Sometimes. I have been sent patients who are being ripped off by massive private prescription costs for Armour thyroid pills. With GP agreement, they have often been converted to a combination of T4 & T3 tabs [to give the same effect as armour without the armed robbery associated with it]
**************************************************************************************
Prof. Tim Reynolds
Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D Lead,
Burton Hospitals NHS Foundation Trust
work tel: 01283 511511 ext 4035
work fax: 01283 593064
work email: [log in to unmask]
work URL: www.burtonhospitals.nhs.uk
This e-mail, and any files transmitted with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person. If you have received this e-mail in error, please notify me on 01283 511511 Ext 4035
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-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Dodd Alan (EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST)
Sent: 11 September 2014 12:27 PM
To: [log in to unmask]
Subject: Re: Low T3 syndrome
---
This message was sent from an email address external to NHSmail but gives the appearance of being from an NHSmail (@nhs.net) address. The recipient should verify the sender and content before acting upon information contained within.
The identified sender is [log in to unmask]
---
With regards to the original question, I do remember coming across far more fT3 requesting, T3 usage, and "odd" thyroid tests that didn't make much sense (unless you assumed T3 usage, despite the GP saying they weren't on this) when I was briefly in Bristol than I have in my very brief career in other trusts - potentially because Bristol is a relatively informed and affluent area?
Incidentally, this is not just a Daily Mail thing, article from July:
http://www.telegraph.co.uk/health/alternativemedicine/10985192/Could-a-renegade-doctor-save-your-life.html
I was particularly entertained by the section describing the black market in thyroid medications!
Alan.
Dr Alan Dodd, Senior Clinical Biochemist
William Harvey Hospital
Ashford, Kent.
----------------------------------------------------------------------
Date: Wed, 10 Sep 2014 08:23:12 +0100
From: "Reynolds Tim (RJF) BHFT" <[log in to unmask]>
Subject: Re: Low T3 syndrome
I have had a lot of meetings with her and am convinced she is taking the tablets. Also, the symptomatic improvement from the T3 is remarkable. On reflection, I think I will have to try to get the histology results and possibly the notes from the hospital that did the op. It would be interesting to know what symptoms were / lab results before she had the thyroidectomy.
**************************************************************************************
Prof. Tim Reynolds
Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D Lead,
Burton Hospitals NHS Foundation Trust
work tel: 01283 511511 ext 4035
work fax: 01283 593064
work email: [log in to unmask]
work URL: www.burtonhospitals.nhs.uk
This e-mail, and any files transmitted with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person. If you have received this e-mail in error, please notify me on 01283 511511 Ext 4035
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-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Mohammad Al-Jubouri
Sent: 09 September 2014 6:59 PM
To: [log in to unmask]
Subject: Re: Low T3 syndrome
Thanks Tim, fascinating case, at least we know now that despite the industrial doses of T4 & T3, they don't seem to have found their way to the circulation so we can't blame the pituitary gland protesting against insufficient thyroid hormones by sending massive TSH shout. She is either non/partially compliant or not able to absorb thyroid hormones. A trial of witnessed weekly dose or parenteral T3 should resolve the issue.
Mohammad
--------------------------------------------
On Tue, 9/9/14, Reynolds Tim (RJF) BHFT <[log in to unmask]> wrote:
Subject: Re: Low T3 syndrome
To: [log in to unmask]
Date: Tuesday, 9 September, 2014, 17:18
A brief history:
PH - total thyroidectomy for hashimoto's. Histology not done here so I cannot look to see what was found.
Symptomatically very hypothyroid - cold, sluggish significant weight gainetc.
April 2013 TSH 299 fT4 0.7 fT3 1.4:
Referral from GP - taking 200 ug T4 at same time as Ca supplements - advised dose timing change May 2013 TSH 314 fT4 0.8:
Increased dose to 300 ug T4
July 2013 TSH 308 fT4 0.7 fT3
0.4 Missed treatment due to UTI - left dose at 300 ug Sept 2013 TSH 331 fT4 0.3 fT3 0.7
Had definitely been taking tablets
- no improvement: changed to T3 40am/40pm Nov 2013 TSH 100 fT4 0.3 fT3
0.4 Symptomatically improved
but not 'normal - increased to T3 60/40 am/pm Jan 2014 TSH 100 fT4 0.3 fT3
0.4 Feeling improved - dose left unchanged Mar 2014 TSH 100 fT4 0.3 fT3 1.0 Still tired but improved
- increased to T3 80/40 am/pm
May 2014 TSH 164 fT4 0.3 fT3
0.4 Now lost 2 stone in wt
[back to mormal], able to wake up in the morning, not feeling cold. Symptomatically feels much better [like she was before thyroidectomy]
As she is on a high dose of T3, I have not increased the dose and she is symptomatically well. So, I am monitoring but not increasing doses to get the numbers correct.
**************************************************************************************
Prof. Tim Reynolds
Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D Lead, Burton Hospitals NHS Foundation Trust work tel: 01283 511511 ext 4035 work fax: 01283 593064 work email: [log in to unmask]
work URL: www.burtonhospitals.nhs.uk
This e-mail, and any files transmitted with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person. If you have received this e-mail in error, please notify me on 01283 511511 Ext 4035
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-----Original Message-----
From: Mohammad Al-Jubouri [mailto:[log in to unmask]]
Sent: 09 September 2014 4:55 PM
To: [log in to unmask];
Reynolds Tim (RJF) BHFT
Subject: Re: Low T3 syndrome
Really Tim, 500 mcg thyroxine and no effect on TSH >100?
what was the FT4 level? I would seriously consider false elevation of TSH due to HAMA, HARA ore even Macro-TSH especially that even T3 didn't suppress it.
Regards
Mohammad
Dr. M A Al-Jubouri, MB ChB, MSc, EurClinChem, FRCP Edin, FRCPath Consultant Chemical Pathologist
--------------------------------------------
On Tue, 9/9/14, Reynolds Tim (RJF) BHFT <[log in to unmask]>
wrote:
Subject: Re: Low T3 syndrome
To: [log in to unmask]
Date: Tuesday, 9 September, 2014, 16:44
Whilst there are some patients who are mad there are some that really do seem to need T3. I have one patient (age
22) whose TSH remains
> 100. On doses of up to 500mg of T4 there was no change but when given T3, she lost weight and began to resume normal activities [she can even make it to clinic on time now instead of turning up 3 hours late]. Even now on T3 her TSH has not dropped much but the obviously symptomatic hypothyroidism has resolved and she is much better. Biochemistry does not always give the right answers...
**************************************************************************************
Prof. Tim
Reynolds
Consultant Chemical Pathologist /
Clinical Director -
Diagnostics / R&D Lead,
Burton Hospitals NHS
Foundation
Trust
work tel: 01283 511511 ext
4035
work fax: 01283
593064
work email:
[log in to unmask]
work URL:
www.burtonhospitals.nhs.uk
This e-mail,
and any files transmitted
with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person.
If you have
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From: Clinical
biochemistry discussion list
[mailto:[log in to unmask]]
On Behalf Of Salter Simon (ROYAL FREE LONDON NHS FOUNDATION TRUST)
Sent: 09 September 2014 4:39
PM
To: [log in to unmask]
Subject: Re: Low T3
syndrome
---
This message was sent from an email address external to NHSmail but gives the appearance of being from an NHSmail
(@nhs.net) address. The recipient should verify the sender and content before acting upon information contained within.
The identified sender is
[log in to unmask]
---
During
my short time in clinical biochemistry, I have seen a number of cases of patients desperate for their
FT3 to be measured and not being given it.
