation is going. Let's say you have a baseline of a. T. Three. That's about 100 and 20 nanograms per dl, within, well within the normal range. But after three hours that the patient took the pill, T three levels are going to to 50. That's too high. It means that during a significant number of hours that patient is going to exhibit uh tyra toxic levels of the three and you don't want to have that. Therefore, I always like to measure baseline and the peak at around three hours because then you can tell yourself I'm happy I'm safe here. Because even though the before and after they took the pill that the excursion of the T. Three levels did not go outside of the normal range. In fact, Francesco chili did some studies in his lab in which he measured the fluctuation of the three in the circulation. After patients took different amounts of the three. And he saw that if a patient takes uh between 25 and 75 micrograms of the three Uh twice a day, that patient, the excursion of T. three levels are, it's not going to be outside of the normal range above 7.5. It might take that patient to above the normal range. Now the issue is that one grain of the tea contains nine micrograms of T. Three, which is slightly more than the 7.5 micrograms that Francisco determined. So I will be careful. I would be monitoring that because we want to make sure that we're not going overboard and the patient is not experiencing a few hours of thyroid toxic causes or Elevated 73 after they took that pill.