What is the Best Thyroid Medication? Use this Guide to Help Find Out

What is the Best Thyroid Medication? Use this Guide to Help Find Out

Feel confused on which thyroid medication you should be on? or which one is the best?

You're not alone...

There are many people out there willing to tell you what worked best for THEM.

But that's just it - it's what worked for them.

And it's not necessarily what will work for YOU. And that's what matters the most.

I can tell you that from working with hundreds of patients I am still surprised at how much medication certain patients need, or what type of medication they do best on.

Through this trial and error I've come up with some guidelines that I use on my patients that you can use to find the best type and dose of thyroid medication for YOUR body.​..


Is There a Best Thyroid Medication?

It turns out the answer is not that simple. 

If you start reading around on the internet you will probably find most people talking up Natural Dessicated Thyroid as the best medication around.

And that if you don't tolerate this medication or it isn't working for you it's because of some other problem in your body​. 

​I even fell victim to this trap early on in my career. 

But after treating so many patients I can tell you that some people just do NOT respond well to medications containing T3 or natural dessicated thyroid medication of ANY type.

​And these people shouldn't feel bad about it, they just need some guidance from an experienced physician to help find the right medication for them...

But the question is:

How do you do that? ​

​Finding the Right Medication for YOUR Body

​When I am evaluating a new patient there are several factors that I use in helping me determine which medication to start with, how to dose that medication and how often to follow up. 

​Even with these factors I still come up incorrect and I have to go back to the drawing board. 

In the end the best way to determine your type of medication and dose is a combination of Trial and Error that is guided by your laboratory results.

It's also important to use family history and personal history as well.

Let me give you some examples...

​Patients who should consider using NDT (Armour thyroid, Naturethroid, WP-Thyroid, etc.) medications:

  • Patients who have not felt better on T4 only medications like Synthroid, Levothyroxine or Tirosint
  • Patients with mild weight problems (10-20 pounds overweight)
  • Most patients who have not been on thyroid medication before
  • Patients with Low Free T3 and Low Free T4 Levels with relatively normal Reverse T3

Patients who should consider using T3 (Cytomel, Liothyronine, SR T3) only medications:

  • Patients with high levels of Reverse T3 (>15) or thyroid resistance
  • Patients with Leptin Resistance
  • Patients with Diabetes, Prediabetes or Insulin Resistance
  • Patients with extremely low body temperatures (< 97 degrees)
  • Patients with a personal history of bipolar disorder or a strong family history of mental health disorders
  • Patients with a personal history of Fibromyalgia or Chronic fatigue syndrome
  • Patients who have failed both T4 medications and NDT medications

Patients who ​should consider using T4 only (Synthroid, Levothyroxine, Tirosint, etc.) medications: 

  • Patients who find NDT too stimulating
  • Patients with Normal Free T3 levels and Normal Reverse T3 levels
  • Patients who experience palpitations on T3 medications regardless of the dose
  • Patients who are extremely sensitive to all other medications and supplements

​Generally I prefer to start patients off on Natural Dessicated Thyroid unless their history suggests that they will do much better on T3 only medications. 

In my practice the breakdown of medication goes something like this:

  • 60-70% of people do the best on NDT
  • 20-30% of patients do best of T3 only medications
  • 5-10% of patients do the best on T4 only medications

​It's unusual to find someone that does better on T4 only medications, but it definitely does happen. 

Dosing and Starting NDT

If you're like most people (about 60-70%) then NDT may be the right medication for you.

​Your starting dose really depends on the degree of your symptoms, how sensitive you are to medications and if you are switching over from levothyroxine. 

It's always best to start low and titrate up slowly over time to prevent side effects like palpitations, insomnia and hyperactivity. 

​In general a starting dose may be as low as 16.25mg of WP-Thyroid/Naturethroid or 15mg of Armour thyroid, and up to 60-65mg/day.

The more sensitive (or older) the patient, the slower you should increase the dose.

​I will often have patients slowly increase the dose by 16.25mg every 10-14 days on their own and recheck labs/symptoms/heart rate/basal body temperature at pre determined intervals. 

