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Finding the Perfect Thyroid Medication (Part 2)

September 28, 2012 24 Comments by Scott Isaacs, MD

For some patients, despite valiant efforts, levothyroxine alone is not enough to restore optimal hormone balance. Personalized treatments can often be helpful in these circumstances.

Personalized and Alternative Treatments for Hypothyroidism

New research has found that a relatively common genetic mutation can result in impaired ability of the body to convert inactive T4 to active T3. This mutation of the type 2 deiodinase gene known as Thr92Ala predicts decreased responsiveness of symptoms of hypothyroidism to levothyroxine treatment, even if blood tests are normal. About 16% of individuals with hypothyroidism have this mutation. Deiodinase 2 is an enzyme necessary for converting T4 to T3 in the brain.  The Thr92Ala defect decreases T4 to T3 conversion in the brain. This mutation also causes increased insulin resistance in susceptible individuals.

The use of T3 is considered controversial, however, because the vast majority of clinical studies, including a major study published in the Journal of the American Medical Association, has failed to show a benefit of taking T3 compared to a placebo. Other studies from the Netherlands, China, and from Spain showed that T3 did not improve mood, fatigue, well-being, neurocognitive function, or any other objective measurements compared to taking T4 alone;  however, patients still reported that they preferred taking it. A meta-analysis of 11 well done clinical trials published in the Journal of Endocrinology and Metabolism failed to show a benefit of T3/T4 combination therapy.

A recent article in Internal Medicine News details the use of T3 for cases of resistant hypothyroidism. There has been a call for more personalized treatments. One thyroid guru, Dr. Leonard Wartofsky has stated that “Innovative formulations of the thyroid hormones will be required to mimic a more perfect thyroid hormone replacement therapy than is currently available.”

Liothyronine (Cytomel)

Liothyronine is a synthetic form of T3. T3 supplementation with Cytomel has helped many patients but is still controversial among endocrinologists because studies have failed to show a definite benefit. Despite the research, many patients say they prefer to take a low dose of T3 in addition to levothyroxine. The dose of T3 varies among individuals. The body needs about 20 percent T3 and 80 percent T4; however, the body will make some T3 from T4, even if the process is impaired. I recommend that the dose of T3 not exceed 10 percent of your total thyroid hormone dosage. Many patients do well with 2.5–5 mcg of liothyronine once in the morning. Some people prefer to take a second dose around 2:00 p.m. to prevent an afternoon slump. Liothyronine can be taken three times a day, but it can cause insomnia if taken too close to bedtime. Unlike levothyroxine, if you forget a dose, you cannot double up on liothyronine.

One of the main problems with liothyronine is that it can cause thyroid levels to go too high. If you take liothyronine, your physician will need to check your blood tests more frequently. If thyroid levels are too high or the TSH is too low, your doctor can reduce the dose of levothyroxine or liothyronine to bring tests back into the normal range.

Sustained Release T3

Sustained release T3, custom-made by compounding pharmacists, has shown promise as the ideal method of taking T3, because the T3 that is in liothyronine, Thyrolar, and Armour Thyroid is very short acting. The majority of the T3 from these products is out of your system after a few hours. Sustained release T3 is in special capsules that provide a slower release of the hormone into your system over a period of twelve hours. The problem with sustained release T3 is that the release is not that slow. Pharmacists are still trying to perfect the process of making a better sustained release T3 tablet.

In March 2001, officials from the Georgia Drugs and Narcotics Agency became concerned when several patients who had their T3 filled at a Georgia compounding pharmacy were hospitalized for life-threatening high thyroid levels. It was discovered that pills were made incorrectly and contained one hundred times the prescribed dose of T3. Since that time, reputable compounding pharmacies have become ultra-vigilant in the way they make T3. To find a reputable compounding pharmacist in your area, visit the website http://www.pccarx.com/contact-us/find-a-compounder/.

Liotrix (Thyrolar)

Liotrix is a synthetic mixture of liothyronine (T3) and levothyroxine (T4) available in a single tablet. Available in different strengths, the ratio of T3 to T4 in this fixed combination tablet is 1:4 (one mcg of T3 for every four mcg of T4). This combination tends to have too much T3 for most people. Despite this fact, many doctors believe that the percentage of T3 is too high. Another disadvantage with Thyrolar is that it requires refrigeration.

