What is Resistance caused by RT3

When we talk about "resistance to thyroid hormone" we are talking about people that don't
respond properly to Thyroid Hormone supplementation and appear to have hypothyroid
symptoms despite being on thyroid replacement and having normal blood test results.
One of the most common causes of this lack of response to the thyroid hormone is something
called "Reverse T3" (RT3).
At a very basic level thyroid hormone is made of iodine among other things and the numbers that
are talked about (T4 and T3 etc) represent the number of iodine atoms in the molecule.
T4 is the main hormone that is produced by the thyroid gland and supplemented "Synthroid,
Levoxyl, Thyroxin etc", This hormone is totally inactive biologically and it's only after an iodine
atom is removed making it into T3 that it has an effect on the body.
T4 is a storage hormone and lasts for weeks in the body, T3 is the active one that deiodinates to
T2 and then further to T1 which also have metabolic activities of their own. T3 has a life of a
few days in the body.
T3 is a catalyst that the body needs for it's chemical reactions to progress at the right speed,
without enough of it people are cold, tired, and lethargic.
Reverse T3 (RT3) is what is made when the "wrong" iodine atom is removed from T4, it's a
"mirror image" molecule to T3 and is not bio-active. This in itself is not a problem, the problem
is that in excess it "fits into the T3 receptors" and gets stuck there blocking the action of T3 on
the body. This means that your body doesn't respond properly to T3 leading to hypothyroid
symptoms despite a normal TSH and normal T3 and T4 levels in the body. This is what we refer
to as "Tissue Resistance to Thyroid Hormone". Doctors will tell you this is very rare, this is
because they don't look for it!!
Fortunately there are ways of treating it and people can recover and feel well again

What are the symptoms of RT3 problems

The main symptom of RT3 issues is that of hypothyroidism that won't respond to treatment. If
this sounds a bit like Chronic Fatigue Symptom then that's not unduely surprising.
Unless you have a very clued up Doctor this disgnosis will probably get missed. It can by picked
up by blood tests, but only if they do the right ones and then interpret the results correctly.
It;s interesting that two "modern diseases", Chronic Fatigue Syndrome, and Fibromyalgia only
started being diagnosed in the 1970s. This was the time that the Thyroid Stimulating Hormone

(TSH) test came to be accepted as the "gold standard" for thyroid diagnosis. This so called "Gold
Standard" is really a "tarnished brass standard" as it has hed to generations of people that could
have been helped being written off as "normal" without treatable conditions being diagnosed and
treated.

What do you mean by "Tissue Resistance"

Tissue resistance to thyroid hormone is just what it says it is, there are normal amounts of Free
T3 in the blood and yet the body behaves as though it's hypothyroid. This is often caused be
Reverse T3 blocking the Receptors on the cells that the T3 should stimulate.
There are causes of this other than RT3 but treating resistant hypothyroid people with Natural
Thyroid (Armour Etc) or systhetic T4 leads to large doses being given. This leads to excess
levels of Free T4 and that in turn leads to RT3 being produced and resistance building up. The
only successful way I have heard of to treat people with other resistance is to use T3 only. I have
some other form of resistance as well and had to increase my Armour dose every year until I was
up at 12 grains. On T3 I have been on a constant dose for 6 months now, I am stable at last.

How is it diagnosed
The initial diagnosis tends to be "the normal things don't work, what's happening". If someone
has a low but stable temperature (stability indicating that adrenals are behaving), iron labs at a
satisfactory level, and a Free T3 (FT3) near the top of the range then they may well have a RT3
issue. Their temperature should be normal with the rest of the things right. (updated 10/10)
It can be diagnosed accurately by the ratio of Free T3 to Reverse T3. Once they are in the right
units (the units used by labs differ so some have an FT3 range of 230 to 450 whereas others
might have a range of 2.5 to 4.5) then the ratio of Free T3 divided by reverse T3 should be 20 or
greater. If it's less then that you have a RT3 problem. If it's vastly smaller or larget you may have
to move the decimal point to get the units right. There are some worked examples here (updated
10/10)
If you only have a T3 reading rather than a FT3 reading then the ratio of T3 to RT3 needs to be
10 or greater.

How is it treated
The treatment for too much RT3 involves stopping more being made and waiting for what's in
the body to decay or be excreted.

