Dr. John Dommisse's Publication Addresses Optimal Treatment For Hypothyroidism

More of this Feature • Part 1: Free T3 and Free T4 Are More Effective Than TSH • Part 2: Synthroid, Armour, or Another Drug: What's Best? Join the Discussion "Has anyone tried, either as a patient of Dr. Dommisse, or by following his recommended protocol, the Free T4/Free T3 management he recommends at his site and in his paper?" Mary Related Resources • An Interview with John Dommisse, MD • Interpreting Thyroid Test Results • Rethinking the TSH Test w/Dr. David Derry Elsewhere on the Web • Dr. Dommisse's website

An interview by Mary Shomon

Mary Shomon: This is a fairly medically-focused paper, and would certainly be of interest to medical practitioners working with thyroid treatment. How do you envision patients being able to use this paper?

Dr. Dommisse: In two ways: Either (1) passing a copy of the paper on to their treating physician and asking him/ her to read it and consider applying my method to their treatment of this patient; or (2) studying the paper themselves and then attempting to get their FT4 and FT3 levels to always be measured, at least, and ultimately to get them both optimized by their treatment, regardless of whether their TSH level is then way below its so-called 'normal range' or not.

Let me clarify why I keep referring to the TSH 'normal range' in quotes, or as the 'so-called' normal range. When I started to treat hypothyroid patients, back in 1988/9, I found several whose TSH level was within its normal range but the patients had classic symptoms and signs of hypothyroidism, including very high cholesterol levels, etc., etc., etc.. So I tried to find out how this 'normal range' was ascertained; I could not find the answer to my question but determined, on my own, that the range is actually much too high. I did discover two facts that supported my decision: (1) Textbooks of thyroidology, particularly 'Werner & Ingbar's The Thyroid, talked about a mild grade of hypothyroidism, grade-3, in which FT4 and FT3 levels are low-normal and the TSH is in the upper portion (undefined) of its normal range; and (2) I called a physician who had published a paper on grade-3 hypothyroidism: He and his colleagues had defined grade-3 or 'subclinical' hypothyroidism as "Normal T4, T3 AND TSH levels but in which there is an exaggerated jump in the TSH level after A standardized length of time after a standardized dose of TSH-Releasing Hormone (TRH) is injected into the patient": I asked him whether the patients in whom this exaggerated 'jump' was found in the post-TRH-stimulated TSH level were not actually also the same patients in whom the original, 'basal' sensitive TSH level was in the upper portion of its normal range: His answer was in the affirmative. At that time, the TRH-stimulated TSH level was a $600 test. So I decided to simply bypass this test in my patients and treat all those whose TSH level was above 2.0 mIU (in the presence of Low-normal FT4 and FT3 levels).

As time went on, I found that some patients whose TSH was even below 2.0 (and whose FT4 and FT3 levels were low-normal) had classic hypothyroid symptoms and signs. So I started treating all those with TSH >1.5 (and low FT4 and FT3). Eventually, I have ended up at 1.0 as my cut-off point for the 3rd-generation TSH (when FT4 and FT3 are low-normal); I don't believe I will ever go below 1.0 for a diagnosis of primary hypothyroidism (meaning the deficit is in the thyroid gland). This does not by any means exclude cases of secondary (pituitary), tertiary (hypothalamic) and nonthyroidal hypothyroidism, in which the TSH is below that - or even below the lower limit of its normal range - while the FT4 and/ or FT3 levels are below their normal ranges.

Recently, on May 13 of this year, Dr Denis O'Reilly, of Glasgow, published a paper ( Thyroid function tests: time for a reassessment ) in the British Medical Journal on the unreliability of thyroid function tests (mainly the TSH), and revealed how the TSH 'normal range' was obtained. Apparently, 28 people who were presumed to be euthyroid (have normal thyroid function), had their TSH levels measured. When the small percentage of them whose TSH were at the low and high extremes were removed, and the average range of the remainder calculated, the world was provided with a range of 0.4-5.0. This range varies slightly in different labs where it is measured, but within fairly close approximation to this range. When it is realized how many people are walking around with undiagnosed hypothyroidism, it can also readily be realized that that original 'normal range' probably included people who were hypothyroid, and therefore that 'normal range' is too high. Be that as it may, and regardless of whether the sample did include patients who it can now be agreed upon to be hypothyroid, or not, my judgment is that patients whose 3rd-generation TSH level is above 1.0 (in the presence of low-normal FT4 and FT3 levels) have grade-3, the mildest grade of, primary hypothyroidism - and in every such case it has been my experience that treatment has greatly benefited the patient and removed all the classic symptoms and signs of hypothyroidism that they had previously exhibited.

Mary Shomon: How can readers obtain their own copy of this paper?

Dr. Dommisse: As I explained, because of the problems with getting this leaked paper into a medical journal, I decided to simply copyright it and e-publish it on my own website. So that is where it is available for your readers right now. I believe it is easier and cheaper to obtain this paper than any recently published medical journal article, so that is actually an advantage for your readership. Of course, the more true my claim is proven to be in the future (namely that this is the best way to approach the diagnosis and treatment of all types and grades of hypothyroidism), the more of an advantage it will be to them.

Note: To order the paper, which is $10, visit the order page at Dr. Dommisse's website.

> Page 1, 2, 3