Some of the comments on the article interesting...one particularly, which blames us lab staff for being part of the problem... "The arrogance of those running the laboratory service astounded me"
"Whilst the article points
out "So, if your blood
test doesn't show you to be low in T4, you won't be prescribed thyroid hormones that could alleviate your symptoms", there's a good chance that your local lab (which supposedly works for your Doctor) won't provide a
T4 result. The testing
laboratory have their own protocol which frequently means that if the TSH result is in the Normal Range (~ usually 0.3 to 5.0), then they routinely don't provide a T4 result let alone any of the other thyroid function tests. My result was just above the Reference Range and my own doctor asked three times for more than the TSH but was ignored and when I wrote to the Area Health Authority, I received a reply which said that my own doctor ought to know better than to ask.
They said they had provided GP's with guidelines as to what they would test for and she should not have asked! The arrogance of the those running the laboratory service astounded me. "
When lab reports go directly to patients I imagine we will receive a significant number of calls from educated patients wanting
FT4/FT3 measurements
if they haven't been given one.
Simon
From: Clinical
biochemistry discussion list
[mailto:[log in to unmask]]
On Behalf Of Peter Beresford
Sent: 09 September 2014
16:19
To: [log in to unmask]
Subject: Low T3
syndrome
Dear
Mailbase,
We have
received calls from GPs who have been approached by a number of patients regarding the article below, which was published in the Daily Mail last week.
http://www.dailymail.co.uk/health/article-2734215/Cold-hands-Always-tired-It-hidden-thyroid-problem-doctors-refuse-treat.html
The
subject of the article is 'Low T3 syndrome", and it suggests to patients that they require FT3 measured routinely in addition to FT4, as well as opening up a debate with regards to treatment with T3. The article quotes respectable Endocrinologists quoted both for and against (although I suspect some of their comments may have been taken out of context).
I would be
interested to know if others have also been approached in
response to this
article and what guidance has been given to GPs responding
to these
queries.
The
guidance documents available on the British Thyroid
Association website (http://www.british-thyroid-association.org/Guidelines/
) are very helpful, but recognising that this is a complex
area I wonder if
anyone is aware of any more recent evidence or guidelines
about the role of T3
in the aetiology and treatment of hypothyroidism?
Best
wishes
Peter
Peter
Beresford
Consultant
Clinical Scientist
Southmead
Hospital
DISCLAIMER: The information in this
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------------------------------
Date: Wed, 10 Sep 2014 07:36:44 +0000
From: Jonathan Kay <[log in to unmask]>
Subject: Re: Low T3 syndrome
How about an "n of 1 trial"?
Jonathan
On 10 Sep 2014, at 08:23, Reynolds Tim (RJF) BHFT <[log in to unmask]> wrote:
> I have had a lot of meetings with her and am convinced she is taking the tablets. Also, the symptomatic improvement from the T3 is remarkable. On reflection, I think I will have to try to get the histology results and possibly the notes from the hospital that did the op. It would be interesting to know what symptoms were / lab results before she had the thyroidectomy.
>
>
>
>
> Whilst there are some patients who are mad there are some that really do seem to need T3. I have one patient (age
> 22) whose TSH remains
> 100. On doses of up to 500mg of T4 there was no change but when given T3, she lost weight and began to resume normal activities [she can even make it to clinic on time now instead of turning up 3 hours late]. Even now on T3 her TSH has not dropped much but the obviously symptomatic hypothyroidism has resolved and she is much better. Biochemistry does not always give the right answers...
>
------ACB discussion List Information--------
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Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content.
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------------------------------
Date: Wed, 10 Sep 2014 08:40:42 +0100
From: "Barlow Ian (NORTHERN LINCOLNSHIRE AND GOOLE NHS FOUNDATION TRUST)"
<[log in to unmask]>
Subject: Re: Low T3 syndrome
I would suggest consider doing a 1mg thyroxine loading test - it is amazing how well patients can absorb thyroxine under supervised conditions.
Ian
-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Reynolds Tim (RJF) BHFT
Sent: 10 September 2014 08:23
To: [log in to unmask]
Subject: Re: Low T3 syndrome
I have had a lot of meetings with her and am convinced she is taking the tablets. Also, the symptomatic improvement from the T3 is remarkable. On reflection, I think I will have to try to get the histology results and possibly the notes from the hospital that did the op. It would be interesting to know what symptoms were / lab results before she had the thyroidectomy.
**************************************************************************************
Prof. Tim Reynolds
Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D Lead, Burton Hospitals NHS Foundation Trust work tel: 01283 511511 ext 4035 work fax: 01283 593064 work email: [log in to unmask] work URL: www.burtonhospitals.nhs.uk This e-mail, and any files transmitted with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person. If you have received this e-mail in error, please notify me on 01283 511511 Ext 4035
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-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Mohammad Al-Jubouri
Sent: 09 September 2014 6:59 PM
To: [log in to unmask]
Subject: Re: Low T3 syndrome
Thanks Tim, fascinating case, at least we know now that despite the industrial doses of T4 & T3, they don't seem to have found their way to the circulation so we can't blame the pituitary gland protesting against insufficient thyroid hormones by sending massive TSH shout. She is either non/partially compliant or not able to absorb thyroid hormones. A trial of witnessed weekly dose or parenteral T3 should resolve the issue.
Mohammad
--------------------------------------------
On Tue, 9/9/14, Reynolds Tim (RJF) BHFT <[log in to unmask]> wrote:
Subject: Re: Low T3 syndrome
To: [log in to unmask]
Date: Tuesday, 9 September, 2014, 17:18
A brief history:
PH - total thyroidectomy for hashimoto's. Histology not done here so I cannot look to see what was found.
Symptomatically very hypothyroid - cold, sluggish significant weight gainetc.
April 2013 TSH 299 fT4 0.7 fT3 1.4:
Referral from GP - taking 200 ug T4 at same time as Ca supplements - advised dose timing change May 2013 TSH 314 fT4 0.8:
Increased dose to 300 ug T4
July 2013 TSH 308 fT4 0.7 fT3
0.4 Missed treatment due to UTI - left dose at 300 ug Sept 2013 TSH 331 fT4 0.3 fT3 0.7
Had definitely been taking tablets
- no improvement: changed to T3 40am/40pm Nov 2013 TSH 100 fT4 0.3 fT3
0.4 Symptomatically improved
but not 'normal - increased to T3 60/40 am/pm Jan 2014 TSH 100 fT4 0.3 fT3
0.4 Feeling improved - dose left unchanged Mar 2014 TSH 100 fT4 0.3 fT3 1.0 Still tired but improved
- increased to T3 80/40 am/pm
May 2014 TSH 164 fT4 0.3 fT3
0.4 Now lost 2 stone in wt
[back to mormal], able to wake up in the morning, not feeling cold. Symptomatically feels much better [like she was before thyroidectomy]
As she is on a high dose of T3, I have not increased the dose and she is symptomatically well. So, I am monitoring but not increasing doses to get the numbers correct.
**************************************************************************************
Prof. Tim Reynolds
Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D Lead, Burton Hospitals NHS Foundation Trust work tel: 01283 511511 ext 4035 work fax: 01283 593064 work email: [log in to unmask]
work URL: www.burtonhospitals.nhs.uk
This e-mail, and any files transmitted with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person. If you have received this e-mail in error, please notify me on 01283 511511 Ext 4035
[Picture of tree not available] Please consider the environment before printing this e-mail
-----Original Message-----
From: Mohammad Al-Jubouri [mailto:[log in to unmask]]
Sent: 09 September 2014 4:55 PM
To: [log in to unmask];
Reynolds Tim (RJF) BHFT
Subject: Re: Low T3 syndrome
Really Tim, 500 mcg thyroxine and no effect on TSH >100?
what was the FT4 level? I would seriously consider false elevation of TSH due to HAMA, HARA ore even Macro-TSH especially that even T3 didn't suppress it.