This is relatively easy but there are pitfalls along the way. A lot of Drs are worried by people
doing this as things happen too quickly to be done by lab tests, patients need to adjust dose by
symptoms and vital signs.
RT3 is only made from T4. If you get rid of T4, both from your own thyroid and from
supplements, then no more RT3 gets made. In order to do this and stay alive an alternative
source of the bio-active T3 is needed and this is readily available in the form of synthetic T3
hormone.
The basic treatment is to stop all meds containing T4 and start T3 instead, The dose of this is
slowly increased week by week as the T4 levels in your body diminish. After 6 weeks or so the
T4 and RT3 levels in your blood will be very low. You need to keep going longer than this
though as it takes around 12 weeks for the RT3 to clear the receptors as well.
During this time you may not be able to take enough T3 to fully clear hypo symptoms though
some people may feel pretty well at this stage. It all depends on hy hypo you were, how high the
T3 and RT3 levels were, and your iron and adrenal status. We do not recommend going above
125 of T3 during this clearing process, there is no improvement in clearance achieved with a
larger dose, provided there is enough to suppress TSH and stop T4 production then clearance
will occur. (updated 10/10)
If the T3 you are taking does clear most hypo symptoms and you had high in range or over
range RT3 levels then be prepared to drop the amount of T3 you are taking when resistance
clears. This can be dramatic and you can end up needing half what you needed the day before
when the resistance clears. This is one of the reasons that you need to go by symptoms and
pulse/temperature, things happen too fast to base it all on lab numbers. (updated 10/10)
You can of course keep the dose lower and put up with feeling hypo for longer, when it clears
you simply end up feeling less hypo. Dosing at this time is a compromise between symmptoms
and the effect when clearing and we do not recommend going above 125mcg of T3.

What are the causes of RT3

The body naturally produces some RT3 and this isn't a problem in most people. The problem
arises when the ratio of FT3 to RT3 sinks too low as the RT3 then gets in the way of the T3 that
we need to function causing hypothyroid symptoms.
There are several causes for this ratio getting disturbed, the principal ones that we know of are:

Extreme dieting, the RT3 increases to slow the metabolism and make better use of the
available food
Low Iron (including Ferritin)
High cortisol, this disturbs the balance of the thyroid hormones
Low cortisol, this again disturbs the balance of the thyroid hormones
Insulin dependent Diabetes

Low Vitamin B12 levels

Graves disease or other causes of being Hyper Thyroid (New 10/10)
Other forms of thyroid resistance causing heavy supplementation of thyroid Meds (new
10/10).

In addition to these common causes there are a large list of causes which I have copied from here
Ageing [12]
Burns/thermal injury[63]
Caloric restriction and fasting[64-66]
Chemical exposure[67]
Cold exposure[68]
Chronic alcohol intake[69]
Free radical load[30]
Hemorrhagic shock[70]
Insulin-dependent diabetes mellitus[71]
Liver disease[31]
Kidney disease[72,73]
Severe or systemic illness[74]
Severe injury[76]
Stress[77]
Surgery[15,78-80]
Toxic metal exposure[26-29

I am already on Thyroid treatment, do I need

to change it
If you are on synthetic T4 medication such as Synthroid or Natural Desiccated Thyroid such as
Armour you will need to change your medication as these all contain T4 and all the time you
have T4 in the body it will carry on making RT3 as well as T3.
Changing over to T3 only, and adding enough to suppress your own thyroid's production of
hormone, eliminates T4 from the body. Without T4 no more RT3 can be made and hence if you
wait long enough the RT3 circulating in your body will decay or be excreted and you will greatly
improve the ratio. After around 12 weeks the remaining RT3 that is "stuck in the T3 receptors"
also clears and resistance greatly reduces.

What is this T3 medication?

T3 only medication is the main bio-active thyroid hormone. Brands include Cynomel (Mexican),
Cytomel (American), or Tertroxin (UK). The Chemical names for this are Liothyronine

sodium or triiodothyronine. This Wikepedia article gives you more information on what T3 is.
There is also more information here and here
Changing over to T3 only, and adding enough to suppress your own thyroid's production of
hormone, eliminates T4 from the body. Without T4 no more RT3 can be made and hence if you
want long enough the RT3 circulating in your body will decay or be excreted and you will
greatly improve the ratio.
Fairly early on the lab tests will show a great reduction in RT3 but don't hurry to change back to
Armour or T4 as it takes longer to clear the T3 receptors that are blocked up with RT3.
It typically takes 12 weeks of T3 only for this to happen and then the results are sudden, you can
find overnight that you need to drop your medication almost completely for a day or two and
ramp back up again to around half the level that you needed before to stop feeling hypo.
I will talk more about dosage on the next question.

How much T3 do i need?