Desiccated Thyroid (Armour Thyroid, Nature-Throid, Westhroid, and Thyroid USP)

Some patients prefer desiccated thyroid, which is produced from pig (also called porcine) thyroid glands. Because it comes from a pig, it is considered natural. Desiccated thyroid contains about 25 percent T3 and 75 percent T4, which is different from the normal T4:T3 ratio for humans, who need 20 percent T3. Some people feel better with the higher T3 level; some don’t. Some of my patients have done very well taking a low dose of desiccated thyroid (15–30 mg) in addition to their standard dose of levothyroxine.

The quality and potency of desiccated thyroid has improved in recent years. Despite the higher T3 levels and past availability issues, many of my patients feel great and have perfect thyroid levels on desiccated thyroid. Thyroid USP offers an advantage because the dose of the pills can be customized. One problem with desiccated thyroid is that the T3 part tends to wear off early in the day. A solution is to take a second dose around 2:00 p.m.

Custom T3/T4 Combination Products

Compounding pharmacies can make just about any dose combination of T3 (usually in sustained release form) and levothyroxine. Compounded thyroid hormone products are difficult to make correctly. It is important to choose a reputable compounding pharmacist that has rigid protocols and regularly tests its products at an independent laboratory.

Thyroid Hormone Abuse

Some people adhere to the philosophy that “if a little is good for me, then more must be better.” Maybe that’s the case with some things, but with thyroid hormone, it is a prescription for disaster. Unfortunately, since thyroid hormone is usually recommended for people suffering from weight gain caused by hypothyroidism (and that’s key—it’s not simply weight gain), some patients will increase their dosage on their own, thinking that taking more hormone will speed their metabolism and help them lose weight even faster. Let me emphasize: increasing your thyroid hormone dose is extremely dangerous.

First of all, the “benefits” (if you want to call them that) are short term at best: yes, metabolism may pick up. Yes, it may help shed a few pounds, but the body is as ill equipped to handle what becomes “forced hyperthyroidism” as it is to handle hypothyroidism. Increased dosages blow blood pressure sky high, cause the heart to fibrillate and function poorly, weaken muscle tissues, and bring on thinning of the bones (osteoporosis). Thyroid hormone is a serious matter. Endocrinologists painstakingly work to find exactly the right dosage for their patients, tweaking the daily regimen by as little as 12 micrograms (that’s twelve millionths of a gram, or .000012 grams). They also make patients come in regularly for blood tests to make sure the dosage is still correct. Like any other drug, thyroid hormone is not to be abused. The results can be calamitous.

Diet and Lifestyle for a Healthy Thyroid

About 50% of patients ask if they can change their diet to treat hypothyroidism. The Hormonal Health Diet (in Hormonal Balance, third edition) is ideal for people with thyroid problems. This diet not only helps you lose weight, it also promotes optimal thyroid balance, psychological well-being, and physical health.

 Eat Lots of Fruits and Vegetables

Fruits and vegetables act as antioxidants. Among the best-known antioxidants are beta-carotene, vitamin A, and vitamin C. Antioxidants promote the binding of what are called free radicals—oxygen-rich substances in the body that damage cells and hinder the immune system. Immune system attack is the main cause of hypothyroidism. Antioxidants clear toxins from the body and are even thought to help ward against cancer.

 Get the Right Amount of Iodine

The recommended daily allowance (RDA) for iodine is 150 micrograms; however, in the United States, the usual consumption ranges between 300 and 700 micrograms a day—a testament to our love of salt and salty products—because most of the salt used in the United States is iodized. (One teaspoon of iodized salt contains more than 300 mcg of iodine.) Iodine has nothing to do with sodium; it’s just added to the salt. Non-iodized salt (known as free running) and kosher salt do not contain iodine. Iodine also comes from seafood and sea vegetables, and it is found in preservatives and in red dye #3 (red dye #40 does not contain iodine). Many red, orange, or brown processed foods, pills, and capsules contain red dye #3. Iodine is in many medications, such as amiodarone, levothyroxine, liothyronine, cough syrups (expectorants), povidone-iodine topical antiseptics, and IV contrast dye. When reading labels, the words iodate, iopodate, iodide, potassium iodide, or sodium iodide mean the product contains iodine.

