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T3/T4: Cases from My Practice

The table below tracks cases in my practice (some features have been changed to protect patient identity); last update Oct 17, 2001. [Update Jan 2004:  I'll update the table soon.  In general most of those improved are still dramatically improved, including the one who put me on to all this -- she's going to graduate school now were before she couldn't hold a job.  However, one of my patients clearly did worse on T3/T4 than on T4 alone, and after that experience, I really backed off on this approach and haven't bothered updating the table.  

That's because with that one case it became clear to me that T3/T4 thyroid, used instead of T4 alone, can be harmful.  And one of the reasons I'd been exploring this approach so actively was that in theory it seemed very unlikely to be harmful (if TSH was kept in the normal range), and that therefore we didn't need as much evidence to consider using this approach, because even if it didn't work, it wasn't likely to be harmful -- or so I thought.   

However, the experience of the woman above who's now in graduate school suggests that there may be some people for whom this combined approach can be very helpful (hard to be too certain on the basis of that one patient, and a few more who are listed below).  One of these days I'll get around to writing her up as a case report.]  

Here then are the cases I collected back in 2001.  Asterisks mark cases with profound improvements akin to those seen with recognized mood stabilizers.

  • Improved or much improved    17/25     (68%)
    Note below how many of these people had a "normal" TSH prior to this treatment. 
  • Worse                                        5/21       (20%)
    These were my patients with most treatment resistant illness, early in my experience with T4/T3.  Note prevalence of diagnosis or possible diagnosis of "personality disorder" amongst those who worsened.  Note also that some were clearly started too high, in retrospect, most (but not all, interestingly) with TSH <0.5.  Finally, note that none have sustained worsening; all returned to prior baseline after thyroid was discontinued.
  • No Change:                                 3/25       (12%)
  • For Prescribers: clear improvement in mood stability with T3/T4, who did not improve on T4 alone:                                           10/13    ( 77%)
    These patients are marked with a bold case number.  Their experience supports the hypothesis that T3/T4 has substantially more mood stabilizing effects (like lithium and Depakote) than T4 alone.   

 

TABLE: Details by case: improved, worsened, no change, pending

Improved

Pt.# Age F/M

Symptoms

TSH
before rx (no lithium)
Prior
T4 dose
Doses
T4  /  T3
used
Result - effects TSH on T3/T4 start date 
 

1*

30s F Years of severe mood instability;
BPI, borderline features.  
Could not tolerate any 
antidepressant without cycling
3.4 100 150/37.5 Mood stable for first time in years, though depressed; tolerating antidepressant now None 0.023

(caveat)

 
4/01
2* 50s F Bipolar II, borderline features Not available
(antithyroid+)
150 150/12.5 Profound improvement, back to work  None 2.06 7/01
3* 30s F Years of severe mood instability;
clear bipolar II
1.32 100 50/12.5 Much improved, as good as conventional mood stabilizers (better?) None 0.06

(caveat)

5/01
4* 50s F PTSD, BPII mixed 8.9 at one time 200 50/12.5 Much improved, back to work None 0.2
(caveat)
f/u via PCP
5* 40s F Severe BPII; called "borderline" by others 2.9 50 for mood stabilizer adjunct, no effect 50/12.5 Profound improvement, back to work, only two other mood stabilizers (was 4) Agitated on 75/18, TSH .03 0.5 on 50/12.5 6/01
6* 40s F Bipolar II, mixed, severe 3.2 on lithium 100 100/12.5; decreasing to 75/18 Clearly better, nearly symptom free despite severe stressors None, despite TSH 0.1 on 100/25 Pending on lower dose 8/01
7 50s F PTSD/probable BPII Prior rx for hypothyroid 175 125/37 
too much; 100/25 too much; now 75/18 
Much improved Agitation on 100/25, TSH 0.03  1.49 on 75/18 6/01
8 50s F
Bipolar II with borderline features
Not available 50-
100
Armour 1gr. Moderately improved None 1.12, adherence uncertain 7/01
9 60 F BPII mixed, severe 3.09 100 for mood stabilizer adjunct, no effect 50/12.5 Finally stable after years of many rx's None 0.7 8/01
10. <20 F Bipolar with catatonia (on Paxil and T4) 6.2 100, no better after 1.5 mos; paxil added 50/12.5 "Back to normal" after stopping Paxil, switching to T4/T3 none f/u via PCP 8/01
11* 30s M Intermittent explosive disorder vs. BPII mixed Not available None 75/18, decreasing to 50/12.5 Profound response, clearly as good as Trileptal; on only T4/T3 now Agitation on 100/25 .03 on 75/18, pending on 50/12.5 5/01
12* 40s M Longstanding BPI 1.8 on Lithium for >10 years; thyroid started when TSH rose to 3.6 None 50/10 Profound response, from depressed/SI to full recovery (would it have occurred with T4 though?) None 0.65 8/01
13*. 40s M BPII with mild rapid cycling 0.97 None Armour 1/2 grain, decreasing to 3/4 pill Clearly improved, able to stop lamotrigine which was inducing cyling Subtle agitation, sweating with TSH of 0.41 0.41 on 1/2 gr. 9/01
Pt.# Age F/M