​What to Expect

Up to 15-20% of people may feel an IMMEDIATE improvement in their symptoms right after starting NDT.

Patient case study on naturethroid and AIP

​The patient above was one of those - she felt better immediately upon switching to naturethroid and continued to notice improvement with each interval increase in dosing. 

You can read her entire case study here.

​For the other 80% or so of patients it may take up to 1-4 months before you start to notice serious improvements in your symptoms. 

Most patients by the 4-6 week mark begin to notice changes, but the full effects may not be realized for several months.

​Still, some patients will notice an immediate improvement in symptoms upon starting NDT but the benefits will quickly fade - usually around the 2 week mark. 

This is why I recommend increasing the dosing every 10-14 days to prevent this from happening. ​

If you fall into this category it doesn't mean that NDT is the wrong medication for you, instead it might mean you need MORE medication. ​

When transition over from Levothyroxine I recommend starting lower but titrating up more quickly:

  • 50 mcg of Levothyroxine -> Start with 1 grain and titrate up by 16.25mg
  • 100 mcg of Levothyroxine -> Start with 1.5-2 grains and titrate up
  • 150mcg of Levothyroxine -> Start with 2-3 grains and titrate up quickly

​Quick titration will help offset the lower amount of T4 in these medications while still preventing the side effects from increasing T3 levels quickly (heart palpitations). 

When you should consider switching medications

Not everyone will do well on NDT.

​Patients who do not tolerate NDT will present with one or more of the following symptoms:

  • Racing heart or palpitations
  • Jittery sensation
  • Increased fatigue
  • Headaches
  • Insomnia
  • Increase hair loss

​If you experience these symptoms before reaching your optimal dosing (meaning your basal body temperature is still low, your lab tests are suboptimal or your heart rate is continually low) then you are likely not tolerating the T3 in the medication. 

​For these patients it's reasonable to switch to another brand of NDT to see if the symptoms subside, but for some patients they may actually need T4 only medications. 

Side effects to watch out for

​If used in the right doses you should NOT experience adverse side effects. 

Remember that NDT is bioidentical to the hormones that your thyroid creates.

As long as you are replacing what your body is deficient in you should not have negative side effects.

If you do, it may be due to cellular sensitivity, untreated adrenal fatigue or untreated iron deficiency. ​

Do you need T3 in addition to your NDT?​

Are you doing well on NDT but feel like you could still improve?

If you fall into this category then it may be time to consider adding additional T3 to your current NDT dosing.

Many of my patients feel the best when combining NDT + T3.

Dosing ranges from 1-2 grains of NDT + 12.5-37.5mcg of T3.

​Using this combination allows for the benefits of NDT (instead of switching to compounded T4 + T3 preparations) while still increasing the amount of T3. 

These combinations work especially well for patients who have undergone a thyroidectomy because most are treated with T4 only medications!​

Dosing and Starting T3 Medication

T3 only medications are probably my favorite to start patients on. 

T3 is the ACTIVE hormone in the body and therefore the most potent of thyroid medications that you can get. 

Now let me be clear: 

Not everyone tolerates pure T3, but for those that do - it can be life changing. 

Because T3 is more powerful the dosing you should start out with should be lower.

I've found that patients with weight loss resistance, leptin resistance and insulin resistance seem to tolerate higher doses of T3 without many side effects.

If patients have been on NDT in the past they also seem to tolerate T3 much better than thyroid naive patients.

Typical starting doses for non sensitive patients:

​10-12.5mcg x10 days, followed by 20-25mcg x10 days, followed by 30-37.5mcg x 1 month. 

Whenever using T3 containing medications ALWAYS follow the resting heart rate and basal body temperature.

Basal body temperature when hypothyroid

Do not let your resting heart rate exceed 90. ​

Resting heart rate while on T3

​What to Expect

​Again as many as 20% of patients might feel an immediate reduction in symptoms when taking T3 including: increase energy, reduced brain fog, improved weight loss, decreased hair loss, etc. (see more symptoms of hypothyroidism here). 

​For those taking T3 for weight loss you should notice an improvement in your weight in 1-2 months. 

