About 10% of hypothyroid patients have reduced quality of life despite normal TSH under therapy with levothyroxine (L-T4). A new randomised, double-blind trial demonstrated better QoL under L-T4 + L-T3 compared to L-T4 alone. 🧪🩺 #MedSky pubmed.ncbi.nlm.nih.gov/39865226/ doi.org/10.1186/s129... - ThreadSky

drjwdietrich.bsky.social • 22 days ago

About 10% of hypothyroid patients have reduced quality of life despite normal TSH under therapy with levothyroxine (L-T4). A new randomised, double-blind trial demonstrated better QoL under L-T4 + L-T3 compared to L-T4 alone. 🧪🩺 #MedSky

https://pubmed.ncbi.nlm.nih.gov/39865226/

https://doi.org/10.1186/s12902-025-01840-4

Comments

expendo.bsky.social•22 days ago

Interesting study! But...TSH was significantly lowered in the T4+T3 cohort while unchanged in T4+placebo. Evil reviewers could argue that more thyroxine (causing a comparable change in TSH) might have achieved the same in QoL. Also the p-value for physical activity seems wrong given the same mean.

drjwdietrich.bsky.social•22 days ago

OK. We cannot judge the physical activity without access to the original data. TSH may reflect central actions of T3. Statements from previous decades suggested TSH to be always reduced under therapy with L-T3, but this is probably incorrect. The definition of euthyroidism remains difficult.

sammy1974.bsky.social•15 days ago

I had a suppressed TSH with increased doses of T4 and still a bad QoL. The game changer definitely was switching to combined therapy. TSH is within range and QoL is so much better.

expendo.bsky.social•15 days ago

Glad to hear it! I am not saying more T4 is the solution, I was just highlighting that the study was not well done. If you want to compare QoL, it should be done in comparable groups, ie ideally in individuals that are not happy on mono T4 with comparable pre and post intervention TSH.

drjwdietrich.bsky.social•15 days ago

Generally, I agree, and this study has, in fact, several shortcomings. However, demanding that TSH be equal in both groups would imply that it is a universal measure of thyroid signalling, which is incorrect in light of current evidence.

https://pubmed.ncbi.nlm.nih.gov/29375474/

https://doi.org/10.3389/fendo.2017.00364

expendo.bsky.social•15 days ago

Fully agree, especially in patients that are unhappy on T4 substitution, it is evident that it does not reflect TH action in all tissues. But it should be easy if you do a study like this to randomize the participants properly so that TSH is comparable and not confounding the results.

drjwdietrich.bsky.social•15 days ago

OK. It would, perhaps, be a good idea to complement such a study with a subgroup analysis of persons with comparable TSH, comparable SHBG and comparable ostase concentrations in order to capture TR-alpha action as well as central and peripheral TR-beta signalling.

echinatum.bsky.social•22 days ago

Though many patients get told they cannot have T3. But nor can they have more T4 as their FT4 is in range.

My own FT4 is v close to top, and FT3 is just about adequate, but I'd like to know what it is like to have a tiny increment in FT3 - even with a decrement in FT4.

expendo.bsky.social•22 days ago

Controversial topic and more solid studies are needed. I think moving away from treating TSH to treating patients is important. There is an interesting book by Dr Bianco on the topic:
https://www.amazon.de/Rethinking-Hypothyroidism-Treatment-Patients-English-ebook/dp/B0B3S6X8RR/

echinatum.bsky.social•22 days ago

For ONE issue of many:

While testing does not take account of time of day, nor time from ingestion of thyroid hormone, we will never see proper diagnosis and treatment.

https://onlinelibrary.wiley.com/doi/10.1155/2013/831275

endocrinemed.bsky.social•14 days ago

Useful trial. Well done to the authors. I see your point @expendo.bsky.social , but I can’t deny this work adds doubt to the (almost dogma) position that T3 adds nothing for patients.

duckii.bsky.social•21 days ago

Glad this info is out. I prefer to treat with T4/T3 combo. TSH is not always accurate; have to look at FT3 and FT4 levels. Also LFTs.. enzymes can be high is over (or under) treated. Low TSH but normal FT3/FT4, normal LFTs, and pt feeling good are reassuring.

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