Regards
Mohammad
Dr. M A Al-Jubouri, MB ChB, MSc, EurClinChem, FRCP Edin, FRCPath Consultant Chemical Pathologist
--------------------------------------------
On Tue, 9/9/14, Reynolds Tim (RJF) BHFT <[log in to unmask]>
wrote:
Subject: Re: Low T3 syndrome
To: [log in to unmask]
Date: Tuesday, 9 September, 2014, 16:44
Whilst there are some patients who are mad there are some that really do seem to need T3. I have one patient (age
22) whose TSH remains
> 100. On doses of up to 500mg of T4 there was no change but when given T3, she lost weight and began to resume normal activities [she can even make it to clinic on time now instead of turning up 3 hours late]. Even now on T3 her TSH has not dropped much but the obviously symptomatic hypothyroidism has resolved and she is much better. Biochemistry does not always give the right answers...
**************************************************************************************
Prof. Tim
Reynolds
Consultant Chemical Pathologist /
Clinical Director -
Diagnostics / R&D Lead,
Burton Hospitals NHS
Foundation
Trust
work tel: 01283 511511 ext
4035
work fax: 01283
593064
work email:
[log in to unmask]
work URL:
www.burtonhospitals.nhs.uk
This e-mail,
and any files transmitted
with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person.
If you have
received this e-mail in error, please notify me on 01283
511511 Ext
4035
[Picture of
tree not available]
Please
consider the environment
before printing this e-mail
From: Clinical
biochemistry discussion list
[mailto:[log in to unmask]]
On Behalf Of Salter Simon (ROYAL FREE LONDON NHS FOUNDATION TRUST)
Sent: 09 September 2014 4:39
PM
To: [log in to unmask]
Subject: Re: Low T3
syndrome
---
This message was sent from an email address external to NHSmail but gives the appearance of being from an NHSmail
(@nhs.net) address. The recipient should verify the sender and content before acting upon information contained within.
The identified sender is
[log in to unmask]
---
During
my short time in clinical biochemistry, I have seen a number of cases of patients desperate for their
FT3 to be measured and not being given it.
Some of the comments on the article interesting...one particularly, which blames us lab staff for being part of the problem... "The arrogance of those running the laboratory service astounded me"
"Whilst the article points
out "So, if your blood
test doesn't show you to be low in T4, you won't be prescribed thyroid hormones that could alleviate your symptoms", there's a good chance that your local lab (which supposedly works for your Doctor) won't provide a
T4 result. The testing
laboratory have their own protocol which frequently means that if the TSH result is in the Normal Range (~ usually 0.3 to 5.0), then they routinely don't provide a T4 result let alone any of the other thyroid function tests. My result was just above the Reference Range and my own doctor asked three times for more than the TSH but was ignored and when I wrote to the Area Health Authority, I received a reply which said that my own doctor ought to know better than to ask.
They said they had provided GP's with guidelines as to what they would test for and she should not have asked! The arrogance of the those running the laboratory service astounded me. "
When lab reports go directly to patients I imagine we will receive a significant number of calls from educated patients wanting
FT4/FT3 measurements
if they haven't been given one.
Simon
From: Clinical
biochemistry discussion list
[mailto:[log in to unmask]]
On Behalf Of Peter Beresford
Sent: 09 September 2014
16:19
To: [log in to unmask]
Subject: Low T3
syndrome
Dear
Mailbase,
We have
received calls from GPs who have been approached by a number of patients regarding the article below, which was published in the Daily Mail last week.
http://www.dailymail.co.uk/health/article-2734215/Cold-hands-Always-tired-It-hidden-thyroid-problem-doctors-refuse-treat.html
The
subject of the article is 'Low T3 syndrome", and it suggests to patients that they require FT3 measured routinely in addition to FT4, as well as opening up a debate with regards to treatment with T3. The article quotes respectable Endocrinologists quoted both for and against (although I suspect some of their comments may have been taken out of context).
I would be
interested to know if others have also been approached in
response to this
article and what guidance has been given to GPs responding
to these
queries.
The
guidance documents available on the British Thyroid
Association website (http://www.british-thyroid-association.org/Guidelines/
) are very helpful, but recognising that this is a complex
area I wonder if
anyone is aware of any more recent evidence or guidelines
about the role of T3
in the aetiology and treatment of hypothyroidism?
Best
wishes
Peter
Peter
Beresford
Consultant
Clinical Scientist
Southmead
Hospital
DISCLAIMER: The information in this
message is confidential and may be legally privileged. It is
intended solely for
the addressee. Access to this message by anyone else is
unauthorised. If you are
not the intended recipient, any disclosure, copying, or
distribution of the
message, or any action or omission taken by you in reliance
on it, is prohibited
and may be unlawful. Please immediately contact the sender
if you have received
this message in error. Thank
you.
------ACB discussion List
Information-------- This is an open
discussion list for the academic and clinical community
working in clinical
biochemistry. Please note, archived messages are public and
can be viewed via
the internet. Views expressed are those of the individual
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Date: Wed, 10 Sep 2014 09:12:34 +0100
From: "Sharpe, Peter" <[log in to unmask]>
Subject: Re: Low T3 syndrome
Dear Colleagues,
When I came to this Trust in 1998, I was the first Chemical Pathologist to be appointed. Before this a Haematologist with an interest in Clinical Biochemistry had been looking after the service.
A routine thyroid profile consisted of both fT4 & fT3 plus TSH. I'm unsure as to the reasons for this other than "historical".
Within a few months, after widespread consultation with all requestors including Endocrinologists, we removed the routine fT3 measurement. It became clear that fT3 was adding very little (if anything) to the interpretation of thyroid profile results. fT3 can still be specially requested and we do run it under certain circumstances, but the numbers have dwindled to a few per week.
My Endocrinology colleagues remain very sceptical about the so called diagnosis of low fT3 syndrome.
Best wishes
Peter
Dr Peter Sharpe
Consultant Chemical Pathologist
Associate Medical Director, Research & Development
Southern Health & Social Care Trust
Chair RCPath NI Regional Council
Ext: 60869
Tel: 028 38360696
Fax: 028 38334582
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Peter Beresford
Sent: 09 September 2014 16:19
To: [log in to unmask]
Subject: Low T3 syndrome
Dear Mailbase,
We have received calls from GPs who have been approached by a number of patients regarding the article below, which was published in the Daily Mail last week.
http://www.dailymail.co.uk/health/article-2734215/Cold-hands-Always-tired-It-hidden-thyroid-problem-doctors-refuse-treat.html
The subject of the article is 'Low T3 syndrome", and it suggests to patients that they require FT3 measured routinely in addition to FT4, as well as opening up a debate with regards to treatment with T3. The article quotes respectable Endocrinologists quoted both for and against (although I suspect some of their comments may have been taken out of context).
I would be interested to know if others have also been approached in response to this article and what guidance has been given to GPs responding to these queries.
The guidance documents available on the British Thyroid Association website (http://www.british-thyroid-association.org/Guidelines/ ) are very helpful, but recognising that this is a complex area I wonder if anyone is aware of any more recent evidence or guidelines about the role of T3 in the aetiology and treatment of hypothyroidism?
