Medicine For People!

February 2019: When to Ignore the Guidelines

Exhausted Human
Mitchell Haindfield
Licensed under Creative Commons

When to Ignore the Guidelines


  • Treat the Patient, Not the Thyroid Test
  • Sometimes the Patient is the Best Guide to the Medication Dose
  • Thought-Provoking Postscript

Treat the Patient, Not the Thyroid Test

The Lab Test Said We were Overdosing: We Weren't

Mr. Mandell had developed hypothyroidism decades ago.

If you have an underactive thyroid gland, you know that your doctor uses a test called the TSH—thyroid stimulating hormone—to determine the optimal dose for thyroid replacement. About 6 years ago, Mr. Mandel's TSH began to indicate that I was giving him too high a dose. Unfortunately, when we adjusted his dose to get a normal TSH, Mr. Mandell felt terrible. He developed dry skin, constipation and coldness of his hands and feet. His wife said he was slowing down. All these are signs of thyroid deficiency, not the thyroid excess that the TSH test indicated. When we increased his thyroid dose to make him feel normal again, the TSH level indicated that the dose was excessive.

The symptoms of excessive thyroid replacement mimic those of the condition we call hyperthyroidism. In contrast to what you might think, hyperthyroidism makes people tired. Their hearts race, they lose weight, they feel agitated, and they tolerate heat poorly. Mr. Mandel had none of these symptoms. We decided to treat him and not the laboratory number.

After some years Mr. Mandell developed an irregular heartbeat. Because that can be a result of excessive thyroid replacement, I reduced his thyroid dose. I began treatment for the irregularity and sent him to the cardiologist. I halfway expected the cardiologist to call me up and accuse me of causing the cardiac arrhythmia.

So be it. No doctor bats a thousand.

A couple of months later I did get a call from the cardiologist: "For God's sake, please adjust his thyroid dose back up to what it was. He feels miserable."

That was not the phone call I was expecting, but I was happy once again to treat the patient and not the laboratory test. Although Mr. Mandell still has his irregular heartbeat, he's happy not to have to suffer all the symptoms of thyroid deficiency as well.

The Lab Test Said We Weren't Giving Enough Medication: Wrong Again

Just coincidentally, Mr. Shaw also recently came in to our office to see us about his hypothyroidism. He has the opposite problem. His TSH level indicates that we are not giving him enough thyroid hormone. Thinking it best, I have over the years pushed him to increase the dose and make his TSH level normal. Mr. Shaw won't do it. Each time he returns and says that a higher dose of thyroid medication causes him to be hyperalert and sleepless.

This time, fresh from Mr. Mandell's experiences, I didn't argue. I said "Take the amount that makes you feel best, neither too tired nor too hyper. Come and see us next year and we'll go from there."

Medication Doses Often Need to be Customized

On the same subject, recently a patient who has been told that she has chronic obstructive pulmonary disease—I'm not sure that she does—was enjoined to take her pulmonary steroid inhaler twice every day.

Our office meter measured her peak expiratory flow rate as normal. I asked her to stop the inhaler entirely for a few weeks. Without it she can still walk several miles a day and climb hills. She experiences no shortness of breath. She still tests well on the meter. It may be that when the spring brings the pollen she will need the inhaler. We will find out. We will also find out whether she really needs it twice a day or if once a day is enough.

"But my other provider told me I needed to take it twice daily," she repeated.

The object of the practice of medicine is to help people feel better. The object is to prevent problems. It is not to squeeze everyone into the pronouncements made in the medical guidelines. Yes, yes—we need to know those guidelines and know them cold. And we need to know the people we are treating, and accept that it is their goals, not ours, that are most important.

Thought-Provoking Postscript

At their last visit, Mr. and Mrs. Mandell related to me that his mother had also suffered from hypothyroidism. Mr. Mandell did not know her laboratory results, but he clearly recalls that she may have suffered from the same laboratory test mismatch that he does. In her early 90s, when she moved to an assisted-living facility, her new medical team looked at her laboratory work and abruptly reduced her thyroid dose. She became fatigued, then lethargic and delusional. Finally, she stopped eating and talking. Typical of extreme forms of hypothyroidism, she became almost comatose. Her niece, a pharmacist at UCLA, went in to the assisted living facility and paid some attention to what was going on. She prevailed upon the medical treatment team to increase the thyroid dose. The patient soon awoke from her delusional state. In Mr. Mandell's words, she was "completely with us until the day she died" two years later.



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Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.