I do not feel that T3 therapy is necessary if a patient is not symptomatic even if the temperature runs below 98.6. I have been amazed at how sensitive patients are to small changes in their body temperature patterns. If their temperatures are not doing well they can usually tell it by the way they feel. So if a patient has absolutely no complaints, and feels very well, I don't feel treatment is necessary.
 

Before therapy is started, and at each step along the way, the patient and physician must carefully weighs the pro's and the con's, and all the alternatives to T3 therapy. If the pro's of T3 therapy do not outweigh the con's, then of course T3 therapy should not be started, or if it has been started it should be gradually (not necessarily slowly-see c22) weaned.
 

Some of the most gratifying symptoms to treat include migraines, PMS, panic attacks, and depression. These symptoms have two things in common. First, they are among the most debilitating of complaints, and secondly, they are among the most typically responsive to T3 therapy. On the other hand, other symptoms are less predictably responsive. For example, it's harder to predict who might enjoy relief from the disturbing complaint of easy weight gain, and who will not. For instance, in some cases patients may experience an appreciable weight gain together with the onset of many other symptoms of Wilson's Temperature Syndrome, after a major stress. And with treatment all of those symptoms may resolve, while the weight remains. In such cases, the patients are often perplexed. They wonder why the weight didn't normalize with the other symptoms, when it clearly came on with them. I personally feel that part of the explanation for this phenomenon has to do with the change in a patient's surface area to volume ratio which is an issue discussed in the book: Wilson's Temperature Syndrome - A Reversible Thyroid Problem. At any rate, it is clear that weight is a multi-faceted issue that depends on a number of factors such as diet and exercise, among others. These observations suggest that the symptoms that are the most predictably responsive depend on factors that are the most directly influenced by body temperature patterns.
 

If this is not the first cycle, then sufficient time should be allowed between cycles to allow the T3 levels to steady down (p96). If this is the first cycle, then the T3 level should be endogenously steady (p88). Or the patient may be taking a T4-containing medicine, which should be weaned prior to initiation of T3 therapy.
 

The percentage index is useful in giving one a general idea of how well the patient is doing on the treatment protocol. Patients usually determine their complaints to be symptoms of some problem when they consider them to be inappropriate given the circumstances. To get a feel for how abnormal a patient judges his or her collection of symptoms to be, I will frequently ask him/her, "Compared to a normal person, all things taken together, would you say you feel 20, 40, 60, or 80 percent normal?" Or, "Compared to the way you felt before developing all these symptoms, all things taken together would you say you feel 20 percent normal, 40 percent, 60 percent, or 80 percent?" It is often helpful to get this overall subjective assessment of a patient's clinical status initially and at each office visit. The symptoms often worsen and improve together in a group and this assessment helps give one an idea of a trend.
 

If you don't increase a patient's T3 dose quickly enough, then you may not give her enough T3 to get her temperature up, but only enough to make it unsteady. Her temperature will still be as low as it ever was, but now not only will it be too low, but also it will be unsteady, and her symptoms may actually become worse than they were when she started T3 therapy (p97).
 

Patients may feel very well with temperatures less than 98.6, but they usually feel better when their temperatures are averaging 98.6 when measured as indicated (p19, Q14). The whole reason therapy is being implemented in the first place is in the hopes of resolving the patient's symptoms. So if the symptoms are gone, even if the temperature is a little less than 98.6, then that goal has been achieved.
 

The higher the dose of T3 therapy, the harder it is to keep T3 levels steady. So at some point during treatment, it may be felt that the current degree of symptom resolution is sufficient for now, and that it might be best to leave well enough alone for the time being, rather than to risk destabilizing things while attempting to further resolve the symptoms. To illustrate, I will review briefly an analogy I often give patients:

Let's suppose a person traveling to a distant city stopped along the way in an intermediate city, and really liked it there. He could stay there for three weeks if he wanted to. But he is not going to get to his final destination of the distant city until he gets back on the road and continues his journey. Likening this to the progress of T3 therapy, the distant city represents the ultimate goal of the patient's body temperature patterns remaining more normal and the patient's symptoms remaining resolved even after T3 therapy has been discontinued. If on the way to that goal the patient notices a remarkable improvement (and not necessarily complete symptomatic improvement) he may remain at that T3 dose and in that cycle of T3 therapy for a period of time if he prefers, and if he is without complaints. He may even remain at that level and in that cycle indefinitely (for as long as a year or more). However, the patients that do accomplish the ultimate goal of T3 therapy usually accomplish it by going up and down on the T3 therapy, getting closer and closer to normal on less and less medicine until the ultimate goal of being normal off medicine is accomplished.