Best wishes
Peter
Peter Beresford
Consultant Clinical Scientist
Southmead Hospital
DISCLAIMER: The information in this message is confidential and may be legally privileged. It is intended solely for the addressee. Access to this message by anyone else is unauthorised. If you are not the intended recipient, any disclosure, copying, or distribution of the message, or any action or omission taken by you in reliance on it, is prohibited and may be unlawful. Please immediately contact the sender if you have received this message in error. Thank you.
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------------------------------
Date: Wed, 10 Sep 2014 09:29:32 +0100
From: Mike Waterson <[log in to unmask]>
Subject: Re: Low T3 syndrome
In the 1980s the lab I worked at used TSH and FT3 as a front line screen for a couple of years. I can't think of any cases where the FT3 was unexpectedly low. The main problem with using FT3 was that FT3 levels were often mantained within the reference range despite high FT4 and (as a second line test) low FT4. I think true low T3 syndrome must be very rare.
There do appear patients who respond better to T3 replacement than T4, I don't know how these patients can be recognised. Also in our area we have quite a few patients on "natural thyroid", Armour thyroid etc. These always have high FT3 level and suppressed TSH - and low normal FT4 - difficult to interpret the results in a consistent way
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------------------------------
Date: Wed, 10 Sep 2014 09:39:53 +0100
From: Nick Miller <[log in to unmask]>
Subject: Re: Low T3 syndrome
The problem here, actually, is that peripheral de-iodination from T4 to T3
becomes less efficient with ageing, and so it is inappropriate to use the
same reference intervals for T4 in the over-60's as we do for the rest of
the population. This is in the literature, but generally ignored. Older
subjects need more T4 to make the same amount of T3. They also may have
pituitary insensitivity to feedback control (everything wears out as you
get older, believe me) and hence are less likely to elicit a TSH response
to inadequate thyroid hormone production.
Comments about the staggering incompetence and arrogance of lab staff when
dealing with the problems of actual people do ring a bell, but I must agree
that T3 measurement adds nothing to the diagnostic process, except when you
encounter hyperthyroidism with normal T4 levels.
Finally, I've seen a case just like the one Tim describes. She had a
sub-total thyroidectomy after a thyroid storm and sustained a TSH of c. 360
for 6 months (after which it came down). I used her serum as a control for
years afterwards!
Nick Miller
London
On 10 September 2014 09:12, Sharpe, Peter <
[log in to unmask]> wrote:
> Dear Colleagues,
>
>
>
> When I came to this Trust in 1998, I was the first Chemical Pathologist to
> be appointed. Before this a Haematologist with an interest in Clinical
> Biochemistry had been looking after the service.
>
>
>
> A routine thyroid profile consisted of both fT4 & fT3 plus TSH. I'm
> unsure as to the reasons for this other than "historical".
>
>
>
> Within a few months, after widespread consultation with all requestors
> including Endocrinologists, we removed the routine fT3 measurement. It
> became clear that fT3 was adding very little (if anything) to the
> interpretation of thyroid profile results. fT3 can still be specially
> requested and we do run it under certain circumstances, but the numbers
> have dwindled to a few per week.
>
>
>
> My Endocrinology colleagues remain very sceptical about the so called
> diagnosis of low fT3 syndrome.
>
>
>
> Best wishes
>
> Peter
>
>
>
> *Dr Peter Sharpe*
>
> *Consultant Chemical Pathologist*
>
> *Associate Medical Director, Research & Development*
>
> *Southern Health & Social Care Trust*
>
> *Chair RCPath NI Regional Council*
>
> *Ext: 60869*
>
> *Tel: 028 38360696*
>
> *Fax: 028 38334582*
>
>
>
> *From:* Clinical biochemistry discussion list [mailto:
> [log in to unmask]] *On Behalf Of *Peter Beresford
> *Sent:* 09 September 2014 16:19
> *To:* [log in to unmask]
> *Subject:* Low T3 syndrome
>
>
>
> Dear Mailbase,
>
>
>
> We have received calls from GPs who have been approached by a number of
> patients regarding the article below, which was published in the Daily Mail
> last week.
>
>
>
>
> http://www.dailymail.co.uk/health/article-2734215/Cold-hands-Always-tired-It-hidden-thyroid-problem-doctors-refuse-treat.html
>
>
>
> The subject of the article is 'Low T3 syndrome", and it suggests to
> patients that they require FT3 measured routinely in addition to FT4, as
> well as opening up a debate with regards to treatment with T3. The article
> quotes respectable Endocrinologists quoted both for and against (although I
> suspect some of their comments may have been taken out of context).
>
>
>
> I would be interested to know if others have also been approached in
> response to this article and what guidance has been given to GPs responding
> to these queries.
>
>
>
> The guidance documents available on the British Thyroid Association
> website (http://www.british-thyroid-association.org/Guidelines/ ) are
> very helpful, but recognising that this is a complex area I wonder if
> anyone is aware of any more recent evidence or guidelines about the role of
> T3 in the aetiology and treatment of hypothyroidism?
>
>
>
> Best wishes
>
>
>
> Peter
>
>
>
> Peter Beresford
>
> Consultant Clinical Scientist
>
> Southmead Hospital
>
>
>
>
> DISCLAIMER: The information in this message is confidential and may be
> legally privileged. It is intended solely for the addressee. Access to this
> message by anyone else is unauthorised. If you are not the intended
> recipient, any disclosure, copying, or distribution of the message, or any
> action or omission taken by you in reliance on it, is prohibited and may be
> unlawful. Please immediately contact the sender if you have received this
> message in error. Thank you.
>
> ------ACB discussion List Information-------- This is an open discussion
> list for the academic and clinical community working in clinical
> biochemistry. Please note, archived messages are public and can be viewed
> via the internet. Views expressed are those of the individual and they are
> responsible for all message content. ACB Web Site http://www.acb.org.uk
> Green Laboratories Work http://www.laboratorymedicine.nhs.uk List
> Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List
> Instructions (How to leave etc.) http://www.jiscmail.ac.uk/
>
> The Information and the Material transmitted is intended only for the
> person or entity to which it is addressed and may be Confidential/Privileged
> Information and/or copyright material.
>
> Any review, transmission, dissemination or other use of, or taking of
> any action in reliance upon this information by persons or entities
> other than the intended recipient is prohibited. If you receive this in error,
> please contact the sender and delete the material from any computer.
>
> Southern Health & Social Care Trust archive all Email (sent & received)
> for the purpose of ensuring compliance with the Trust 'IT Security Policy',
> Corporate Governance and to facilitate FOI requests.
>
> Southern Health & Social Care Trust IT Department 028 38613600
>
>
> ------ACB discussion List Information-------- This is an open discussion
> list for the academic and clinical community working in clinical
> biochemistry. Please note, archived messages are public and can be viewed
> via the internet. Views expressed are those of the individual and they are
> responsible for all message content. ACB Web Site http://www.acb.org.uk
> Green Laboratories Work http://www.laboratorymedicine.nhs.uk List
> Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List
> Instructions (How to leave etc.) http://www.jiscmail.ac.uk/
>
------ACB discussion List Information--------
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------------------------------
Date: Wed, 10 Sep 2014 10:30:10 +0100
From: "OConnor John (ROYAL DEVON AND EXETER NHS FOUNDATION TRUST)"
<[log in to unmask]>
Subject: Re: Low T3 syndrome
Out of interest, does anyone measure Selenium in patients with Low T3, normal T4 (and not on thyroxine)?
