Some info on interest I hope will be of use to members here on thyroid meds:

A book called "Thyroid Disorders" written by a Dr Gilbert Daniels, listed as Co- Director of the Thyroid Clinic at Mass General Hospital makes for a good reference guide. The book was published in 2006, so I am assuming he's still there. The book is written for physicians, specifically for GPs/family physicians vs. specialists. Most of the information would be basic rehash for the people here that have already done a lot of research on the topic, and most of what he recommends is in line with the standard recommendations.

However, he makes a few salient points regarding optimizing therapy, which seems to be the major issue for most people. Unlike many 'traditional' docs out there, Dr Daniels seems fairly open minded. For those looking for a decent reference guide to tests, diagnoses, etc, it's a good little book. It could also be helpful for when making your case that you are not happy with your current meds/dose, etc and the doc you are working with is resistant. For example, he states:

“Although thyroid function can be precisely, monitored, not all 'optimally treated' patients feel well. For example in one study in which patients were treated with increments of thyroid hormone, those whose T4 dose was increased by 25-50 mcg/d, resulting in a suppressed serum TSH, felt consistently better than those receiving the highest dose at which TSH could be maintained within the normal range. In another community population-based study, patients taking T4 felt psychologically less well than a matched control population.”

Possible explanations for the above findings he lists as:

o Some of these patients may have been subtly under treated. When hypothyroid patients remain symptomatic, the T4 dose should be increased until TSH reaches the lower normal range.

(Note, however, he's clear to point out that an intact hyopthalamo-pituitary axis is necessary for TSH to reflect thyroid status appropriately and other measures such as free hormones and symptoms should be used in that situation in addition to TSH)

o The patients may have remained symptomatic because their symptoms were related to other disorders possibly associated with Hashimoto's thyroiditis, such as depression.

o True physiological replacement of thyroid hormone may require both T4 and T3.

o Clinical deterioration after starting T4 therapy should raise the question of concomitant adrenal insufficiency, known as Schmidt's syndrome.

For a 'traditional' endocrinologist I thought his comments above showed an open minded approach I wish more docs followed.

Additionally, and changing topics a bit here, but germane to the situation of many people, recent studies find that t3 augments the effects of SSRIs, even with treatment resistant MDD, so those on SSRIs not experiencing improvements may want to talk with their physician/therapist about adding a small amount of t3.

Recent t3 and SSRI studies of interest:

J Clin Psychiatry. 2005 Aug;66(8):1038-42.

An open study of triiodothyronine augmentation of selective serotonin reuptake inhibitors in treatment-resistant major depressive disorder.

* Iosifescu DV,
* Nierenberg AA,
* Mischoulon D,
* Perlis RH,
* Papakostas GI,
* Ryan JL,
* Alpert JE,
* Fava M.

Depression Clinical and Research Program, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.

OBJECTIVE: In an open trial, we investigated the efficacy of triiodothyronine (T(3)) adjuvant to selective serotonin reuptake inhibitors (SSRIs) in subjects with major depressive disorder (MDD) resistant to SSRI treatment. METHOD: Twenty subjects who met DSM-IV criteria for MDD (mean +/- SD age = 44.3 +/- 10.3 years; 55% [N = 11] women) and had failed to respond to a course of treatment of at least 8 weeks with an SSRI antidepressant were enrolled in a 4-week open-label augmentation treatment with T(3) 50 microg/day. Atypical and melancholic sub-types of MDD were diagnosed using Structured Clinical Interview for DSM-IV Axis I Disorders criteria. We administered the 17-item Hamilton Rating Scale for Depression (HAM-D-17) 4 times during the study (which was conducted between 2001 and 2003). RESULTS: During T(3) augmentation, the severity of depression decreased from an initial mean +/- SD HAM-D-17 score of 20.5 +/- 3.6 to a final HAM-D-17 score of 14.0 +/- 7.1 (p < .001). Seven subjects (35.0%) were treatment responders (HAM-D-17 reduction >or= 50%), and 6 subjects (30.0%) achieved clinical remission (final HAM-D-17 <or= 7). The 5 subjects with atypical depression experienced significantly (p < .01) greater clinical improvement (final HAM-D-17 scores 6.6 +/- 1.8 vs. 16.4 +/- 4.5), and higher rates of treatment response (100% [5/5] vs. 13.3% [2/15]) and remission (80.0% [4/5] vs. 13.3% [2/15]), compared to subjects with nonatypical MDD. The 8 subjects with melancholic MDD experienced significantly (p < .05) greater depression severity at the end of the study compared to nonmelancholic MDD subjects (final HAM-D-17 scores = 18.3 +/- 6.6 vs. 11.1 +/- 6.1). CONCLUSION: Triiodothyronine augmentation of SSRIs may be a promising treatment strategy in SSRI-resistant MDD, particularly in subjects with the atypical MDD subtype.

J Affect Disord. 2006 Apr;91(2-3):211-5. Epub 2006 Feb 17.
T3 augmentation of SSRI resistant depression.

J Clin Psychiatry. 2001 Mar;62(3):169-73. Links
Triiodothyronine augmentation of selective serotonin reuptake inhibitors in posttraumatic stress disorder.

Am J Psychiatry. 2006 Sep;163(9):1519-30;
A comparison of lithium and T(3) augmentation following two failed medication treatments for depression: a STAR*D report.