So even though a patient may feel well on a certain dose in a certain cycle indefinitely, he may not be able to obtain the ultimate goal of remaining well off medicine until his system is better corrected. Better correction may require him to "get back on the road" by continuing to increase and decrease the medicine through the process of cycling until he gets closer and closer to normal on less and less medicine until the process is complete. Thus, as long as a patient is not having any problems or complaints, when a patient goes up and when a patient goes down on T3 therapy is largely a matter of preference according to the doctor's and patient's priorities.
 

Patients are much more likely to need less medicine on subsequent cycles, if their temperatures are captured on previous ones. If it's the first dosage increment, and the patient hasn't "compensated" before, then you may have to wait 3 weeks to see if the patient is going to compensate, because if the patients haven't compensated within about 3 weeks, they're probably not going to compensate. If this is not the first dosage increase of the first cycle, and the patient has compensated before, then you can wait to see if the patient will compensate again in about that same time period. If the patient does not compensate back down, then the patient's temperature has been "captured".
 

(Q14).
 

However, just because a patient presented taking a T4-containing medicine does not necessarily mean she is hypothyroid. If it is felt the patient may not be hypothyroid, she may be challenged by gradually weaning her off the T3 therapy without T4-support to see if she can maintain her temperature and clinical status on her own. When challenged, if her temperature begins to drop as soon as the weaning process begins, she is probably being weaned too quickly. However, if her temperature holds well through several decrements in T3 dose it suggests that the patient is not being weaned too quickly. Then as the patient continues to wean if she then hits a "wall" where the T3 dose cannot be decreased any further without the temperature dropping, the patient probably is hypothyroid and cannot make sufficient T4 on her own to provide for sufficient levels of T3. When it is felt a patient should be supported with T4, add back a small amount of T4 (.0125mg - .05mg) even if the patient presented on .2 mg. Because after cycling on T3 therapy, patients can often do much better even on much less T4 medicine. Continue the process above, and add back more T4 if another "wall" is encountered. It's best to have patients remain on the smallest amount of T4 possible (The taller the tree, the harder it falls. I believe patients on the smallest dose of T4 needed to do the job are less susceptible to a relapse of Wilson's Temperature Syndrome). If she can stay off T4 then she is probably not hypothyroid and may be cycled on and off the T3 therapy in the usual fashion. And she can be watched expectantly for 1 - 2 months after the last cycle of T3 has been weaned to see if her symptoms relapse or if low T4/ high TSH levels appear. If T4 is added back, and another T3 cycle is to be started, go through Module 1: Wean T4-containing medicine before T3 cycle first.
 

I usually start by weaning the patients by one 7.5 mcg decrement per dose, every 2 days. For example, if the patient is now on 30 mcg p.o. BID then I would recommend that the patient go down to 22.5 mcg's tomorrow, and then down to 15 mcg's p.o. BID two days later, and so on. However, if the patients' temperatures are clearly trending downward, then I would decelerate the weaning process to one decrement every 4 days. And if that's still too fast, I would decelerate the wean to one decrement every 6 days. The less a patient's temperature drops during the weaning process, the less medicine (often many multiples less-one-fifth, one tenth, one twentieth, etc.) will be needed to get the temperature up the next cycle. If one weans too quickly off a cycle, and does not give the body a chance to take over again, then one can squander much of the benefit of a cycle. If there has been any improvement with a given cycle, much if not all of it is retained if the T3 is weaned slowly enough and the patient is not under a great deal of stress (Q10).
 

In some cases, it can be a symptomatic treatment in that it may be used to improve a patient's symptoms, when other treatments fail, even if for some reason the symptomatic improvement does not persist after the T3 therapy has been discontinued.

In some cases, it can be a therapeutic treatment in the sense that the symptoms remain improved even after the treatment has been discontinued.

It can also be used as a prophylactic treatment in that some patients have noticed that small doses of T3 can be used to ward off relapses of Wilson's Temperature Syndrome. Some patients (especially those with hereditary predispositions to Wilson's Temperature Syndrome) have learned to predict when their symptoms are likely to relapse. Upcoming conditions of emotional stress can cause relapses in patients who are remaining well after the T3 therapy has been discontinued. For example, one susceptible patient was required to give an important presentation every 3 months. She noticed her symptoms relapsing after her first "post-T3" presentation. She was able to quickly nip her symptoms "in the bud," by starting back up on a small cycle of T3 therapy once her symptoms reappeared. She found she was able to predict a relapse with almost every quarterly presentation she was required to make. She also found that she was able to ward off relapses by taking the lowest dose of 7.5 mcg p.o. BID (lower doses can be made for more sensitive patients, but it is rarely necessary) the day before, the day of, and the day after her presentations. And thus she was able to see her presentations come and go without the first onset of symptoms. Likewise, some such patients feel more comfortable just staying on the lowest dose of T3 therapy as maintenance to more continually exert the slightest pressure against a relapse, but such cases are exceptional.
 

