DIET AND EXERCISE WILL ALWAYS REMAIN IMPORTANT AND CANNOT BE IGNORED OR ABANDONED!
1) Medical history and physical exam, any questions re printed info?
2) Teach patient to understand and perform basal BP and P. First thing after awakening, before arising, before any physical activity, perform BP and P. Upon arising, weigh and record. Keep notebook/diary (Excel spread sheet is great) and record daily basal BP and P, weight, dose of T3/day, and anything noticed that is different. Bring notebook to appointments. Patients almost always forget this.
3) Teach patient signs and symptoms of hyperthyroidism (wired feeling, rapid pulse, elevated BP, hands shaking), esp. exophthalmus (change in convergence, gritty feeling in eye(s) on first awakening), and give business card with personal cell # on back and advise patient call or text anytime.
4) Explain pros and cons of T3’s short duration of action.
Allows frequent dosage adjustments. Short duration of action makes toxic symptoms, esp. exophthalmus impossible or of very short duration. When dose gets high enough to feel its effect wearing off, note time of first dose going away and schedule second dose 30 min. before that time, so blood level of T3 stays fairly uniform throughout the day, not swinging dramatically up and down. This interval will vary somewhat, probably a little longer as dosage is increased, and somewhat shorter as tolerance to medication develops as it does normally with all medications. If this duration of effect becomes short enough or you have a long day, a third daily dose might be desired. Adverse effects of T3’s short duration of action is that multiple daily doses are required.
5) Explain that patient feedback is essential to achieve proper dose. Write Rx with progressive range of dosage, allowing patient to choose which dose feels best. Only the patient can tell this, and patient’s participation here is essential for proper dosage.
6) I write first Rx (with explanatory letter to pharmacist below) using “half strength” 25 mcg tabs (NEVER ACCEPT MYLAN BRAND GENERIC) with instructions for patient to progress, at rate decided by patient, from ½ to 2 tablets twice daily, the interval between first and second doses determined as above. Patient is seen weekly during the first two months of treatment.
7) Because of unexpected effect of T3 LOWERING blood pressure, patient is advised to discontinue all antihypertensive diuretics and to be prepared to immediately stop all other antihypertensive medications due to hypotension, (BP too low).
8) At second appointment one week after starting T3 the Rx is
(usually) changed to “full strength” 50 mcg tabs, with same
instructions as with first week, proceeding from ½ to 2 tablets
twice daily. Prescriptions are usually written initially allowing adequate dosage for one week only, until good patient compliance is established. Weekly appointments are required and to assure this, payment is required monthly in advance. Missing an appointment does not extend the patient’s monthly credit, i.e. payment is required even if patient fails to keep appointment.
9) Daily data, weight loss, and symptoms are reviewed weekly. Rx instructions are progressed upward, sometimes as far as 3 or 3 ½ tablets (150-175 mcg) two or three times daily, but more typical is twice daily dosage of 100 to 200 mcg. Maximum dose so far has been 600 mcg/day in a patient weighing over 400 lbs. For patients starting between 200 and 300 lbs, maximum daily dosage thus far has been 525 mcg, with patient happy as a clam at high tide and no signs of excessive dosage. As her tolerance (rT3 if you insist)wore off a little, the patient chose (as I advise) to reduce her daily dose to 350 mcg by omitting the third dose which had been required earlier.
10) Adjust dosage to establish no more than 5 lbs/week weight loss. Follow and adjust as needed weekly.
11) Discontinue any cholesterol lowering medications as cholesterol routinely drops to below normal values. Many patients will no longer need their chronic anti-depressants either.
12) Patients must work at changing their universally poor self image, poor self esteem, which plagues overweight people. As weight comes down, self image should go up. Thinking better of one’s self, adjusting mental self image to match a better physical appearance, is often one of the hardest challenges to patients experiencing significant weight loss. Previous failures at weight loss create an ingrained sense of inferiority and failure that is quite difficult to dislodge. Patients will not experience failure with T3 and must come to believe that their previous weight loss problems are the fault of modern medicine’s failure to accurately diagnose their hypothyroidism (because of normal thyroid blood tests), not the fault of weak-willed self indulgence and laziness. Also, there will not be a rebound weight gain at the end of treatment because thyroid hormone replacement will be continued at stable-weight dose permanently, as it should have been throughout the patient’s entire life.
To: Pharmacist filling Cytomel Rx
From: Michael Morris, MD G-23554
Subject: Previously unseen dosages of T3 Cytomel
Dear respected professional,
Thank you for your concern about my patient. Yes, you are correct, such T3 dosages, anywhere from 200-600 mcg daily, are currently quite unheard of. I was recently introduced to the medical concept “inability to convert T4 to T3” and had a DUUHH moment, namely “then just treat them with T3.” In my ensuing efforts to study this topic I learned that apparently, I am the first MD around to have such a DUUHH moment, as the concept is non-existent in current “common medical knowledge”. My T3-only weight loss practice was well underway before I discovered the fact that as near as I can tell, I am the first MD to do so. This apparently makes me the current expert on the subject, by default. You can find a more in depth review of this concept on my new Facebook page Michael Morris, MD.
These “high” doses of T3 have not only given rapid easy weight loss without significant negative side effects, but an accidental discovery is even more important. It is imperative for me personally to disclose this accidental finding to any medical professional who will listen. Given the following fact, the “ho hum, who cares” response from the medical profession so far has been both surprising and disillusioning. I hope this raises at least one eyebrow with you.
T3 AT THESE DOSES IMMEDIATELY DROPS BLOOD PRESSURE TO NORMAL!
This effect lasts for the duration of action of the Cytomel itself, with blood pressure rising to previous abnormally high levels as Cytomel-induced thyroid effect diminishes/ceases within 3-6 hours. I have the problem, however, of (with T3 effect gone) patients’ blood pressure being elevated at night during sleep and before first daily AM T3 dose, after which blood pressure immediately (<1 hr) returns to normal.
So yes, T3 doses of 200-600, usually with BID dosage, but sometimes TID, QID, and at times QID + HS to keep BP down during sleep (which is universally reported as vastly improved) are the correct doses I am prescribing. The usual first Rx is Cytomel 25 mcg ½ -2 BID. After one week the same Rx usually is written with 50 mcg tabs. Please feel free to call anytime @ office 909 888-2000 or my personal (text enabled) cell 909 533-7180.
Michael Morris, MD
198 N Arrowhead Avenue
San Bernardino, CA 92408