There is an interesting link here
http://www.medscape.com/viewarticle/777483
John
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Nick Miller
Sent: 10 September 2014 09:40
To: [log in to unmask]
Subject: Re: Low T3 syndrome
The problem here, actually, is that peripheral de-iodination from T4 to T3 becomes less efficient with ageing, and so it is inappropriate to use the same reference intervals for T4 in the over-60's as we do for the rest of the population. This is in the literature, but generally ignored. Older subjects need more T4 to make the same amount of T3. They also may have pituitary insensitivity to feedback control (everything wears out as you get older, believe me) and hence are less likely to elicit a TSH response to inadequate thyroid hormone production.
Comments about the staggering incompetence and arrogance of lab staff when dealing with the problems of actual people do ring a bell, but I must agree that T3 measurement adds nothing to the diagnostic process, except when you encounter hyperthyroidism with normal T4 levels.
Finally, I've seen a case just like the one Tim describes. She had a sub-total thyroidectomy after a thyroid storm and sustained a TSH of c. 360 for 6 months (after which it came down). I used her serum as a control for years afterwards!
Nick Miller
London
On 10 September 2014 09:12, Sharpe, Peter <[log in to unmask]<mailto:[log in to unmask]>> wrote:
Dear Colleagues,
When I came to this Trust in 1998, I was the first Chemical Pathologist to be appointed. Before this a Haematologist with an interest in Clinical Biochemistry had been looking after the service.
A routine thyroid profile consisted of both fT4 & fT3 plus TSH. I'm unsure as to the reasons for this other than "historical".
Within a few months, after widespread consultation with all requestors including Endocrinologists, we removed the routine fT3 measurement. It became clear that fT3 was adding very little (if anything) to the interpretation of thyroid profile results. fT3 can still be specially requested and we do run it under certain circumstances, but the numbers have dwindled to a few per week.
My Endocrinology colleagues remain very sceptical about the so called diagnosis of low fT3 syndrome.
Best wishes
Peter
Dr Peter Sharpe
Consultant Chemical Pathologist
Associate Medical Director, Research & Development
Southern Health & Social Care Trust
Chair RCPath NI Regional Council
Ext: 60869
Tel: 028 38360696
Fax: 028 38334582
From: Clinical biochemistry discussion list [mailto:[log in to unmask]<mailto:[log in to unmask]>] On Behalf Of Peter Beresford
Sent: 09 September 2014 16:19
To: [log in to unmask]<mailto:[log in to unmask]>
Subject: Low T3 syndrome
Dear Mailbase,
We have received calls from GPs who have been approached by a number of patients regarding the article below, which was published in the Daily Mail last week.
http://www.dailymail.co.uk/health/article-2734215/Cold-hands-Always-tired-It-hidden-thyroid-problem-doctors-refuse-treat.html
The subject of the article is 'Low T3 syndrome", and it suggests to patients that they require FT3 measured routinely in addition to FT4, as well as opening up a debate with regards to treatment with T3. The article quotes respectable Endocrinologists quoted both for and against (although I suspect some of their comments may have been taken out of context).
I would be interested to know if others have also been approached in response to this article and what guidance has been given to GPs responding to these queries.
The guidance documents available on the British Thyroid Association website (http://www.british-thyroid-association.org/Guidelines/ ) are very helpful, but recognising that this is a complex area I wonder if anyone is aware of any more recent evidence or guidelines about the role of T3 in the aetiology and treatment of hypothyroidism?
Best wishes
Peter
Peter Beresford
Consultant Clinical Scientist
Southmead Hospital
DISCLAIMER: The information in this message is confidential and may be legally privileged. It is intended solely for the addressee. Access to this message by anyone else is unauthorised. If you are not the intended recipient, any disclosure, copying, or distribution of the message, or any action or omission taken by you in reliance on it, is prohibited and may be unlawful. Please immediately contact the sender if you have received this message in error. Thank you.
------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk Green Laboratories Work http://www.laboratorymedicine.nhs.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/
The Information and the Material transmitted is intended only for the
person or entity to which it is addressed and may be Confidential/Privileged
Information and/or copyright material.
Any review, transmission, dissemination or other use of, or taking of
any action in reliance upon this information by persons or entities
other than the intended recipient is prohibited. If you receive this in error,
please contact the sender and delete the material from any computer.
Southern Health & Social Care Trust archive all Email (sent & received)
for the purpose of ensuring compliance with the Trust 'IT Security Policy',
Corporate Governance and to facilitate FOI requests.
Southern Health & Social Care Trust IT Department 028 38613600
------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk Green Laboratories Work http://www.laboratorymedicine.nhs.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/
------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry. Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content. ACB Web Site http://www.acb.org.uk Green Laboratories Work http://www.laboratorymedicine.nhs.uk List Archives http://www.jiscmail.ac.uk/lists/ACB-CLIN-CHEM-GEN.html List Instructions (How to leave etc.) http://www.jiscmail.ac.uk/
********************************************************************************************************************
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sender that you have received the message in error before deleting it.
Please do not disclose, copy or distribute information in this e-mail or take any action in reliance on its contents:
to do so is strictly prohibited and may be unlawful.
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NHSmail is the secure email and directory service available for all NHS staff in England and Scotland
NHSmail is approved for exchanging patient data and other sensitive information with NHSmail and GSi recipients
NHSmail provides an email address for your career in the NHS and can be accessed anywhere
********************************************************************************************************************
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------------------------------
Date: Wed, 10 Sep 2014 11:01:08 +0100
From: Fiona Davidson <[log in to unmask]>
Subject: Re: Low T3 syndrome
Nobody seems to have really addressed Pete's original question of "has anybody had enquiries from GPs about this" and what do we suggest to GPs who have an irate patient in front of them demanding measurement of FT3.
I can't think that we have recently had any specific enquiries about FT3 that relate to this article, however, we do occassionally get specific requests from very demanding patients who have read something similar on the internet and are convinced that they need their FT3 measured. Whilst we always try and reason that their normal TSH (we do not offer FT4 as first line) means that they are more than likely completely euthyroid we always offer them the option to pay for FT4 and/or FT3 privately. You would be surprised how many of them are completely thrilled by this suggestion so you get the double bonus of gettting them to stop shouting at you whilst also proving your original assertion to be entirely correct.
I think the other important point made by others here is that the numbers don't always tell the whole picture. It's important that our GPs know that we are there on the end of the phone and we are always happy to make exceptions for individual cases where the clinical picture just doesn't fit with what the TSH (and/or FT4) is telling you. Perhaps there are very rare cases of pure low T3 syndrome and while this possibility doesn't justify measuring FT3 in everyone who wants it we have to remember that (in most cases) we don't see (or have to deal with) the patient and there may be times when measurement is fully justified even if it is only to act as a rule out. Aren't we always being told to treat the patient and not the numbers?
Fiona Davidson
Senior Clinical Biochemist
Kingston Hospital NHS Trust
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------------------------------
Date: Wed, 10 Sep 2014 10:02:40 +0000
From: David James <[log in to unmask]>
Subject: Re: Low T3 syndrome
Treat the patient not the numbers is often a good rule!
dj
-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Fiona Davidson
Sent: 10 September 2014 11:01
To: [log in to unmask]
Subject: Re: Low T3 syndrome
Nobody seems to have really addressed Pete's original question of "has anybody had enquiries from GPs about this" and what do we suggest to GPs who have an irate patient in front of them demanding measurement of FT3.
