Add Back Therapy for Graves' & Hyperthyroidism: Block & Release

Add Back Therapy for Graves’ & Hyperthyroidism: When to use Levothyroxine

Is there ever a situation in which it makes sense to use levothyroxine to treat hyperthyroidism

It may sound crazy, but the truth is that there might be. 

And, yes, just to clear things up, I’m talking about the use of levothyroxine in a patient that is hyperthyroid. 

I know that intuitively this doesn’t make any sense. 

After all, why would someone who already has too much thyroid hormone in their body want to use thyroid medication? 

Wouldn’t that make the situation worse?

Well, yes, and no. 

Emerging data (1) and hyperthyroid patient experience suggest that there may be a reason to use levothyroxine if you are hyperthyroid and taking anti-thyroid medication like methimazole. 

But there are only unique circumstances in which it may make sense. 

So before you run out and request to be placed on levothyroxine make sure you continue reading. 

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Treatments for Graves’: Understanding Add Back Therapy or Block and Replace Therapy

Because this can get confusing, let’s talk about some of the basics of hyperthyroidism treatment. 

The first thing you need to understand is that hyperthyroidism is a disease of excess thyroid hormone in the body. 

All of the symptoms that patients with Graves’ disease and hyperthyroidism experience are a direct result of this extra thyroid hormone. 

Symptoms like tremors, sweating, hot flashes, weight loss, diarrhea, and so on, all stem from this effect

This hyperthyroid state, and the symptoms that it creates, can result in serious (and potentially fatal) consequences such as a thyroid storm or thyrotoxicosis. 

As a result, your doctor will want to bring your thyroid levels down as quickly as possible. 

This is where anti-thyroid medications step in. 

If you’ve been diagnosed with hyperthyroidism then your doctor will most likely have given you a prescription medication meant to block your thyroid. 

The one most often used is methimazole. 

The problem with methimazole is not that it doesn’t work but that it often works too well. 

So when your doctor puts you on methimazole to slow down your thyroid he/she is doing that to bring you back to a normal level. 

But the initial doses of methimazole are often much higher than needed. 

And guess what happens if that’s the case?

Instead of experiencing symptoms of excess thyroid hormone, you will start to experience the symptoms of too little thyroid

In other words, the thyroid-blocking medication you were taking turns you from hyperthyroid (too much thyroid) to hypothyroid (too little thyroid). 

And instead of experiencing the symptoms of excess thyroid hormone like diarrhea, weight loss, tremors, and sweating, you will now experience the symptoms of too little thyroid hormone like weight gaindepressioncold intolerance, and constipation. 

Unfortunately, many hyperthyroid patients live in a state of relative hypothyroidism because of their dose of thyroid-blocking medication. 

This often leads to a lot of confusion on the part of the patient (for good reason) as well as residual symptoms that negatively impact their quality of life. 

This doesn’t happen to everyone, mind you, because your doctor will try to adjust your dose to an ideal level. 

A level that brings your thyroid back to “normal” while blocking any extra thyroid hormone. 

As a hyperthyroid patient, you’ll know that this is no easy task as your doctor is often constantly adjusting your dose up and down to try and find the right level. 

If you are one of those people who struggle to get your thyroid medication just right then add-back therapy may be the answer for you. 

Add back therapy, sometimes referred to as “block and replace” (2), opens up the door to another way to manage hyperthyroidism, especially Graves’ disease. 

The logic behind this treatment is simple:

You will both simultaneously block thyroid function with an anti-thyroid medication while also taking extra thyroid hormone with thyroid medication. 

In other words, you will use two medications at the same time both of which counteract the other. 

Does Add Back Therapy Work?

Even though it doesn’t intuitively make sense that you should use two medications that counteract one another, in the real world it can actually work. 

Here’s why:

Because of the way that anti-thyroid medications work, it’s actually easier to dose them using higher doses than lower doses. 

This means that your doctor can put you on a relatively higher dose of methimazole than you might need which acts to block most of the thyroid hormone and function in your body. 

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Then at the same time, your doctor can provide you with bio-identical thyroid hormone (in the form of levothyroxine or another thyroid medication) to increase your thyroid up to an ideal level. 

Why does it work?

For starters, doctors have a lot more experience in using thyroid medication than they do thyroid blocking medication. 

Because of this familiarity, you will probably end up feeling better using both medications than just thyroid blocking medication by itself. 

Again, the data is still unclear but some studies have shown several benefits to using add-back therapy. 

Potential benefits may include:

  • Assist with the reversal of Graves’ disease (highly controversial)
  • It may help delay permanent hyperthyroid treatments such as radioactive iodine ablation and thyroid surgery
  • May improve quality of life and symptoms
  • May improve compliance with medications

So, does add-back therapy work? 

