Medical Musings <br/><br/><a href="https://johnsonthomasmd.substack.com?utm_medium=podcast">johnsonthomasmd.substack.com</a>
Deep Dive: Medical Perspectives
Claim This Podcastby Johnson Thomas
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Medical Musings <br/><br/><a href="https://johnsonthomasmd.substack.com?utm_medium=podcast">johnsonthomasmd.substack.com</a>
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1/8/2025
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Recent Episodes
March 22, 2025
Why Do Some Patients Do Not Feel Well on Levothyroxine Therapy?
<p>🎙 <strong>Episode Title:</strong> Why Do Some Patients Still Feel Unwell on Levothyroxine Therapy?</p><p>📅 <strong>Release Date:</strong> 3/19/2025</p><p>🔎 <strong>Episode Summary:</strong>In this episode, we dive into a common frustration for many patients with hypothyroidism: feeling unwell despite "normal" thyroid blood tests while on Levothyroxine therapy. Up to <strong>15–20%</strong> of patients report a lower quality of life, and around <strong>1 in 4</strong> continue to experience hypothyroid-like symptoms despite normal TSH levels. We explore <strong>why this happens, potential diagnostic steps, and alternative treatment options</strong> to help patients and providers navigate this complex issue.</p><p><strong>🔹 Episode Breakdown</strong></p><p><strong>🎧 Introduction (0:00 - 5:00)</strong></p><p>Overview of Levothyroxine as the standard treatment for hypothyroidism.</p><p>Acknowledging the persistent symptoms in some patients despite normal TSH levels.</p><p>Discussion of the article <strong>"Why Do Some Patients Do Not Feel Well on Levothyroxine Therapy?"</strong></p><p><strong>🔍 Main Discussion Points (5:00 - 35:00)</strong></p><p><strong>1️⃣ Suboptimal Levothyroxine Dosage or Absorption Issues</strong></p><p>Poor gastrointestinal absorption due to <strong>celiac disease, atrophic gastritis, or H. pylori infection</strong>.</p><p>Medications like <strong>calcium, iron, proton pump inhibitors</strong> interfere with absorption.</p><p>💡 <strong>Actionable Advice:</strong> Take Levothyroxine <strong>on an empty stomach, separate from calcium, iron, and soy by at least 4 hours</strong>.</p><p>🩺 <strong>Diagnostic Steps:</strong> Celiac disease antibodies, Parietal Cell Antibodies (PCA), Levothyroxine absorption test.</p><p><strong>2️⃣ Concurrent Autoimmune Diseases</strong></p><p>Hashimoto’s thyroiditis increases the risk of <strong>adrenal insufficiency, celiac disease, and pernicious anemia</strong>.</p><p>Recommended screening: <strong>Morning cortisol, ACTH, B12 levels</strong>.</p><p><strong>3️⃣ Other Medical Conditions</strong></p><p>Conditions like <strong>diabetes and hypertension</strong> can mimic hypothyroid symptoms.</p><p>Ensuring proper management of these comorbidities is crucial.</p><p><strong>4️⃣ Anemia and Nutrient Deficiencies</strong></p><p><strong>Iron and folate deficiencies</strong> can lead to fatigue, weakness, and cognitive issues.</p><p>Diagnostic tests: <strong>CBC, ferritin, RBC folate levels</strong>.</p><p><strong>5️⃣ Sleep Disorders</strong></p><p><strong>Sleep apnea and insomnia</strong> are common in hypothyroid patients.</p><p>Solutions: <strong>Sleep studies, sleep hygiene counseling, possible sleep medications</strong>.