I can't think that we have recently had any specific enquiries about FT3 that relate to this article, however, we do occassionally get specific requests from very demanding patients who have read something similar on the internet and are convinced that they need their FT3 measured. Whilst we always try and reason that their normal TSH (we do not offer FT4 as first line) means that they are more than likely completely euthyroid we always offer them the option to pay for FT4 and/or FT3 privately. You would be surprised how many of them are completely thrilled by this suggestion so you get the double bonus of gettting them to stop shouting at you whilst also proving your original assertion to be entirely correct.
I think the other important point made by others here is that the numbers don't always tell the whole picture. It's important that our GPs know that we are there on the end of the phone and we are always happy to make exceptions for individual cases where the clinical picture just doesn't fit with what the TSH (and/or FT4) is telling you. Perhaps there are very rare cases of pure low T3 syndrome and while this possibility doesn't justify measuring FT3 in everyone who wants it we have to remember that (in most cases) we don't see (or have to deal with) the patient and there may be times when measurement is fully justified even if it is only to act as a rule out. Aren't we always being told to treat the patient and not the numbers?
Fiona Davidson
Senior Clinical Biochemist
Kingston Hospital NHS Trust
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------------------------------
Date: Wed, 10 Sep 2014 10:14:11 +0000
From: "Waise, Ahmed" <[log in to unmask]>
Subject: Re: Low T3 syndrome
http://www.wilsonssyndrome.com/
So you think Dr Wilson is right!?
Ahmed Waise
Poole Hospital,
________________________________________
From: Clinical biochemistry discussion list [[log in to unmask]] on behalf of Fiona Davidson [[log in to unmask]]
Sent: 10 September 2014 11:01
To: [log in to unmask]
Subject: Re: Low T3 syndrome
Nobody seems to have really addressed Pete's original question of "has anybody had enquiries from GPs about this" and what do we suggest to GPs who have an irate patient in front of them demanding measurement of FT3.
I can't think that we have recently had any specific enquiries about FT3 that relate to this article, however, we do occassionally get specific requests from very demanding patients who have read something similar on the internet and are convinced that they need their FT3 measured. Whilst we always try and reason that their normal TSH (we do not offer FT4 as first line) means that they are more than likely completely euthyroid we always offer them the option to pay for FT4 and/or FT3 privately. You would be surprised how many of them are completely thrilled by this suggestion so you get the double bonus of gettting them to stop shouting at you whilst also proving your original assertion to be entirely correct.
I think the other important point made by others here is that the numbers don't always tell the whole picture. It's important that our GPs know that we are there on the end of the phone and we are always happy to make exceptions for individual cases where the clinical picture just doesn't fit with what the TSH (and/or FT4) is telling you. Perhaps there are very rare cases of pure low T3 syndrome and while this possibility doesn't justify measuring FT3 in everyone who wants it we have to remember that (in most cases) we don't see (or have to deal with) the patient and there may be times when measurement is fully justified even if it is only to act as a rule out. Aren't we always being told to treat the patient and not the numbers?
Fiona Davidson
Senior Clinical Biochemist
Kingston Hospital NHS Trust
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------------------------------
Date: Wed, 10 Sep 2014 11:20:25 +0100
From: "Reynolds Tim (RJF) BHFT" <[log in to unmask]>
Subject: Re: Low T3 syndrome
If we get a request from a GP for fT3 we would do it: The cost of the test is trivial (£1.44) and that is less than the CCG will be billed [so we don't make a loss]. Also, you have to consider thatth eonly extra cost of doing a fT3 when a TSH is also requested is only the consumable cost (£0.61) so it's not exactly going to break the bank. For the aggro that the GP [and eventually the lab] gets for not doing the test for the infrequent patient who wants one, the saving is just not worth it.
TIM
**************************************************************************************
Prof. Tim Reynolds
Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D Lead,
Burton Hospitals NHS Foundation Trust
work tel: 01283 511511 ext 4035
work fax: 01283 593064
work email: [log in to unmask]
work URL: www.burtonhospitals.nhs.uk
This e-mail, and any files transmitted with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person. If you have received this e-mail in error, please notify me on 01283 511511 Ext 4035
[Picture of tree not available] Please consider the environment before printing this e-mail
-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Waise, Ahmed
Sent: 10 September 2014 11:14 AM
To: [log in to unmask]
Subject: Re: Low T3 syndrome
http://www.wilsonssyndrome.com/
So you think Dr Wilson is right!?
Ahmed Waise
Poole Hospital,
________________________________________
From: Clinical biochemistry discussion list [[log in to unmask]] on behalf of Fiona Davidson [[log in to unmask]]
Sent: 10 September 2014 11:01
To: [log in to unmask]
Subject: Re: Low T3 syndrome
Nobody seems to have really addressed Pete's original question of "has anybody had enquiries from GPs about this" and what do we suggest to GPs who have an irate patient in front of them demanding measurement of FT3.
I can't think that we have recently had any specific enquiries about FT3 that relate to this article, however, we do occassionally get specific requests from very demanding patients who have read something similar on the internet and are convinced that they need their FT3 measured. Whilst we always try and reason that their normal TSH (we do not offer FT4 as first line) means that they are more than likely completely euthyroid we always offer them the option to pay for FT4 and/or FT3 privately. You would be surprised how many of them are completely thrilled by this suggestion so you get the double bonus of gettting them to stop shouting at you whilst also proving your original assertion to be entirely correct.
I think the other important point made by others here is that the numbers don't always tell the whole picture. It's important that our GPs know that we are there on the end of the phone and we are always happy to make exceptions for individual cases where the clinical picture just doesn't fit with what the TSH (and/or FT4) is telling you. Perhaps there are very rare cases of pure low T3 syndrome and while this possibility doesn't justify measuring FT3 in everyone who wants it we have to remember that (in most cases) we don't see (or have to deal with) the patient and there may be times when measurement is fully justified even if it is only to act as a rule out. Aren't we always being told to treat the patient and not the numbers?
Fiona Davidson
Senior Clinical Biochemist
Kingston Hospital NHS Trust
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Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content.
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------------------------------
Date: Wed, 10 Sep 2014 10:22:50 +0000
From: "Coward, Steve" <[log in to unmask]>
Subject: Re: Low T3 syndrome
Not sure if this informs the debate:
As Part of Choosing Wisely® Campaign, Endocrinologists Release List of Commonly Used Tests and Treatments to Question
List encourages physician and patient conversations by highlighting potentially unnecessary-sometimes harmful-care in endocrinology.
Chevy Chase, MD and Jacksonville, FL-The Endocrine Society and the American Association of Clinical Endocrinologists (AACE) today released a list of specific tests or procedures that are commonly ordered but not always necessary in endocrinology as part of Choosing Wisely®<http://www.choosingwisely.org/>, an initiative of the ABIM Foundation<http://www.abimfoundation.org/>. The list identifies five targeted, evidence-based recommendations that can support conversations between patients and physicians about what care is really necessary.
In their list, The Endocrine Society and AACE identified the following five recommendations:
§ Avoid routine multiple daily self-glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.
§ Do not routinely measure 1,25 dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function.
§ Do not routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland.
§ Do not order a total or free T3 level when assessing levothyroxine (T4) dose in hypothyroid patients.
§ Do not prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency.
Steve
-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Fiona Davidson
Sent: 10 September 2014 11:01
To: [log in to unmask]
Subject: Re: Low T3 syndrome
Nobody seems to have really addressed Pete's original question of "has anybody had enquiries from GPs about this" and what do we suggest to GPs who have an irate patient in front of them demanding measurement of FT3.