Even though patients can often hold a sub-total improvement indefinitely, the more complete it is, the easier it can be held. The more complete the improvement, the further back the vicious cycle is turned, and the more reserves the patients have.
 

This is especially true when it is caught early. When a person is first treated for Wilson's Temperature Syndrome, the process ideally involves the patient getting better and better, a step at a time, on less and less medicine until the process is complete. When such patients then relapse, their condition doesn't typically relapse immediately back to "square one." Their symptoms tend to start getting worse step by step, especially under stressful circumstances. So if a person needed 3 cycles of T3 therapy with dosage levels as high as 82.8 mcg p.o. BID when initially treated, that same person might only need one cycle with doses up to 15 mcg/dose to easily treat a relapse. Relapses can often be much more easily treated when caught early (within days or weeks, as opposed to months or years), the earlier the better.
 

(p106).
 

When a patient retains a net (albeit subtotal) clinical improvement from a cycle of T3 therapy, that is the first strong indication that the therapeutic trial of T3 therapy has been a success. At that point, it becomes quite likely that the patient has "made it over the hump," and has a good chance of being able to retain more and more net improvement as the cycling process continues. This is especially possible if the patient is not under tremendous stress, and can employ reasonably good habits of diet, exercise, sleep, etc.
 

When weaning T3 therapy it is best to give the patients every opportunity for their systems to come back up to give their bodies every opportunity to maintain naturally the temperature and clinical status that has been re-established artificially. Of course stress and fasting can decrease the conversion of T4 to T3. So, if patients are under a lot of stress that is likely to pass over a week or two, it is often better to wait until then before weaning. If the patients are under chronic stress that does not appear likely to change any time soon, then it is best to just proceed with the therapy as well as possible. Likewise, stringent dieting while the T3 therapy is being weaned, or after the therapy has been discontinued, might cause the patients' systems to slow back down again. So, if patients are planning to diet to achieve some much-needed weight-loss, it is generally best for it to be done before the T3 therapy has been weaned. While on T3 therapy the "T4/RT3-preponderance-generating" effect of fasting on 5'-deiodinase is muted since the patients' T3 is largely being supplied directly by mouth, essentially bypassing the function of the deiodinating enzyme (See p50 for discussion of T4/RT3 preponderance).
 

T3 therapy is not a "no pain, no gain" approach. Patients should not have any complaints and should only feel better. Any complaints, even if mild, simply indicate that the T3 levels are not sufficiently normal and steady, so the T3 therapy should be adjusted to eliminate them. Also, a patient with mild complaints is that much closer to having more severe complaints, and it is best to stay as far away from such complaints as possible.
 

 

 

Severe side effects rarely, if ever, come on all at once, without warning. Side effects tend to appear and worsen gradually, progressively. The major cause of side effects with T3 therapy is unsteady T3 levels.

Two major factors contribute frequently to unsteady T3 levels. The first is patients not being very compliant with the treatment (especially in terms of taking their medicine very much on time-see p102). The second is not taking deliberate control of a person's thyroid system, especially in rapid compensators (p94). The secret is to start the T3 therapy steadily, in patients with steady T3 levels, and to keep the T3 therapy and T3 levels as steady as possible from the start. At the first sign of any potential side effects, a T4-test dose can be considered (p129), as well as weaning the patient gradually off the T3 therapy. A difficult situation arises when the T3 dose is increased in the face of unaddressed potential side effects. The higher the dose of T3 therapy the harder it is to keep T3 levels steady, and the greater the potential of side effects from unsteady T3 levels. It is not wise to decrease the T3 therapy too quickly or to stop it abruptly, lest the patients' own thyroid systems are not given enough time to come back up and support their metabolisms. "Pulling the rug out from under their feet" can cause the T3 level to drop abruptly which can lead to blood pressure, lightheadedness, and palpitations, as well as severe fatigue, headaches and other complaints. And if these patients aren't given thyroid support of any kind these complaints can last as long as 3 weeks. Thus, the difficulty, in circumstances of very severe side effects, is this: the person is having severe side effects which suggest the patient should be weaned off the T3 rather quickly; but, severe side effects can in some cases be worsened by decreasing the T3 therapy too quickly. This is especially difficult should the patient be experiencing any severe cardiovascular complaints, or if there is concern about the patient being close to having a myocardial infarction. The best way to deal with this difficult situation is to avoid the circumstances that lead to it in the first place. It is best not to implement the T3 therapy in older patients who are frail and/or very much at risk for having a myocardial infarction; and it is best to address side effects very early, when they first appear.