</p><p><strong>6️⃣ Mental Health Conditions</strong></p><p><strong>Depression and anxiety</strong> often coexist with hypothyroidism.</p><p>Psychological evaluation and treatment options.</p><p><strong>7️⃣ Fibromyalgia or Chronic Fatigue Syndrome (CFS)</strong></p><p>Overlapping symptoms with hypothyroidism.</p><p>Need for thorough differential diagnosis.</p><p><strong>8️⃣ Medication Side Effects</strong></p><p><strong>Beta-blockers, antidepressants, and other medications</strong> can mimic hypothyroid symptoms.</p><p>Medication review with a healthcare provider is recommended.</p><p><strong>9️⃣ Pituitary or Hypothalamic Disorders (Central Hypothyroidism)</strong></p><p>In some cases, <strong>TSH may be inappropriately normal or low</strong>.</p><p>Important to check <strong>Free T4 and T3 levels</strong> for accurate diagnosis.</p><p><strong>🔟 Overtreatment or Supersensitivity to Thyroid Hormone</strong></p><p>Some individuals may develop <strong>hyperthyroid-like symptoms</strong> even with normal TSH.</p><p>Adjusting dosage may be necessary.</p><p><strong>1️⃣1️⃣ Time-Course Factors</strong></p><p>Recovery from hypothyroidism can take <strong>months</strong>.</p><p>Educating patients about normal recovery patterns can reduce anxiety.</p><p><strong>1️⃣2️⃣ Incomplete T4-to-T3 Conversion</strong></p><p>Some patients have <strong>impaired T4 to T3 conversion</strong>, leading to <strong>low T3 levels despite normal TSH</strong>.</p><p>Genetic variations in <strong>DIO2 enzyme</strong> have been linked to poor well-being on Levothyroxine alone.</p><p><strong>T3 supplementation</strong> may improve symptoms in select cases.</p><p><strong>💡 Alternative Treatment Options (35:00 - 40:00)</strong></p><p><strong>Combination Therapy (Levothyroxine + Liothyronine [T4/T3])</strong></p><p><strong>Desiccated Thyroid Extract (DTE)</strong></p><p><strong>Liquid Levothyroxine or Gel Capsules</strong> for patients with absorption issues.</p><p><strong>🛑 Conclusion (40:00 - 42:00)</strong></p><p>Persistent symptoms on Levothyroxine are a recognized issue with <strong>multiple potential causes</strong>.</p><p>A <strong>personalized approach</strong> is key to improving patient well-being.</p><p>Importance of regular follow-ups with an <strong>endocrinologist or thyroid specialist</strong>.</p><p><strong>📢 Call to Action & Further Discussion (42:00 - 45:00)</strong></p><p>✅ If you <strong>still feel unwell</strong> on Levothyroxine, discuss these possibilities with your doctor.✅ Keep a <strong>symptom journal</strong> and track medication intake.✅ Stay informed and <strong>advocate for your own health</strong>.</p><p>📖 <strong>Source:</strong> Based on the article "Why Do Some Patients Do Not Feel Well on Levothyroxine Therapy?"</p><p>🔔 <strong>Subscribe & Follow</strong> for more in-depth discussions on thyroid health and endocrinology.</p><p>📝 <strong>Disclaimer:</strong> This episode is for educational purposes only and <strong>not a substitute for medical advice</strong>. Always consult a healthcare professional for diagnosis and treatment.</p><p></p> <br/><br/>Get full access to Medical Musings at <a href="https://johnsonthomasmd.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_4">johnsonthomasmd.substack.com/subscribe</a>
March 20, 2025
Why Do Some Patients Not Feel Well on Levothyroxine Therapy?