For those taking T3 for insulin resistance you should notice an improvement in glucose levels in ​1-2 months. 

For those taking T3 with GLP-1 Agonists for Leptin resistance, you should notice weight loss in 1-2 months.

​The other 80% of patients will notice an improvement in symptoms over 2-4 months as the dose is titrated up. 

When you should consider switching medications

​The most common side effect I see from T3 containing medications include:

  • Headaches (#1 by far)
  • Palpitations/racing heart
  • Hair loss (Too much T3 can cause rapid hair turnover and hair loss)
  • Insomnia
  • Inability to exercise due to high resting heart rate

​If you experience any of these side effects consider lowering your dose or switching to NDT. 

Side effects to watch out for

To prevent the side effects listed above I recommend following basal body temperature and resting heart rate. 

If you base dosing off of these parameters then you should NOT experience negative side effects. 

If you are unable to alleviate your symptoms due to side effects then you should consider switching medications. 

Do you need SR T3? ​

Many patients do need T3 containing medications but may experience heart palpitations.

Palpitations and racing heart come from the effect of T3 on the heart.

T3 has direct effect on the heart which leads to an increase in the heart rate which some people feel as palpitations.

This occurs when blood levels of T3 hormone increase rapidly.

To prevent this side effect you can try taking SR T3 which allows for slower absorption into the body and therefore more sustained levels of T3 in the blood (no immediate rise).

This is usually enough to prevent palpitations.

Dosing and Starting T4 only Medication

Believe it or not some people actually do quite well on T4 only medications!

I am not going to touch on this point very long because most of these people are satisfied with seeing their PCP or endocrinologist simply because the medication is working. 

It is worth pointing out that some people who have done well on T4 medications might do even better by adding a little extra T3 to their dosing. 

Doses as small as 10-20mcg per day can seriously reduce symptoms and improve quality of life in many patients. 

What's better is that some endocrinologists and GP's are actually receptive to adding liothyronine or cytomel to your regimen. 

You will have much better luck in asking for liothyronine than asking to switch medications to NDT or pure T3 in this setting. 

​What to Expect

If T4 works for you (about 5-10% of the population), then you will notice an improvement in symptoms within 1-4 months after starting the medication.

I've found that T4 only medications tend to take longer to take effect and some patients don't give them enough of a chance.

If you've been on T4 only medications for more than 6 months and have not noticed a difference in your symptoms then that's a good indication it may not be the right medication for you!​

When you should consider switching medications

​Patients should consider switching to NDT and/or T3 if they have any of the following signs or symptoms: 

  • Weight gain after taking levothyroxine or synthroid
  • Increased Reverse T3 levels
  • Worsening symptoms of hypothyroidism
  • Increased hair loss (especially after starting T4 only medications)
  • TSH > 2 despite being on medication
  • Low Free T3 and low Free T4 levels despite being on medication

​If you fall into these categories don't waste time with a physician who isn't willing to work with you. 

There is a chance you might feel COMPLETELY better on T3 containing medication and life is too short to feel terrible forever!

The Bottom Line

Finding the right type and dose of thyroid medication is HIGHLY individualized. 

Please, please, please avoid the pitfall of asking what worked for other people and trying that. 

No two people are alike and the thyroid is much more complicated than that!

It's best to work with a knowledgable physician who can help guide you through this process but realize that there is a big component of trial and error. 

​In general most people that will be reading this blog will do better on some form of T3 medication. 

For many of you that means either T3 only or a combination of NDT + T3.

​And now... having said all of that...

I want to hear from you!

What medications have you tried? What has worked, what hasn't?

Leave a comment below and I will respond!​

Westin Childs

I’m Dr. Childs and I write these posts. I’m a physician that specializes helping patients lose weight, have more energy and FEEL better. My practice focuses on hormone imbalances, thyroid issues and weight loss resistance. My goal is to provide the BEST information out there on the internet that is both actionable and trustworthy. Get my free 3 day meal plan here. You can also find more about my personal journey back to health here.

Click Here to Leave a Comment Below 86 comments