Most multivitamin and mineral supplements contain 150 mcg of iodine. Sources of dietary iodine include seaweed sushi wraps, seafood, commercial baked goods and snack foods, egg yolks, chocolate, molasses, soy products, rhubarb, potato skins, and fruits and vegetables grown in iodine-rich soil (usually near a coast). Dairy products once contained high amounts of iodine because farmers used it as a disinfectant, but new iodine-free products are being used by some manufacturers. Too much or too little iodine can cause thyroid dysfunction, so it is important for you to get the right amount.

 Eat Foods High in Selenium and Zinc

Selenium and zinc function as antioxidants. Moreover, selenium has a dual role—besides its antioxidizing properties, it helps convert T4 to T3. Lack of selenium and zinc can reduce levels of active T3 by preventing its conversion from T4. Although selenium and zinc supplements are available from most health food stores, I recommend that you increase your consumption of these vital minerals by eating the proper foods. Foods high in selenium include whole grains, tuna, halibut, mushrooms, oatmeal, wheat germ, and sunflower seeds. Because selenium is also needed for survival of bacteria, persons infected with a bacterial illness often find themselves with a selenium deficiency and get a double whammy, because the bacteria, growing fat and happy off all the selenium they’re diverting, also produce substances detrimental to the production of thyroid hormone. Too much selenium can be as damaging as too little. Among the side effects of too much selenium: abdominal pain, nerve damage, and diarrhea. It is estimated that 50 mcg a day is enough to keep your thyroid healthy and provide a decent amount of antioxidant activity.

A diet low in zinc has been found to cause damage to the thyroid gland. Down’s syndrome children are usually low in zinc, and many are hypothyroid as well. Obese people have the same problem. A diet featuring a proper level of this trace mineral can help assuage the problems caused by thyroid dysfunction. Foods high in zinc include beef, herring, maple syrup, turkey, wheat bran, and sunflower seeds.

Take Vitamin A

Take vitamin A in dosages of 7000–9000 IU (International Units) daily. Vitamin A deficiency causes thyroid problems. Vitamin A is involved in T4:T3 conversion and thyroid hormone metabolism throughout the body.

Eat Less Gluten

Having a thyroid problem increases your risk for celiac disease and other forms of gluten intolerance. If you have full-blown celiac disease, you need to be ultra-strict about staying gluten free. Many thyroid patients have mild gluten intolerance and normal testing for celiac disease. Reducing gluten in the diet can sometimes improve absorption of thyroid medications and the symptoms of hypothyroidism.

Spice Up Your Foods

Low metabolism is the hallmark of thyroid problems. Adding chili peppers and other hot spices to your foods can give your metabolism a little boost.

Don’t Eat Too Many Raw Goitrogens

Cruciferous vegetables from the Brassica family, such as cabbage, broccoli, Brussels sprouts, turnips, rutabaga, mustard, kohlrabi, radishes, cauliflower, cassava, millet, and kale are called goitrogens and are listed as foods to avoid in many thyroid-related books and websites, but read on, because you may not yet have all the facts. These vegetables contain naturally occurring substances known as isothiocyanates that interfere with the function of the thyroid gland, but the reality is that these vegetables won’t hurt your thyroid unless you eat huge amounts of them raw. Once cooked, these foods have many health benefits. The key is not to eliminate these foods. Cooking these vegetables is recommended, but you can eat up to two cups of raw cabbage, broccoli, and cauliflower weekly without doing any harm to your thyroid. Peaches, peanuts, pine nuts, spinach, and strawberries also may inhibit thyroid function if consumed in large amounts.

Don’t Eat Too Much Soy

Limit your consumption of soy products to four to five servings a week. Although soy products have many health benefits, soy can also increase the risk of  thyroid problems. Soy has been shown to interfere with the thyroid peroxidase, which is an enzyme responsible for an important step in the production of thyroid hormone. The National Center for Toxicological Research reports that soy isoflavones have a number of anti-thyroid effects that result in soy toxicity. A study from the University of Belgrade showed that soy isoflavones cause destructive changes in the thyroid tissue, leading to hypothyroidism. Another study from England found that soy products increased the risk threefold for an underactive thyroid. Soy also contains natural estrogen-like compounds. These compounds have been thought to affect the thyroid, but the truth is the effect is very small. If you take thyroid medication, to allow for adequate absorption, you should take it at least two hours away from eating soy.