Symptoms

TSH
before rx (no lithium)
Prior
T4 dose
Doses
T4  /  T3
used
Result - effects TSH on T3/T4 start date 
14  50s F BPII vs. GAD Not available None 75/18 Clearly improved, still symptomatic No side effects on 100/25 but TSH 0.03 Pending 7/01
15 40s F PTSD/Bipolar II; some borderline features 2.7 None 75/18, decreasing to 50/12.5 Probable moderate improvement "Wired" on 75/18 with TSH 0.2 Pending on lower dose 7/01
16 40s F mild BPII, some dependent features 2.2 None 12.5/3.1 Much improved: more assertive, confident "Rigid" on 50/12.5 0.9 8/01
17 40s F Moderate BPII with rapid cycling and ADD features 1.65 None 50/12.5 Clearly improved, an emerging depression aborted, calmer None Pending 9/01

No Change

Pt.# Age F/M

Symptoms

TSH
before rx (no lithium)
Prior
T4 dose
Doses
T4  /  T3
used
Result - effects TSH on T3/T4 start date 
18 50s F Severe BPII, can't tolerate antidepressant w/o cycling Not available 125 100/25; increase to 125/28.6 Tolerating no antidepressant w/o cycling? otherwise no better, next step pending None 2.0 on 100/25, follow-up pending 4/01
19 20s M BPII with rapid cycling 0.62 None 50/12.5 No change, still depressed and anxious None Cancelled 1 month of rx
20 50s F BPII with rapid cycling 2.52 None 25/7.25 A little better? equivocal None Pending 10/01

Worse

Pt.# Age F/M

Symptoms

TSH
before rx (no lithium)
Prior
T4 dose
Doses
T4  /  T3
used
Result - effects TSH on T3/T4 start date 
21 40s F Severe PTSD, "borderline",
? BPAD
1.82 100 as adjunct 100/25 Worse Severe agitation, decreased sleep 0.03 1 mo. of rx
22 40s F BPI, has been called borderline  1.64 None 50/12.5 Worse Probable increased panic and tremor .06 1 mo. of rx
23 40s M PTSD, ?BPII, many would call borderline Developed thyroid cancer while under treatment None 50/10; decreased to 50/5, then stopped Worse Increased agitation, "rage" 0.8 1 mo. of rx
24 40s F

BPII?  resistant to all but
Trileptal (great response then allergy)

3.60 with free T4 0.7 100 as adjunct 75/18.75, decreased to 50/12.5 Worse Severe restless legs even after dose decrease 1.68
with restless legs
1 mo. of rx
25 30s F BPII, mixed, severe with borderline features 1.92 None 50/12.5 Worse Agitated, decreased sleep, severe 0.15 1.5 mos. of rx


Pending or uncertain (will move to improved, worse, or no change if course clarifies response)

Pt.# Age F/M

Symptoms

TSH
before rx (no lithium)
Prior
T4 dose
Doses
T4  /  T3
used
Result - effects TSH on T3/T4 start date 
P1 40s F Years of mild mood instability;
BP II
Not available None Armour 1.5 gr Pending Agitation, decreased concentration on 1.5 gr Pending 9/01
P2 30s F severe BPI Not available None 50/12.5, decreased to 37.5/9.3 Possible improvement in mood overall? Increased psychotic symptoms at 50/12.5 0.03 on 50/12.5 8/01
P3 50s F Longstanding BPII     25/7.5       9/01
P4 40s F Severe PTSD, possible underlying Bipolar variant             10/01