This is where it starts to get delicate. If you've stayed with me so far you may have thought "this
sounds like it could be me, I want to try that". You have sold the idea to your Dr and then he says
"I don't know how to dose this". Some of us gave up with the Dr and have imported the T3 from
overseas and self medicate, even if you can get the prescription it can be cheaper to buy T3 that
way then from a USA Pharmacist.
First of all, BEFORE starting T3, we strongly reccomend that you have a full iron panel,
guidance on the required iron levels is here but feel free to post the results on the RT3 Yahoo
group and ask for interpretation (updated 10/10) and you graph your temperatures for a few days
looking for the average to be within 0.2F from day to day. If temperature has a greater variation
than that you need Adrenal support, a 4 times a day saliva test before you start supplementing
would help people advise you of the doseage and timing to follow. Click here for discussion on
adrenals That link includes details of the temperature test and links to adrenal information and
lab tests. Please read it BEFORE starting T3. (updated 10/10)
If your Iron is a bit low you can start T3 and supplement iron at the same time aiming to get iron
to the required levels by the time your T3 has got up to 50mcg a day. If your iron is very
low you will need to supplement iron heavily and may get adverse effects on taking more than a
very small amount of T3. (updated 11/10)
OK, Warnings over, onto the T3 dosing.
The starting dose depends whether you are on any thyroid replacement already and whether that
contains T3 or not:-

If you are not on any thyroid replacement or are on Synthroid, Levoxyl, Oroxine, Levothyroxine,
Eltroxin Thyroxine, or any other med containing T4 then click here
If you are already on Armour, Naturethyroid, or anything else containing T3 click here
Once you get started you are going to need to increase frequently for the first couple of months.
This is because you are chasing the decay in your T4 levels, and hence the reduction in your own
T3 production with the increase in applied T3. Click here to help decide if you need an increase
Most of us need to spread the T3 out, not because it won't stay at a steady enough level in the
system, but because it "uses up" Cortisol getting into the cells and if your body cannot produce
Cortisol fast enough then temperature drops and you slump.
This typically involves doses 4 or 5 times spread through the day. I use a simple way of keeping
track whether I have missed a dose, I count out the number of tablets I am planning to take that
day into an empty bottle and carry that round with me dosing from that bottle. If I am in doubt
how many I have taken I just count how many are left and work it out from there. I also keep a
few spares in my car and my computer bag, just in case I go out forgetting "the bottle"
My dosing times are:7am
10am
1pm
4pm
Bed time as I put the light out.
When you start at a low dose the 25mcg tablets break into quarters with care your initial dose
increases can be by filling in blank time slots.
Once they are all filled in with quarter tablet doses you can start increasing them to half tablet
doses one at a time starting with the morning dose.
Once you are on half a tablet at each slot again you can start increasing to a while tablet at each
starting in the morning.
I was very dubious about the bedtime dose, and many people on the Yahoo group have expressed
doubt. In my case it's because I was on Natural Thyroid and found that if I took that later than
2PM it affected my sleep. T3 does not have this effect with me, in fact it improves the quality of
my sleep by helping me sleep better and have less disturbed nights than I was on Natural.

Following the pattern of increases that I've talked about here and going up initially by 6.25 every
3 to 5 days and then by 12.5 every 5 to 7 days (depending on whether you feel you need/can
tolerate an increase) you will probably end up on around 75mcg at around the 8 week mark. By
this time your T4 levels will have decayed to an insignificant level and you will be able to adjust
dose every 3 to 5 days to try and clear hypo symptoms.
Warning, one of our readers who tends towards high cortisol found that she was never able to
tolerate more than a 6.25mcg rise per week. You may have to keep raising in 6.25mcg
increments if you find 12.5 is too much. It varies a lot between people.

Most people end up needing a dose of 75 to 125mcg of T3 AFTER their resistance has cleared. If
they have severe resistance and increase the dose to clear hypo symptoms in this "waiting time"
then they could end up twice that dose and not be hyper. If you go above 75mcg a day in this
interim period be very careful to check pulse every morning, especially after 10 weeks, as you
may suddenly find resistance clearing and end up hyper with a high temperature and fast pulse.
If this happens then drop your dose to nothing or maybe a quarter of what you were on and take
your pulse each time you would have taken a tablet, if it's high skip it, if it's near normal then
take half what you would have done normally.
You will be going through the dose finding process again but this time without T4 in the way so
you should be able to find a stable place within a week or so at somewhere between half and 2/3
of what you were on before to feel "non-hypo". This should be a long term stable dose needing a
little adjustment between summer and winter but no other changes due to your body.

Interactions
T3 is a pretty benign medication in terms of taking it with other things. You can also take T3
sublingually and this avoids any interaction. The Grossman Cynomel is easy to take like this.

The absorption does not vary as much when you take it with food as T4 meds do so you
seem to be able to take it with food OK.