Work Out

Regular physical activity is a critical element in maintaining a hormonal balance and a healthy metabolism. Hypothyroidism makes people tired, less energetic, and less motivated to exercise. Try to exercise during a time in the day when your energy levels are at their peak.

Don’t Take Thyroid Supplements

There are two types of thyroid supplements: iodine supplements and glandular supplements.

Iodine supplements promise to supply the nutritional needs of the thyroid and contain iodine (in the form of kelp, bugleweed, or bladderwrack), vitamins, minerals, and tyrosine. The high iodine content can cause the thyroid to become underactive or overactive and do more harm than good. It is important to know that thyroid medications contain high amounts of iodine, so taking extra iodine is really not necessary.

Glandular thyroid supplements are products that are similar to desiccated thyroid but are available without a prescription. These products have no quality control and may contain much less or much more than the dose listed on the label. If you want to take a glandular thyroid supplement, work with a qualified physician who will prescribe a high-quality supplement.

Get the Toxins Out

Toxins and pollutants can cause thyroid problems. Known as environmental endocrine disruptors, these substances slow thyroid function and disrupt hormonal balance. The chemical carbon tetrachloride is known to cause thyroid dysfunction and has been found in samples of drinking water. Pesticides have a chronic mineral-depleting effect that can lead to thyroid problems. Polychlorinated biphenyl (PCB) exposure has been associated with impaired intellectual functioning, memory problems, and learning problems thought in part caused by thyroid dysfunction. The weed killer Roundup, which contains the chemical glyphosate, has been blamed for thyroid problems. Smoking may contribute to thyroid disease, because of several toxins, including cadmium, that are contained in tobacco leaves. Cadmium has been linked to thyroid dysfunction. Dried fruits (which are often dried on galvanized chicken wire) can contain high amounts of cadmium as well. Nitrates and mercury have also been linked to thyroid problems. Antibacterial products, from dishwashing liquids to bar soap and toothpaste, have become very popular in the last few years, promising cleaner skin and less risk of infection, but many of these products contain a chemical called triclosan, which is thought to interfere with thyroid hormone metabolism. My recommendation is to avoid antibacterial products. The regular versions of the products do an excellent job of killing microbes, without any potential risk to your thyroid.

Do you actually need thyroid medication?

New research has found that mild elevations in the TSH level can be a normal part of aging and are especially common in 80 and 90 year olds. Anne R. Cappola, MD,of the division of endocrinology, diabetes and metabolism of the Perelman School of Medicine at the University of Pennsylvania, said, “Our study shows that a gradual increase of TSH occurs during healthy aging and that mild increases in TSH are not harmful in the oldest old.” Elderly patients with borderline TSH elevations may not benefit from treatment. “Our findings suggest that reflexively treating mild elevations in TSH in those of advanced age is unnecessary. Further studies are needed to determine threshold levels of thyroid function that would benefit from intervention,” Dr. Cappola remarked.

For more information on thyroid disease and ideal treatments, please read my book Hormonal Balance: How to Lose Weight by Understanding Your Hormones and Metabolism or visit my Facebook page.

www.YourEndocrinologist.com
www.IntelligentHealthCenter.com

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24 Comments

  1. alyssa rabach says:
    Friday, September 28, 2012 at 11:01pm

    Is Hashimoto the same as hypo-thyroid?. Recently I was told that it not. I assumed if you were hypo-thyroid that that was Hashimoto. A naturalpath informed me Hashimoto is auto-immune.I have had it for 8 years and in my 50′s. Weight was not a problem till now. Specially stomach. Will I ever be a size 2 again?

  2. Scott Isaacs, MD says:
    Saturday, September 29, 2012 at 9:51am

    More than 90% of hypothyroidism is caused by Hashimoto’s aka autoimmune hypothyroidism. I discuss this in my book. I hope this article helps you.

  3. pam juback says:
    Saturday, September 29, 2012 at 9:56am

    My husband has been diagnosed with Hoshimotos Disease. What information can you give me?

