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Dx Reverse T3 Treatments:

Hypothyroidism/ Reverse T3
"Some integrative physicians believe that elevated levels of RT3 -- even though TSH, Free T3 and Free T3 values may be within the normal reference range -- reflect a thyroid problem at the cellular level -- a condition that Kent Holtorf, MD calls 'cellular hypothyroidism.'

In this integrative view, elevated RT3 can be triggered by ongoing chronic physical or emotional stress, adrenal fatigue, low ferritin (stored iron) levels, acute illness and injury, and chronic disease, among other factors.

*[Editor] It is important to remember that triiodothyronine is the only active thyroid hormone. Scientifically, TR-alpha is associated with modifications in cardiac behavior, while activation of the TR-beta is associated with increasing metabolic rates, resulting in weight loss and reduction of blood plasma lipid levels.

According to Dr. Holtorf:
Reverse T3 is actually an "antithyroid" -- T3 is the active thyroid that goes to the cells and stimulates energy and metabolism. Reverse T3 is a mirror image -- it actually goes to the receptors, sticks there, and nothing happens. So it blocks the thyroid effect. Reverse T3 is kind of a hibernation hormone, in times of stress and chronic illness, it lowers your metabolism. So many people seemingly have normal thyroid levels, but if they have high Reverse T3, they're actually suffering from hypothyroidism.

A study in The Journal of Clinical Endocrinology & Metabolism found that TSH and/or T4 levels can be poor indicators of the actual thyroid levels in tissues, and therefore, in a substantial percentage of patients, do not reflect whether or not a person has truly normal thyroid levels. This study showed that increased T4 and RT3 levels, along with decreased T3 levels, are associated with symptomatic hypothyroidism at the cellular or tissue level. The authors of this study concluded:
Subjects with low T3 and high reverse T3 had the lowest PPS [a score that evaluates normal activities and measures physical and mental functioning]...subjects with high reverse T3 concentrations had worse physical performance scores and lower grip strength. These high RT3 levels were accompanied by high FT4 levels (within the normal range)…These changes in thyroid hormone concentrations may be explained by a decrease in peripheral thyroid hormone metabolism…

According to Kent Holtorf, MD, a Reverse T3 level above 150 -- or a Free T3/Reverse T3 ratio that exceeds .2 [when the Free T3 is measured in picograms per milliliter (pg/mL)] -- may indicate hypothyroidism.

Says Dr. Holtorf:
A high reverse T3 demonstrates that there is either an inhibition of reverse T3 uptake into the cell and/or there is increased T4 to reverse T3 formation. …reverse T3 is an excellent marker for reduced cellular T4 and T3 levels not detected by TSH or serum T4 and T3 levels. …high or high normal RT3 is not only an indicator of tissue hypothyroidism but also that T4 only replacement would not be considered optimal in such cases and would be expected to have inadequate or sub-optimal results.

A difference of opinion "Although reverse T3 may be elevated in the setting of nonthyroidal illness, it is not reliable in distinguishing between the hypothyroid sick patient and the euthyroid sick patient. This is probably because of drug and disease effects on thyroid hormone metabolism as well as the presence of sufficient T4 substrate for conversion to reverse T3 in many hypothyroid sick patient"

Treating Elevated Reverse T3
According to integrative practitioners, one of the key ways to address elevated RT3 and "cellular hypothyroidism" is through thyroid treatment with a medication that contains T3.
One preferred form is time-released T3. Time-released T3 is a compounded form of T3 available by prescription. In some cases, this T3 is prescribed as a stand-alone thyroid treatment.

In other cases, T3 is added to a synthetic T4 prescription drug (i.e., Synthroid, Unithroid, Tirosint), or a prescription natural desiccated thyroid drug (i.e., Nature-throid, Armour) is prescribed.

Reverse T3: The Challenge
Patients who are interested in RT3 testing may be challenged to find a physician willing to run the tests, or treat any imbalances.
Endocrinologists, many of whom do not test T3, RT3, or prescribe T3 medications, may not be a good choice for those patients. Instead, an integrative physician, holistic MD, or physician with expertise in hormone balance may be needed.
Holistic gynecologist and hormone expert Sara Gottfried, MD, author of The Hormone Cure, has integrated Reverse T3 testing into her practice.

I used to order Reverse T3 in a patient if I'd optimized the TSH and Free T3 but the patient still had hypothyroidism symptoms, but now I discuss compounded T3 more often at the start, because I think it's informative in deciding about the thyroid formulation. For example, if a patient has high Reverse T3, I'm more likely to use the compounded, time-released T3 as part of their treatment."
*[Editor] New evidence for T2 as a supplement has been discussed for weight loss and lowering cholesterol; it need further investigation. T2 in in Nature-thryoid and Armour Thyroid.

*[Editor] The Editor knows Ken Holtorf, M.D., personally, and has come to the same conclusion, independently. The Editor orders Reverse T3 frequently and may decide on replacing compounded sustained release T3 (triiodothyronine) in the morning and at noon. Cytomel®, commercially prepared T3 is not used because Cytomel® has only a 90 minute half-life while the compounded products have a 6 hour half-life.

The other caveat is that individuals who are unable to tolerate thyroid formulations with T3 usually have adrenal exhaustion. These individuals will have fasting morning cortisol levels at or below half-normal (normal is 20-25mcg/dl). Adding a small amount of hydrocortisone, 5mg before and after breakfast and at noon usually allows the patients to tolerate the active thyroid without heart palpitations.

[Editor]Having Hashimoto's Thyroiditis personally for more than 10 years with thyroid and peroxidase enzymes exceeding 500 from two major national reference laboratories, the Editor was able to normalize the antibodies to normal (less than 9) with Nature-throid© prescription medication and multiple doses of compounded 7.5mcg T3.

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