I can't think that we have recently had any specific enquiries about FT3 that relate to this article, however, we do occassionally get specific requests from very demanding patients who have read something similar on the internet and are convinced that they need their FT3 measured. Whilst we always try and reason that their normal TSH (we do not offer FT4 as first line) means that they are more than likely completely euthyroid we always offer them the option to pay for FT4 and/or FT3 privately. You would be surprised how many of them are completely thrilled by this suggestion so you get the double bonus of gettting them to stop shouting at you whilst also proving your original assertion to be entirely correct.
I think the other important point made by others here is that the numbers don't always tell the whole picture. It's important that our GPs know that we are there on the end of the phone and we are always happy to make exceptions for individual cases where the clinical picture just doesn't fit with what the TSH (and/or FT4) is telling you. Perhaps there are very rare cases of pure low T3 syndrome and while this possibility doesn't justify measuring FT3 in everyone who wants it we have to remember that (in most cases) we don't see (or have to deal with) the patient and there may be times when measurement is fully justified even if it is only to act as a rule out. Aren't we always being told to treat the patient and not the numbers?
Fiona Davidson
Senior Clinical Biochemist
Kingston Hospital NHS Trust
------ACB discussion List Information-------- This is an open discussion list for the academic and clinical community working in clinical biochemistry.
Please note, archived messages are public and can be viewed via the internet. Views expressed are those of the individual and they are responsible for all message content.
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------------------------------
Date: Wed, 10 Sep 2014 11:51:14 +0100
From: Nick Miller <[log in to unmask]>
Subject: Re: Low T3 syndrome
Re: Se and the thyroid
Thanks for that John. Yes, I measure plasma selenium in patients having
thyroid tests and no, these measurements do not appear to be
mechanistically related in the population with which I deal. There are
three selenocysteine-containing iodothyronine de-iodinases; the original
description of Se-dependent hypothyroidism was from patients in the Congo
and I don't think this has wide application in the UK population, in which
prolonged Se deficiency is unusual, if not rare. In addition, we see far
more Se excess than deficiency - too many brazil nuts, too many
supplements, etc.
Nick Miller
London.
On 10 September 2014 10:30, OConnor John (ROYAL DEVON AND EXETER NHS
FOUNDATION TRUST) <[log in to unmask]> wrote:
> Out of interest, does anyone measure Selenium in patients with Low T3,
> normal T4 (and not on thyroxine)?
>
> There is an interesting link here
>
> http://www.medscape.com/viewarticle/777483
>
>
>
> John
>
>
>
> *From:* Clinical biochemistry discussion list [mailto:
> [log in to unmask]] *On Behalf Of *Nick Miller
> *Sent:* 10 September 2014 09:40
> *To:* [log in to unmask]
> *Subject:* Re: Low T3 syndrome
>
>
>
> The problem here, actually, is that peripheral de-iodination from T4 to T3
> becomes less efficient with ageing, and so it is inappropriate to use the
> same reference intervals for T4 in the over-60's as we do for the rest of
> the population. This is in the literature, but generally ignored. Older
> subjects need more T4 to make the same amount of T3. They also may have
> pituitary insensitivity to feedback control (everything wears out as you
> get older, believe me) and hence are less likely to elicit a TSH response
> to inadequate thyroid hormone production.
>
>
>
> Comments about the staggering incompetence and arrogance of lab staff when
> dealing with the problems of actual people do ring a bell, but I must agree
> that T3 measurement adds nothing to the diagnostic process, except when you
> encounter hyperthyroidism with normal T4 levels.
>
>
>
> Finally, I've seen a case just like the one Tim describes. She had a
> sub-total thyroidectomy after a thyroid storm and sustained a TSH of c. 360
> for 6 months (after which it came down). I used her serum as a control for
> years afterwards!
>
>
>
> Nick Miller
>
> London
>
>
>
> On 10 September 2014 09:12, Sharpe, Peter <
> [log in to unmask]> wrote:
>
> Dear Colleagues,
>
>
>
> When I came to this Trust in 1998, I was the first Chemical Pathologist to
> be appointed. Before this a Haematologist with an interest in Clinical
> Biochemistry had been looking after the service.
>
>
>
> A routine thyroid profile consisted of both fT4 & fT3 plus TSH. I'm
> unsure as to the reasons for this other than "historical".
>
>
>
> Within a few months, after widespread consultation with all requestors
> including Endocrinologists, we removed the routine fT3 measurement. It
> became clear that fT3 was adding very little (if anything) to the
> interpretation of thyroid profile results. fT3 can still be specially
> requested and we do run it under certain circumstances, but the numbers
> have dwindled to a few per week.
>
>
>
> My Endocrinology colleagues remain very sceptical about the so called
> diagnosis of low fT3 syndrome.
>
>
>
> Best wishes
>
> Peter
>
>
>
> *Dr Peter Sharpe*
>
> *Consultant Chemical Pathologist*
>
> *Associate Medical Director, Research & Development*
>
> *Southern Health & Social Care Trust*
>
> *Chair RCPath NI Regional Council*
>
> *Ext: 60869*
>
> *Tel: 028 38360696*
>
> *Fax: 028 38334582*
>
>
>
> *From:* Clinical biochemistry discussion list [mailto:
> [log in to unmask]] *On Behalf Of *Peter Beresford
> *Sent:* 09 September 2014 16:19
> *To:* [log in to unmask]
> *Subject:* Low T3 syndrome
>
>
>
> Dear Mailbase,
>
>
>
> We have received calls from GPs who have been approached by a number of
> patients regarding the article below, which was published in the Daily Mail
> last week.
>
>
>
>
> http://www.dailymail.co.uk/health/article-2734215/Cold-hands-Always-tired-It-hidden-thyroid-problem-doctors-refuse-treat.html
>
>
>
> The subject of the article is 'Low T3 syndrome", and it suggests to
> patients that they require FT3 measured routinely in addition to FT4, as
> well as opening up a debate with regards to treatment with T3. The article
> quotes respectable Endocrinologists quoted both for and against (although I
> suspect some of their comments may have been taken out of context).
>
>
>
> I would be interested to know if others have also been approached in
> response to this article and what guidance has been given to GPs responding
> to these queries.
>
>
>
> The guidance documents available on the British Thyroid Association
> website (http://www.british-thyroid-association.org/Guidelines/ ) are
> very helpful, but recognising that this is a complex area I wonder if
> anyone is aware of any more recent evidence or guidelines about the role of
> T3 in the aetiology and treatment of hypothyroidism?
>
>
>
> Best wishes
>
>
>
> Peter
>
>
>
> Peter Beresford
>
> Consultant Clinical Scientist
>
> Southmead Hospital
>
>
>
>
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------------------------------
Date: Wed, 10 Sep 2014 12:08:12 +0100
From: "Reynolds Tim (RJF) BHFT" <[log in to unmask]>
Subject: Re: Low T3 syndrome
He is probably mostly wrong - but who knows, there may be some patients
for whom he is correct...
************************************************************************
**************
Prof. Tim Reynolds
Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D
Lead,
Burton Hospitals NHS Foundation Trust
work tel: 01283 511511 ext 4035
work fax: 01283 593064
work email: [log in to unmask]
work URL: www.burtonhospitals.nhs.uk
This e-mail, and any files transmitted with it, are confidential and
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01283 511511 Ext 4035
[Picture of tree not available] Please consider the environment before
printing this e-mail
-----Original Message-----
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Waise, Ahmed
Sent: 10 September 2014 11:14 AM
To: [log in to unmask]
Subject: Re: Low T3 syndrome
http://www.wilsonssyndrome.com/
So you think Dr Wilson is right!?