  4. Scott Isaacs, MD says:
    Sunday, September 30, 2012 at 8:52am

    Hashimoto’s is the most common cause of hypothyroidism (more than 90%) of cases. I write a lot about Hashimoto’s in my book Hormonal Balance. http://www.amazon.com/Hormonal-Balance-Understanding-Hormones-Metabolism/dp/1936693224/ref=pd_bxgy_b_img_y

  5. Sherrie says:
    Sunday, November 4, 2012 at 12:36am

    After being sick for two months straight and feeling like I was going to die they finally checked my levels and at 28. . It took several years to get my levels right. Now the dry hair, dry skin, itchy eyes, lack of energy and forgetfulness is back. My eye lashes and eye brows are falling out. And I am gaining weight. Muscle spams are back. But My levels are normal. The doctor won’t even consider my thyroid. I am a supper high energy person who has hit their slump. Confused about letting my doctor run a whole slew of tests which were all normal six months ago or give up.

  6. Scott Isaacs, MD says:
    Monday, November 5, 2012 at 8:57am

    It is possible it is more than just your thyroid. Maybe you should get a second opinion. I wish you the best.

  7. LMarie says:
    Thursday, November 22, 2012 at 8:08pm

    I received “indeterminate” results from a thyroid biopsy in late October. total thyroidectomy has been recommended. my blood work and thyroid levels are normal. I’ve been told to be prepared for cancer, but be glad if it is not. It seems crazy to remove an organ and then determine if cancer exists and rely on medication for the rest of my life. So I then spoke with someone this weekend who said there is a new way to evaluate whether one has thyroid cancer by removing and testing the lymph node….in order to save the thyroid gland. He also suggested that i see another dr outside my current hospital network. Do you know anything about this alternative surgical option? I’m confused and scared. Thanks

  8. Scott Isaacs, MD says:
    Monday, November 26, 2012 at 10:08am

    Ask your endocrinologist about the new Veracyte Affirma test which is recommended by the American Thyroid Association for evaluating indeterminate thyroid nodules.
    http://www.veracyte.com/afirma/
    I wish you the best.

  9. Darlene says:
    Sunday, December 9, 2012 at 6:48pm

    I have been taking thyroid meds (synthroid) since 1996. Noticed a bit of a difference in my hair – not as much volume – switched to Armout Thyroid 3 years ago – and since then my hair has really thinned – mostly in a male pattern baldness style – in the front. Could I be taking too much thyroid meds? I take 60 mg. a day. My last blood test showed my TSH at 4.4. Do I need to try a different med.?

  10. Scott Isaacs, MD says:
    Friday, December 21, 2012 at 1:55pm

    A lot of patients on Armour do experience hair loss. Too much thyroid medication can also do it.

  11. Mary Dabbs says:
    Thursday, December 27, 2012 at 12:17pm

    My thyroid problem was misdiagnosed as narcolepsy for 14 years, and I was treated with dexedrine in Atlanta, Washington, D.C., New Haven, Ann Arbor, and back to Atlanta. I also had chronic migraines. Finally a G.P. diagnosed me as hypothyroid and treated me with Armour thyroid, which was partly effective. She also prescribed Serzone, which had little effect. Then she switched me to Synthroid, and I developed symptoms of Lupus and generally felt terrible. My husband was working with Dr. Anthony Karpas on testosterone research, and he told Dr. Karpas about my problems with Synthroid. I first saw Karpas in 1998, and he prescribed 5mcg of Cytomel along with Synthroid. I felt a little better. He gradually increased the Cytomel, and with each increase I felt better. Shortly before he retired, He switched me to a combination of 20 mcg.Cytomel and Armour thyroid, and at that point my migraines, which had become less frequent and less severe with each increase in Cytomel, ceased. Dr. Robert Osborne prescribed 25 mcg Cytomel and Armour thyroid. He moved, and I need an new endocrinologist.

  12. Scott Isaacs, MD says:
    Friday, January 4, 2013 at 10:39am

    I knew Dr. Karpas very well. We all miss him. May he rest in peace.

