Once you decide to treat, in order to address the full treatment “outcome” equation—that is, achieving both laboratory (TSH, T4) targets and symptomatic/quality-of-life goals—how do you construct your therapeutic regimen?
So now we're gonna talk about treatment for hypothyroidism. Now there is the conventional approach. Talk about that briefly and that is live with Iraq's in T. four monotherapy and that's pretty much the game the initiating drug that is recommended by all the way to another thyroid organizations, not just country, but also in europe as well. But I want you to understand that there is also discussion going on in some consensus reports that say All right, start with that. But it may not be monotherapy of LT four may not be sufficient for all patients. And we're gonna discuss that because this is a real issue. And when we cannot ignore, so there's a lot of discussion going on what you do when we look at adding not just monotherapy with the four, but when we look at combination therapy when the patient appears to need more of that metabolically active thyroid hormone T three and how we do that with both synthetic and also synthetic forms of T. Three in combination and also desiccated thyroid extracts. So we'll get into that just briefly when the patient's first identified a hypothyroidism. Overtly you've got the lab data that's there, it's very clear it's diagnosed the patient symptomatic. So we're gonna initiate treatment and typically the majority of adults what Who are not over 65 and older. We look at going ahead and initiating By guideline 1.6 micrograms per kilogram and for most patients who have mild to moderate hypothyroidism, usually between 50 and 75 mike's a day is a good place to start. You might need a bit more in pregnant women who are hyper dynamic and clear it. But don't ever make the mistake of treating As I did. I would start to low on. I had patients were special ops patients who have more muscle than Schwarzenegger made him look petite and start on something as low as 75. You go ahead and started 100 and hire. These patients will love you for it because they'll feel better quicker. So you have to look at the at the weight and how you treat how you manage them. Older patients of course you're going to have half the dose. You want to be cautious and in patients with ischemic heart disease. So we look at we started on the leader of the rocks in we do the assessment and how it's doing in about four weeks maybe makes them up ramping the dose in about 6 to 8 weeks. Just needed to get where? Oh well we look at the labs. Right well yeah we can look at the labs. Where is that? TSH, which direction is it going? Um There's gonna be a lag time how the TSH response a little bit slower to changes in doses then T. Four does. So we want to make sure they're they're going in the right direction. T four going up and TSH going down. But you don't stop with just the labs, you gotta see how they feel. Remember one of the goals I mentioned earlier is the alleviation of symptoms of the hypothyroidism which is Hypo T. three. Okay, so it may not be may not be sufficient for symptom alleviation. And so we have to look at when we want to look at bringing in T. Three in combination. Either. Synthetic form is just pure uh T. Three. That is uh given as an extra dose. Usually multiple doses of T. Three with the leave of Iraq's uh T. L. T. Four in combination. Very tricky to do in primary care. I will tell you that. And oftentimes they need multiple doses. The other one could be synthetic doses where you have T. three in combination already and ratio for t 43 and that is also used synthetically. But there's also another Up option out there and that's dedicated thyroid extracts, which many of you may have had experience with. It's been around for 130 years and we'll be talking more about that later.