<p></p><p>Introduction</p><p>Levothyroxine (LT4) is the standard treatment for hypothyroidism and usually restores normal thyroid hormone levels and alleviates symptoms. However, a subset of patients on LT4 continue to feel unwell despite “normal” thyroid blood tests. Studies estimate that 15–20% of LT4-treated patients have a lower quality of life compared to healthy controls, and roughly one in four patients may report persistent hypothyroid-like symptoms even with a normal TSH (thyroid stimulating hormone) level. This article explores why some patients have persistent symptoms, outlines differential diagnoses and additional testing to consider, and reviews alternative treatment options (like adding liothyronine T3 or using desiccated thyroid extract).</p><p><p>Medical Musings is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.</p></p><p>Reasons for Persistent Symptoms and work up</p><p>Several factors may contribute to patients feeling unwell on LT4 monotherapy:</p><p><strong>Suboptimal LT4 Dosage or Absorption Issues</strong>: Some patients require higher doses of LT4 due to poor gastrointestinal absorption caused by conditions like celiac disease, atrophic gastritis, or Helicobacter pylori infection. Medications like calcium, iron, and proton pump inhibitors can also reduce LT4 absorption.</p><p>* Check for celiac disease antibodies if you suspect gluten sensitivity as the reason for malabsorption.</p><p>* If you are suspecting atrophic gastritis, you can start the work up with a complete blood count and ferritin. You could also order Parietal Cell Antibodies (PCA)</p><p>* Advise to take calcium, iron and soy products to be separated from levothyroxine ingestion by at least 4 hours.</p><p>* Levothyroxine absorption test can also be done to rule out issues with absorption.</p><p><strong>Concurrent Autoimmune Diseases (e.g., Addison’s disease, celiac disease, vitamin B12 deficiency)</strong>Patients with Hashimoto’s thyroiditis have a higher risk of developing other autoimmune disorders, which can contribute to fatigue and systemic symptoms. Screening for adrenal insufficiency, celiac disease, and pernicious anemia (B12 deficiency) is recommended in patients with ongoing symptoms.</p><p>* Check morning (8 am) cortisol and ACTH to rule out adrenal insufficiency.</p><p>* Check B12 level</p><p><strong>Other medical conditions like diabetes or hypertension that are not under control.</strong></p><p>Uncontrolled diabetes can lead to fatigue, weight changes, and neuropathy, while poorly managed hypertension can cause headaches, dizziness, and cardiovascular symptoms. Optimizing management of these conditions is essential for improving overall health and symptom resolution.</p><p><strong>Anemia and Nutrient Deficiencies:</strong> Iron deficiency anemia, and folate deficiency can contribute to fatigue, weakness, and cognitive dysfunction. These deficiencies are more common in patients with autoimmune thyroid disease and should be screened for and corrected when necessary.</p><p>* Check CBC and ferritin</p><p>* If folate deficiency is suspected, order Red Blood Cell (RBC) Folate Levels. Elevated plasma homocysteine can be an indirect marker of folate deficiency, but not specific.</p><p><strong>Sleep Disorders (e.g., sleep apnea, insomnia)</strong>Obstructive sleep apnea (OSA) is prevalent in individuals with hypothyroidism and can contribute to persistent fatigue. Insomnia and poor sleep hygiene can also impact energy levels and cognitive function.</p><p>* Sleep studies (home or in hospital) and proper sleep hygiene counseling may improve symptoms.</p><p>* For insomnia, consider sleep medications.</p><p><strong>Mental Health Conditions (Depression, Anxiety Disorders)</strong></p><p>Depression and anxiety frequently coexist with hypothyroidism and can contribute to persistent symptoms such as fatigue, low motivation, and brain fog. Psychological evaluation and appropriate treatment, including therapy or medications, can significantly improve well-being.</p><p><strong>Fibromyalgia or Chronic Fatigue Syndrome (CFS)</strong></p><p>These conditions share many symptoms with hypothyroidism, such as muscle pain, unrefreshing sleep, and chronic fatigue. A thorough evaluation to differentiate these syndromes from residual hypothyroid symptoms is necessary to ensure appropriate treatment.</p><p><strong>Medication Side Effects: </strong>Certain medications, such as beta-blockers,and antidepressants, can mimic or exacerbate symptoms of hypothyroidism, including fatigue and cognitive dysfunction. Reviewing a patient’s medication list and adjusting or substituting medications when appropriate can help alleviate symptoms.