It would appear that it certainly works for some people, especially those who have trouble optimizing their dose of methimazole. 

But even if it does work, does it make sense for all hyperthyroid patients to use it? Are there better options available? 

I’m going to make the argument that there might be in just a few minutes. 

Does Add Back Therapy or Block & Replace Help Put Graves’ Into Remission?

One of the main reasons to use anti-thyroid medications like methimazole is to try and give your body enough time to naturally put Graves’ disease into remission. 

If you think about it, why don’t doctors just immediately cut out the thyroid gland or ablate it with radioactive iodine once they know you have a diagnosis of hyperthyroidism?

The answer is they don’t want to do something permanent if they don’t have to. 

So instead of using those permanent options, your doctor will recommend that you take methimazole for some length of time (usually a few years (3)). 

Your doctor knows that a certain percentage of patients with hyperthyroidism will spontaneously experience remission (4) of their Graves’ disease and no longer need any treatments. 

The number of patients with Graves’ disease that experience spontaneous remission varies anywhere from 10% to 40% depending on which study you look at. 

Any other patients which don’t experience remission can then undergo further permanent treatments as needed. 

This is why methimazole is so important. 

It really buys you extra time as a hyperthyroid patient. 

And while you are taking methimazole you should be doing everything in your power to increase the chance that you can put your hyperthyroid state into remission (because the permanent options should be avoided if possible). 

It’s not exactly known why certain patients experience spontaneous remission of their Graves’ disease but there are ongoing tests and studies to try and figure that out. 

It’s been suggested and shown by some researchers that using levothyroxine (add-back therapy) in combination may increase your odds of putting Graves’ disease into remission. 

There are some studies that show this benefit and others that do not, so it doesn’t look like we know for sure whether it is helpful. 

But even if it’s the case that add-back therapy doesn’t help you put Graves’ into remission, it’s still probably worth trying it out if you are suffering from symptoms that impair your quality of life. 

Should You Consider Add Back Therapy If You Have Graves’ Disease?

Add-back therapy is definitely a good option for some patients with hyperthyroidism but the question is who should try it?

Given that there isn’t much risk in adding an extra medication to your existing regimen, I would say that it’s a great potential option for many patients with hyperthyroidism and Graves’ disease. 

But if you are still on the fence or if you just want to minimize your exposure to medications then here are some guidelines. 

You can consider add-back therapy if:

  • You are currently having trouble managing your dose of methimazole (5)
  • You are experiencing negative side effects caused by methimazole such as liver damage
  • The symptoms you are experiencing from your methimazole dose cause you to miss or skip doses. 
  • You want to try and prevent radioactive iodine ablation or thyroid surgery for as long as possible. 
  • You need a high dose of methimazole to keep your thyroid in check.

Here are some reasons you may not want to try it:

  • Your doctor isn’t familiar with the therapy or doesn’t want you to try it. 
  • You already have trouble remembering to consistently take your dose of methimazole each day. 
  • Your thyroid is perfectly normal while taking methimazole and you are not experiencing negative side effects from that medication. 
  • Your dose of methimazole is already very small. 

Regardless of which option you should, I would still strongly suggest that you take time to look into additional therapies that can be added to your dose of methimazole. 

These additional therapies are probably much better than add-back therapy because they may increase your shot of remission. 

A Better Option: Try to Put Graves’ Into Remission on Your Own

You can spend a lot of time thinking about whether or not you should consider add-back therapy or block and release therapy but at the end of the day, it doesn’t really matter. 

The single most important thing you can do as a patient with Graves’ disease (but this also applies to some cases of hyperthyroidism) is do whatever you can to try and put your disease into remission. 

Even though it’s so important, it’s often not discussed between doctors and patients. 

Here’s why:

We don’t have a lot of evidence to suggest that there is a guaranteed way to put Graves’ disease into remission and the information we do have suggests that it may only be possible for certain people. 

But does that matter? Should it impact whether or not you try?

Not at all!

The idea that a therapy MUST work in order for you to try it is a silly one. 

Instead, you should think about a treatment in terms of its cost vs reward. 

In the case of natural treatments for Graves’ disease, the rewards are potentially very high and the risks are virtually zero. 

At least for the treatments that I would recommend that you consider. 