  13. Katrina says:
    Friday, January 18, 2013 at 1:15pm

    I was diagnosed with Hashi Hypothyroidism roughly five years ago and have significant family HX of autoimmune disorder (brother lupus, mother deaf due to Autoimmune plus Hypo also). I was previously being managed well on Armour’s but the MD that prescribed it has retired and there is no one locally here that would keep me on it. So I started seeing an Endo to get a baseline and start over (TSH baseline was 55 without medication) and so was started on Synthroid .137mcg 2 years ago. My labs have all normalized but I never felt well again. Since Synthroid I have gained 30lbs, lost a lot of hair, have the worst PMS you can imagine with very painful periods, melasma that is horrifically embarrassing and the list goes on and on. I am on no other medications and simply wanted my Endo to consider that maybe Synthroid is not the “end all be all” for my body. I was eventually transferred over to his Nurse Practicioner (due to scheduling availability) which as been the worst experience of my life. I have never met someone with such an awful bedside manner as this woman. Because I am questioning my symptoms, she is defensive and downright bullish because she thinks I am questioning her treatment. I am simply asking the questions I feel I should be allowed to ask because it’s my body. I am not looking for the magic pill, I just want to feel better. After an argument, in office, whereby she insulted my intelligence numerous times, raised her voice and was what I would consider to be incredibly unprofessional, she hesitantly agreed to put me on a low dose of Cyto to my Synthroid stating that Cyto is purely a placebo and that if there was any benefit, she would only attribute it a psychological effort on my part. Wow. I have never run into this sort of behavior with another Doctor. Is this normal? I left the conversation in tears and am just baffled why I am running into this at an Endos office. Thanks for any insight you can provide.

  14. Scott Isaacs, MD says:
    Friday, January 18, 2013 at 1:20pm

    Katrina, That sounds like a difficult situation.

  15. Rachel Halverson says:
    Saturday, February 2, 2013 at 8:53am

    Dr. Isaacs,

    This article was very enlightening. I have been incorporating some items in my diet that I believe are causing thyroid issues. I had a TSH, a Free T3 and a Free T4 run and was advised by my Medical Doctor that I was in a “low normal” range. I have CAD and at the time he felt that any type of thyroid medication or over the counter support would be more harmful than helpful. It has been 8 months since this visit and my energy levels have returned, I attribute it to drinking Mate tea’s and Pu-erh tea’s. Do you have any information on how these tea’s may positively or negatively affect my thyroid?

  16. Scott Isaacs, MD says:
    Monday, February 4, 2013 at 1:13pm

    I have not heard about how those teas can affect your thyroid.

  17. Lisa says:
    Thursday, May 23, 2013 at 8:24pm

    Hi. I was diagnosed with Hashimotos and Addison’s disease in 2007. After taking synthroid for 3 years with moderate hair loss, and a year an a half of that being overdosed on it, as indicated by bloodwork. In January 2013 I switched from 88mcg synthroid (lowered from 100 mcg) to 60 mg armour. After 2 months bloodwork indicated that t3 was elevated, 4.7). I have been having severe hair loss. My dr lowered the dose to 45 mg but the hair loss, 300- 1000 a day has continued. Is it likely that it is the high t3 and how long does it take to lower within the upper 34 of the range? Is it likely that my t4 will drop too low with the reduced dose? Thanks for any input.

  18. Scott Isaacs, MD says:
    Friday, June 21, 2013 at 11:21am

    This sounds complicated. I recommend working with an endocrinologist. I wish you the best.

  19. Chele says:
    Sunday, July 28, 2013 at 11:31am

    Hello Dr. Isaacs, thank you for the article. Are there tests that will affirmatively identify individuals with the deiodinase 2 mutation? Alternatively, can the presence of the mutation be deduced from lab tests?

  20. Chele says:
    Sunday, July 28, 2013 at 1:47pm

    Dr. Isaacs, just one more related question – how are individuals with impaired T4->T3 conversion identified? What are the tests that show this?

  21. Scott Isaacs, MD says:
    Wednesday, August 21, 2013 at 8:35am

    It is complicated. I discuss T3 conversion issues in my book Hormonal Balance.

  22. Scott Isaacs, MD says:
    Wednesday, August 21, 2013 at 8:35am

    Testing is only done at academic centers at this time.

  23. Lisa says:
    Wednesday, November 6, 2013 at 1:33pm

    Great article.My dr. and I have finally have found a great compound that is working with my thyroid. It finally leveled out when I added iosol drops along with it. You mentioned in your article that adding iodine could be harmful. Should I discontinue? If you’re unfamiliar with iosol – it is ammonium iodide ( supports the thyroid) NOT potassium iodide ( which inhibits the thyroid). Your insight is greatly appreciated.
    Thank you!

  24. Scott Isaacs, MD says:
    Tuesday, November 19, 2013 at 2:29pm

    Thyroid medication contains a lot of iodine.

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