</p><p><strong>Pituitary or Hypothalamic Disorders (Central Hypothyroidism): </strong>In central hypothyroidism, TSH is often low or inappropriately normal, making free T4 and T3 the primary indicators of thyroid status. Patients with pituitary disease often require individualized LT4 dosing, targeting free T4 in the upper normal range to ensure adequate hormone availability.</p><p><strong>Overtreatment or increased sensitivity to Thyroid Hormone:</strong> Some patients may experience symptoms of hyperthyroidism, such as anxiety, palpitations, and insomnia, even when TSH is within the normal range / on the lower side. This may be due to individual sensitivity to thyroid hormone levels or excessive LT4 dosing. Reducing the dose while monitoring symptoms can help restore balance.</p><p><strong>Time-Course Factors:</strong> Recovery from hypothyroidism is not immediate, and some symptoms may take months to resolve after achieving biochemical euthyroidism. Patients with high health-related anxiety may misinterpret normal fluctuations in energy and mood as continued hypothyroidism. Education and reassurance can be valuable in these cases.</p><p><strong>Incomplete T4-to-T3 Conversion: </strong>Levothyroxine gets converted to T3, the active hormone, in tissues. Some patients may not convert T4 to T3 efficiently, leaving tissues relatively T3-deficient despite normal blood T4 and TSH. For example, LT4-treated patients as a group have a ~15–20% lower T3:T4 ratio and about 15% fail to maintain normal T3 levels in serum. A common genetic variation in the Type 2 deiodinase enzyme (DIO2 Thr92Ala polymorphism) has been linked to impaired psychological well-being on LT4 alone and reduced T4-to-T3 conversion. These findings suggest that standard LT4 therapy might not fully restore tissue T3 levels or euthyroidism in every individual. Indeed, one clinical trial found that adding T3 improved mood and neuropsychological function in LT4-treated patients, supporting the idea that T4 alone may be inadequate for a subset of patients. In such patients treatment that contains T3 might be helpful.</p><p>Alternative Treatment Options for Persistent Symptoms</p><p>If a patient’s LT4 dose is optimized and other conditions have been ruled out or treated, yet they still feel poorly, clinicians and patients may consider alternative thyroid hormone therapies. These include:</p><p>* Combination Levothyroxine + Liothyronine Therapy (T4/T3 Combination)</p><p>* Desiccated Thyroid Extract (DTE)</p><p>* In patients with absorption issues - liquid levothyroxine or gel capsules can be considered.</p><p>Conclusion</p><p>While levothyroxine monotherapy effectively treats most hypothyroid patients, a considerable minority experience ongoing symptoms or intolerance. A careful differential diagnosis and targeted testing are essential to uncover contributing factors. If persistent symptoms remain after optimization of standard therapy and management of comorbidities, individualized treatment approaches can be explored. Patient-centered care, regular follow-ups, and therapy adjustments based on subjective and objective measures can help optimize well-being.</p><p><p>Thanks for reading Medical Musings! This post is public so feel free to share it.</p></p><p></p><p>References</p><p>* Peterson SJ, Cappola AR, Castro MR, et al. An Online Survey of Hypothyroid Patients Demonstrates Prominent Dissatisfaction. Thyroid. 2018;28(6):707-721. doi:10.1089/thy.2017.0681</p><p>* Hidalgo J, Vallejo BA, Soto Jacome C, et al. Real Practice Assessment of Persistent Symptoms After Initiation of Levothyroxine. Endocr Pract. 2024;30(2):95-100. doi:10.1016/j.eprac.2023.10.132</p><p>* Vargas-Uricoechea H, Wartofsky L. LT4/LT3 Combination Therapy vs. Monotherapy with LT4 for Persistent Symptoms of Hypothyroidism: A Systematic Review. Int J Mol Sci. 2024;25(17):9218. Published 2024 Aug 25. doi:10.3390/ijms25179218</p><p>* Bunevicius R, Kazanavicius G, Zalinkevicius R, Prange AJ Jr. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients with hypothyroidism. N Engl J Med. 1999;340(6):424-429. doi:10.1056/NEJM199902113400603</p> <br/><br/>Get full access to Medical Musings at <a href="https://johnsonthomasmd.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_4">johnsonthomasmd.substack.com/subscribe</a>
February 13, 2025
The Many Faces of Hunger: Physiological, Psychological, and Beyond