For starters, here’s a list of things that you can do that may (keyword may) help:

  • Change your diet to eat healthy whole foods while avoiding the “western diet” (6) – There are many diets that can help improve your overall health and potentially help put Graves’ into remission. The AIP diet is popular among patients with Graves’ disease but other diets such as the ketogenic diet, the carnivore diet, the paleo diet, the gluten-free diet, and whole 30 may also work. There are many options to choose from and the key to success is picking one and sticking with it. Healthy whole food diets such as these may help lower inflammation, improve your gut health, and provide your body with the nutrients it needs to function optimally. 
  • Exercise regularly – Are you exercising regularly? If not you should be. Exercise helps balance your immune system (7), reduces stress, and keeps your hormones at healthy levels. You don’t have to get fancy with your exercise routines, either, just staying active 3-5 times per week can make a big difference. 
  • Take Vitamin D – Low levels of vitamin D may increase your risk of developing autoimmune conditions and we know that patients with Graves’ disease have lower vitamin D levels (8) compared to healthy controls. Taking vitamin D won’t necessarily “cure” your Graves’ disease but it is important for other processes in your body including thyroid function. Increasing your vitamin D is simple with the right supplement. 
  • Consider other supplements – Other supplements such as zincseleniumprobioticsfish oil, and magnesium can be considered basic hyperthyroid supplement staples. Many hyperthyroid patients don’t have enough of these vitamins and they can easily be replaced with some simple over-the-counter supplements. 
  • Improve your gut health – It’s been said that all disease begins in the gut, which is probably not entirely true, but the adage does carry some weight. Your gut plays an important role in regulating your hormones, immune system, and overall health. If you are experiencing any symptoms such as gas, bloating, constipation, diarrhea, acid reflux, or any other gut-related condition then that’s a sign that something is not right in that area and should be addressed. 
  • Manage your stress levels – Easier said than done, I know, but managing your stress is very important. The stress hormone cortisol impacts inflammation and the immune system and may be at the heart of many autoimmune diseases (9). Managing your stress may not reverse your condition but it may prevent things from getting a lot worse. 
  • Get quality sleep – Not getting enough sleep can wreak havoc on your entire body ranging from your hormones to your immune system. And since the immune system is the primary driver of Graves’ disease it makes sense that you should get more sleep. 

These are really just a few simple things that you can get started with right away. 

And guess what? They can safely be added to methimazole or to levothyroxine if you are opting to use block and replace. 

The only downside is that we don’t know how these treatments are at putting Graves’ disease into remission but we do know that they have worked for other patients out there. 

And when it comes to thinking about whether or not they are worth it, because the risk is virtually zero and the potential benefit is the prevention of permanent thyroid gland damage, it’s obvious that you should at least consider them. 

No matter how you look at it, eating more whole foods, getting more sleep, and exercising more regularly are things that both conventional and natural doctors can get behind. 

The question is, does it make more sense to do research on something like block and release while not also paying attention to these treatments?

Not really. 

If you are already spending the time to be an informed patient then you might as well continue on learning. 

Final Thoughts

Add back therapy or block and replace is a way for certain hyperthyroid patients to better manage their hyperthyroidism. 

This treatment paradigm allows you to further refine your thyroid lab tests with another input. 

Even though it doesn’t intuitively make sense to use both a thyroid-boosting medication and a thyroid-blocking medication, there are situations where it works. 

Two of the most common situations in which add-back therapy makes sense are in those hyperthyroid patients who have a hard time managing their dose of methimazole and in those who are trying to prevent radioactive iodine ablation and thyroid surgery. 

Even if you do decide to use this treatment just remember that there are other things you can do that may help you put your disease into remission. 

And doing that is more important than anything else. 

Now I want to hear from you:

Is this the first time you’ve heard of add-back therapy or block and replace?

Have you tried this type of treatment before? 

If so, what type of results did you see? Did it help?

Are you planning on making a concerted effort to add treatments designed to increase your odds of putting your disease into remission?

Leave your questions or comments below! 

#1. frontiersin.org/articles/10.3389/fendo.2020.560157/full

#2. pubmed.ncbi.nlm.nih.gov/31713721/

#3. ncbi.nlm.nih.gov/pmc/articles/PMC149254/

#4. ncbi.nlm.nih.gov/pmc/articles/PMC6435849/

#5. ncbi.nlm.nih.gov/books/NBK545223/

#6. ncbi.nlm.nih.gov/pmc/articles/PMC4034518/

#7. pubmed.ncbi.nlm.nih.gov/29108826/

#8. ncbi.nlm.nih.gov/pmc/articles/PMC4446781/

#9. pubmed.ncbi.nlm.nih.gov/18190880/

using both methimazole and levothyroxine to treat graves' disease

About Dr. Westin Childs

Hey! I'm Westin Childs D.O. (former Osteopathic Physician). I don't practice medicine anymore and instead specialize in helping people like YOU who have thyroid problems, hormone imbalances, and weight loss resistance. I love to write and share what I've learned over the years. I also happen to formulate the best supplements on the market (well, at least in my opinion!) and I'm proud to say that over 70,000+ people have used them over the last 6 years. You can read more about my own personal health journey and why I am so passionate about what I do here.

P.S. Need more help? Check out my free thyroid downloads and resources.

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