What laboratory and/or clinical features, especially persistent symptoms, suggest the need for combination therapy—including with a DTE—to optimize management? What have trials evaluating patient preferences suggested about combination therapy?
the patient population that may respond, or maybe the target for therapeutic treatments beyond the Little Rocks in. Usually our patients that do not feel okay on the water rocks in alone do not have any obvious underlying co morbidity that can explain their not feeling well. And um and usually they're requesting this therapy. Very seldom providers are prompt themselves to start a different type of formulation. So generally speaking, the patients initiated the request to do something about it. And again, uh symptoms can be very disabling from the patient's perspective and they need to be addressed by the provider. Another I would call it circumstantial evidence that may lower the threshold from the providers and point to initiate alternative treatments is the observation of of low T. three levels in patients that are treated with the water rocks in alone. Again, now, in the absence of symptoms, uh I would be at the art pressed to make any therapeutic change. But if the patient is not doing well and I see a lower T. Three level at the three level law law or below normal range, they would probably prompt me to consider alternative treatments. The problem of going on alternative treatments, particularly when we At the AT. three which is like a hearing. Is that the current formulation of libertarian in require, if we look at the pharmacogenetics twice a day administration, we have experimental evidence that the lives of Iranian as a very short equal liberation phase in its former cocaine aesthetics, equal liberation phase means that the immediately after absorption the coyote Iranian is rapidly distributed in the serum poll, resulting in a rise of T. Three level, often above normal range. And then a relatively quick disappearance from zero data causes peaks and troughs of T. three levels. If we're giving a relatively idols on a single daily administration. So if our goal is maintaining relatively steady level of T. Three, we should look for twice a day administration in terms of dozing, Currently available doses of loyalty, running our 5 25 and 50 micrograms. The usual dozing of leo tyranny is everywhere between 2.5 and five micrograms on twice daily administration. This is really not carved in stone. The only by the only society that gives some degree of recommendation is the european tired association, which aims to the equivalent of 3.75 Micrograms twice a day, which is very difficult to achieve in in the setting of what we have here in the United States. Um one, once we decided to go on uh combination therapy, we also may want to consider whether using uh desiccated thyroid extracts. The secretary of extracts have been around since 1851 and they were the primary way of treating patients with hypothyroidism. one thing that we need to recognize is that those are thyroid extracts, meaning that the content of T. Three is higher as compared to the circulating levels of T. Three in a racial T. 3 24 in circulation in humans. So even desiccated thyroid extracts, which are definitely natural, are not as physiological as we'd like them to be, and the ratio of the 4 23 24 is skewed toward the relative ira Presence of T. three as compared to what would be normal in circulation in humans. When it comes to assessing the success of the therapy. Then we need to look at two different parameters. One is a Syrian tiro, doorman and TSH levels, and then comparing these parameters with the patient's symptoms.