<p>Here's something that might surprise you - our bodies can actually experience three completely different types of hunger, and most of us are responding to the wrong signals every single day.</p><p>That's fascinating, and it explains so much about why we sometimes feel hungry right after eating a full meal. What exactly makes these different types of hunger so distinct?</p><p>Well, it comes down to the complex interplay between our hormones, brain chemistry, and even our emotions. The first type - physiological hunger - is what we'd call "true hunger." It develops gradually over several hours and comes with actual physical symptoms like a growling stomach or feeling weak.</p><p>So that's completely different from when I walk past a bakery and suddenly feel like I need a croissant right this second, right?</p><p>Exactly right - that's what we call sensory hunger, and here's what's really interesting: our ancestors developed these responses when food was scarce. Their brains were wired to say "eat this high-calorie food while you can!" The problem is, we still have those same circuits, but now we're surrounded by tempting foods 24/7.</p><p>Hmm... and I'm guessing this is where the hormone ghrelin comes into play?</p><p>You know, that's EXACTLY right. Ghrelin is fascinating because it's like our body's internal fuel gauge. When we need energy, our stomach produces ghrelin, sending signals to our brain saying "time to eat!" But here's the kicker - lack of sleep can actually increase ghrelin levels making us feel artificially hungry.</p><p>That explains why I always want to eat everything in sight after a bad night's sleep! And I've noticed it's usually carb-heavy foods I'm craving in those situations.</p><p>Well, there's actually a scientific reason for that. When we're sleep-deprived, our bodies crave quick energy sources - mainly carbs and sugars. But here's something most people don't realize: just one night of poor sleep can increase our calorie intake by up to 300 calories the next day.</p><p>And then there's emotional hunger - which I'm guessing is behind a lot of our stress eating?</p><p>Oh absolutely - and this is where it gets really interesting. Studies show that when we're stressed, our bodies release cortisol, which can increase appetite. Even more fascinating? Research has found that stressed individuals tend to choose foods with more calories compared to when they're relaxed.</p><p>Those numbers are staggering. So how do we actually manage these different types of hunger?</p><p>Well, I've found the "apple test" to be incredibly effective - if you wouldn't eat an apple when you're feeling hungry, you're probably experiencing emotional or sensory hunger rather than true hunger. Studies show this simple check-in can reduce unnecessary snacking.</p><p>That's such a practical tip. I've also heard that drinking water can help, since we sometimes confuse thirst with hunger.</p><p>You know what's fascinating about that? Research shows that sometimes when we think we're hungry, we're actually just thirsty. And here's another surprising fact: eating protein-rich foods can reduce ghrelin levels compared to high-carb meals.</p><p>Speaking of meals, I've noticed that eating at consistent times seems to help manage my hunger better.</p><p>That's because our bodies actually have an internal clock that anticipates meal times. Studies show that people who eat at regular times have better appetite control and fewer cravings throughout the day. Plus, consistent meal timing can help regulate those hunger hormones we talked about earlier.</p><p>These insights really change how we should think about hunger, don't they?</p><p>They really do, and here's what it all comes down to: understanding these different types of hunger gives us the power to make better choices. Research shows that people who can identify their hunger type are 40% more likely to maintain a healthy weight long-term.</p><p>And I suppose the key is not beating ourselves up when we occasionally give in to those non-physiological hunger cues.</p><p>That's exactly right. The goal isn't perfection - it's awareness. And remember, while these strategies can be helpful, consulting with healthcare professionals for personalized advice is always recommended, especially since everyone's body responds differently to hunger signals.</p> <br/><br/>Get full access to Medical Musings at <a href="https://johnsonthomasmd.substack.com/subscribe?utm_medium=podcast&utm_campaign=CTA_4">johnsonthomasmd.substack.com/subscribe</a>
6 total episodes available
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