But should this difficult circumstance develop, it is probably best to err on the side of going down quickly on the T3 therapy, perhaps even faster than one decrement per day, or perhaps even faster than one decrement per dose. The plummeting T3 levels would at least reduce what is likely to be a major factor in the side effects: T3 unsteadiness. If the T3 therapy is decreased very quickly, a commensurately supportive dose of T4 therapy should be considered. For example, if the T3 was being decreased from 75 mcg/dose down to 37.5 mcg/dose in one day, a supportive dose of .025mg - .05mg of T4 should be considered. And if that 37.5 mcg/dose was reduced to zero the next day, the T4 dosage could be continued or perhaps increased slightly. Remember, T4 is 4 times less potent than T3, less than half of the T4 prescribed will be converted to T3, and it will take a week for 1/2 of what will be converted to T3, to be converted. But, it will be a steady source, and it will help to give the patient's own thyroid function time to come up.
 

The side effects of T3 levels that are too high, too low, or too unsteady are very similar. It is assumed by many that if a patient on T3 therapy begins having symptoms of shakiness, increased heart rate, and increased awareness of the heart beat, then that patient is necessarily suffering the effects of excessive T3 levels. But actually, patients can develop these same symptoms if there is a sudden drop in their T3 levels (due to compensatory increased sympathetic tone to maintain blood pressure) due to the patients missing doses of the T3 for instance. In such a circumstance, adding T3 can help resolve the complaints. Also, such side effects often respond to a stabilizing T4 test dose in those patients with unsteady T3 levels due to, say, decreased dosing compliance.

The distinction can easily be made by the patient's average body temperature. If it is too low, and the clinical picture would correlate to a drop in T3 levels, then the side effects are likely to be due to T3 levels that are too low. If the temperature is averaging normal, but the temperature and clinical story would correlate with unsteady T3 levels, then the side effects would likely respond to a T4 test dose. If the temperature is too high, then it may be that the patient is on too much T3. However, in patients being treated with the T3 therapy protocol described in this manual, it is very rare that such side effects are due to excessive T3 levels. This is because patients are not to increase the T3 therapy unless their temperatures are below 98.6 on average. And by following this guideline, it is very unusual to overshoot the needed level of T3. If patients are having these kinds of side effects, yet their temperatures are not above 98.6, then they are not on too much T3 (except perhaps in the sense that it is difficult to keep their T3 levels steady on their current doses.... see c24).
 

Nevertheless, by weaning off the T3 therapy and starting another cycle, patients are often able to get their temperatures up on much lower doses (which are easier to keep steady). Thus, with patients often requiring less and less medicine on subsequent cycles than they did on previous ones, they are often able to wean off the T3 therapy completely with their temperature and symptoms remaining improved. See (p123, c8, c22, and c28).
 

(p74, p90, and p121).
 

(p90, p97, p103).
 

(p110, p165 and c22).
 

Sometimes, when the patient's temperature is averaging normal, and the patient is still not feeling as well as one would hope, it is due to unsteady T3 levels. This is evidenced by such a patient's appreciable clinical improvement (within about 45 minutes) with a T4 test dose (p129), and/or over a week or two of increased compliance with the dosing times. And sometimes patients can notice not feeling quite as well on a given dose than they were previously, even though their temperatures are still averaging normal. Such patients can often associate the slip in their clinical status with a time that they were having trouble taking their doses on time, or during a time of destabilizing stress (e.g. significant emotional stress or mental pressure). Increased compliance with dosing times and/or a T4 test dose might restore their clinical improvement, but sometimes it doesn't. It is easier for T3 levels to get unsteady, and also to stay unsteady, when the patients are on higher doses of T3 therapy. When clinical improvement cannot be restored in the present cycle, then it is usually best to wean off the T3 therapy (to let things steady down), and start again (Q13).
 

To illustrate: If the T3 levels were to be kept steady enough, even people who don't need T3 therapy would not have side effects from exogenous T3 (provided their temps were kept close to 98.6). Because when people are given T3 their own systems compensate (through negative feedback inhibition of the pituitary) by making less T3 of their own. If enough T3 were given by mouth to healthy people, their own systems would be completely suppressed and their T3 levels would be completely replaced with exogenous T3. If their temperatures were not too high or too low, then how they would feel while replaced on the exogenous T3 would mainly depend on how close to endogenously steady the T3 levels could be kept.