Ahmed Waise
Poole Hospital,
________________________________________
From: Clinical biochemistry discussion list
[[log in to unmask]] on behalf of Fiona Davidson
[[log in to unmask]]
Sent: 10 September 2014 11:01
To: [log in to unmask]
Subject: Re: Low T3 syndrome
Nobody seems to have really addressed Pete's original question of "has
anybody had enquiries from GPs about this" and what do we suggest to GPs
who have an irate patient in front of them demanding measurement of FT3.
I can't think that we have recently had any specific enquiries about FT3
that relate to this article, however, we do occassionally get specific
requests from very demanding patients who have read something similar on
the internet and are convinced that they need their FT3 measured.
Whilst we always try and reason that their normal TSH (we do not offer
FT4 as first line) means that they are more than likely completely
euthyroid we always offer them the option to pay for FT4 and/or FT3
privately. You would be surprised how many of them are completely
thrilled by this suggestion so you get the double bonus of gettting them
to stop shouting at you whilst also proving your original assertion to
be entirely correct.
I think the other important point made by others here is that the
numbers don't always tell the whole picture. It's important that our
GPs know that we are there on the end of the phone and we are always
happy to make exceptions for individual cases where the clinical picture
just doesn't fit with what the TSH (and/or FT4) is telling you. Perhaps
there are very rare cases of pure low T3 syndrome and while this
possibility doesn't justify measuring FT3 in everyone who wants it we
have to remember that (in most cases) we don't see (or have to deal
with) the patient and there may be times when measurement is fully
justified even if it is only to act as a rule out. Aren't we always
being told to treat the patient and not the numbers?
Fiona Davidson
Senior Clinical Biochemist
Kingston Hospital NHS Trust
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Date: Wed, 10 Sep 2014 12:26:48 +0100
From: Fiona Davidson <[log in to unmask]>
Subject: Re: Low T3 syndrome
Interesting comment on the website:
"I have seen some 500+ patients, all self-referred, for this condition in
the last 8 years. Around 85 to 90% of the patients that I treat for
Wilson's Temperature Syndrome respond to the treatment, to some degree. Of
those about 50 percent seem to recover fully with only one cycle of T3
therapy and are able to wean off and be done."
If they only need one cycle of T3 therapy then this rather supports the
idea that it may be a placebo affect?
Fiona
On Wed, Sep 10, 2014 at 11:14 AM, Waise, Ahmed <[log in to unmask]>
wrote:
> http://www.wilsonssyndrome.com/
>
> So you think Dr Wilson is right!?
>
> Ahmed Waise
> Poole Hospital,
>
>
>
> ________________________________________
> From: Clinical biochemistry discussion list [
> [log in to unmask]] on behalf of Fiona Davidson [
> [log in to unmask]]
> Sent: 10 September 2014 11:01
> To: [log in to unmask]
> Subject: Re: Low T3 syndrome
>
> Nobody seems to have really addressed Pete's original question of "has
> anybody had enquiries from GPs about this" and what do we suggest to GPs
> who have an irate patient in front of them demanding measurement of FT3.
>
> I can't think that we have recently had any specific enquiries about FT3
> that relate to this article, however, we do occassionally get specific
> requests from very demanding patients who have read something similar on
> the internet and are convinced that they need their FT3 measured. Whilst
> we always try and reason that their normal TSH (we do not offer FT4 as
> first line) means that they are more than likely completely euthyroid we
> always offer them the option to pay for FT4 and/or FT3 privately. You
> would be surprised how many of them are completely thrilled by this
> suggestion so you get the double bonus of gettting them to stop shouting at
> you whilst also proving your original assertion to be entirely correct.
>
> I think the other important point made by others here is that the numbers
> don't always tell the whole picture. It's important that our GPs know that
> we are there on the end of the phone and we are always happy to make
> exceptions for individual cases where the clinical picture just doesn't fit
> with what the TSH (and/or FT4) is telling you. Perhaps there are very rare
> cases of pure low T3 syndrome and while this possibility doesn't justify
> measuring FT3 in everyone who wants it we have to remember that (in most
> cases) we don't see (or have to deal with) the patient and there may be
> times when measurement is fully justified even if it is only to act as a
> rule out. Aren't we always being told to treat the patient and not the
> numbers?
>
> Fiona Davidson
> Senior Clinical Biochemist
> Kingston Hospital NHS Trust
>
> ------ACB discussion List Information--------
> This is an open discussion list for the academic and clinical community
> working in clinical biochemistry.
> Please note, archived messages are public and can be viewed via the
> internet. Views expressed are those of the individual and they are
> responsible for all message content.
> ACB Web Site
> http://www.acb.org.uk
> Green Laboratories Work
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> DISCLAIMER: This email and any files transmitted with it are
> confidential and intended solely for the use of the individual,
> individuals or entity to whom they are addressed. Any views or opinions
> expressed are those of the author and do not necessarily represent the
> views of Poole Hospital NHS Foundation Trust unless otherwise explicitly
> stated. This email may contain confidential and/or privileged
> materials. In the case of confidential and/or privileged materials, any
> review, retransmission, dissemination or other use of these materials by
> individuals or entities other than the intended recipient may be the
> subject of legal action. If you receive an email in error from Poole
> Hospital NHS Foundation Trust, please contact the sender and delete the
> material from your computer.
>
>
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------------------------------
Date: Wed, 10 Sep 2014 13:00:56 +0100
From: Laura Owen <[log in to unmask]>
Subject: FW: white cider assays
Dear All,
I have been contacted by some researchers who would like to measure thiamine concentrations in alcoholic beverages. Does anyone know of anywhere that might consider offering a service such as this?
Thanks in advance
Laura
Laura Owen
Principal Clinical Scientist
& Honorary Lecturer
Biochemistry Dept
University Hospital of South Manchester
Manchester
M23 9LT
0161 291 5084
________________________________
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------------------------------
Date: Wed, 10 Sep 2014 14:01:05 +0100
From: "Barnes Sophie (IMPERIAL COLLEGE HEALTHCARE NHS TRUST)"
<[log in to unmask]>
Subject: Permanent 8a and fixed term 7 CS posts at Imperial, London
Hello
Please could I draw your attention to two Clinical Scientist positions currently being advertised at Imperial College Healthcare NHS Trust in west London:
We have a permanent band 8a position which has arisen due to a recent retirement and realisation of internal succession planning. The closing date for this post is 28th September. For more information or to arrange an informal visit, please contact me on 020 3311 5183 or [log in to unmask]<mailto:[log in to unmask]> http://jobs.imperial.nhs.uk/job/-v329703?_ts=1705335
We also have funding for a fixed term band 7 position to work from 1st October 2014 until 31st January 2015 whilst we recruit to the above post. We are happy to organise laboratory visits for after the closing date which is very soon (Sunday 14th September) as we would like to have someone in post as soon as we can. For more information, please contact me as above or Emma Walker on 020 3313 5921 or [log in to unmask]<mailto:[log in to unmask]> in my absence. http://jobs.imperial.nhs.uk/job/-v329674?_ts=795315
There are no internal applicants for either position.
We look forward to hearing from potential applicants.
Kind regards,
Sophie
Mrs Sophie Barnes
Consultant Clinical Scientist, Director of the SAS Renin Aldosterone Service
Clinical Biochemistry, 12th Floor Lab Block
Charing Cross Hospital
LONDON, W6 8RF
Please note I am part time. I work Monday, Tuesday, Wednesday.
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End of ACB-CLIN-CHEM-GEN Digest - 9 Sep 2014 to 10 Sep 2014 (#2014-184)
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