There is no interaction with Hydrocortisone, you can take it at the same time if you are
on HC.
Iron does affect absorption, although T3 absorbs MUCH faster than Armour or T4,
Taking iron even an hour after T3 is fine but at least 4 hours before the next dose. It takes
about 4 hours to absorb the iron so it is not waiting in the digestive tract to disrupt the T3.
So T3 1 hour BEFORE Iron or 4 hours AFTER iron. Vitamin C may be taken with
Iron, other things should be separated.
You can take T3 1 hour BEFORE calcium or three hours AFTER it. The Calcium in a
multivitamin is normally too low to be a problem

Which brands of T3 are the best

There appears to be a significant variation in the apparent strength between the various brands of
T3 medication. This is probably due to differences in absorption in the body rather than
differences in the amount of hormone in the tablet. A few brands that we know of and comments
on them are:

Cytomel made by King Pharmaceuticals. This is the main branded T3 drug in the USA
against which others are compared. It is available in 5mcg, 25mcg and 50mcg doses
(splitting the 50mcg tablets can be a way of saving money).
Generic Cytomel by Paddock. The reports from people on this generic are that they need
more than when they were on branded Cytomel. One report indicated a 15% difference.
Generic Cytomel by Mylan, again reports are that it is subjectively weaker than King
Pharmacuiticals brand. (updated 10/10)
Cynomel (Spanish spelling) from Mexico. Manufactured by Grossman Laboratories and
available for private importation from some mail order pharmacies. This is very
competitively priced and is reported to be as strong as Branded Cytomel but at a fraction
of the price. The 25mcg tablets are scored in half and can be quartered with care. This is
our "best buy" recommendation
Cynomel from Aventis France. Another brand of cynomel. This is reportedly weaker than
the branded Cytomel but is several times the price or Grossman Cytomel. It can be good
for starting off on as the tablets are larger than the Grossman and are scored in quarters. It
is expensive to remain on long term.
Tertroxin (UK and Australia). This is available in 20mcg tablets. It is reportedly weaker
than branded Cytomel or Grossman Cynomel
Generic T3 made by Goldshield, has had good reports from one of our readers. It is not as
cheap as the Grossman but worked well for her.

Val gave me this report on the various brands she's tried.

Strengths of T3 brands.. OMG I have tried almost all of them. Cynomel
from Aventis is pretty weak.
Tryotex from Mexico is a total waste of money,
UniPharma T3 is VERY weak,
Geneza Pharmaceuticals T3 is about the same as Unipharma,
Tiromel from Turkey is about the same as Aventis Cynomel.
LA Pharm T3 is OK and cheap but weaker than cynomel and about the same as Tertroxin form
the UK,

So from strongest to weakest:Cynomel Mexico (Grossman)

Cytomel USA (branded)
Tertroxin UK
LA Pharma (not sure where from)
Aventis Cynomel
others not worth buying!

Temperature and what it means

Body temperature is what brought a lot of us to the information on Thyroid and Adrenal function
that's on the Internet.
Most doctors are in total denial, they will say "some people just have a low temperature, it
doesn't mean anything" and "only a high temperature means anything".
In fact, as Broda Barnes established a long time ago, temperature, in particular the "basal
temperature" is a very strong marker for low thyroid. Basal temp is one you take first thing in the
AM before moving., when you first wake. It SHOULD be lower than your daytime temps. You
can take basal temps orally or axially (under the arm, the thermometer needs 10 mins here and
the reading is a little lower than oral).
Basal temperatures are also used by people trying to get pregnant (or trying not to get pregnant)
as a marker of ovulation.
This is a classical article by Mary Shannon on body temperature and the female cycle plus the
thyroid implications of temperature. I came across this in 1999 and it was one of the things that
started me along a route to health
Oral temps are just that, temperatures taken at any time during the day by mouth. They follow a
cycle through the day with a peak in the afternoon to early evening before falling again in
preparation for sleep. Val's go like this when I she not hypo and
is functioning well

5AM
10am
2PM
6PM
8PM
10PM

98.2 (36.8)
98.4 (36.9)
98.6 (37)
98.8-99( 37.1-37.2)
98.4 (36.9)
98.2 (36.8)

As you can see from that "healthy performance" there is a gentle drift up and down through the
day which is very different to how people with cortisol or thyroid issues temperature patterns go.

Hypothyroid but Adrenals OK

People in this condition tend to have a low but steady temperature.
Adrenals low and possibly hypothyroid as well
This is a very dynamic condition. The temperature graphs done to the Dr Rind timing of
averaged show significant variation from day to day as per the example in that link.

Are there other ways of clearing RT3

Yes, the problem is that they are not guaranteed and may take longer.
Getting onto enough T3 to suppress TSH and stopping taking any T4 meds works every time.
If your Ferritin or Cortisol are off balance then they will prevent you taking enough T3 so that's
the thing to watch.

Other Imbalances
The body is a complex chemical factory with lots of interactions. Imbalances in the ratios of
these trace elements can cause lots of problems with similar symptoms.
In particular :Iron (and not just Ferritin) (heavily updated 10/10)
Adrenals (heavily updated 10/10)
Electrolytes
Vitamin D Most people in the Western world have low levels of this important Vitamin, This is
an External link discussing this. (New 10/10)
Vitamin B12, an external link talking about this (New 10/10)
A posting from the list about B12
Here's where I learned all I know about B12 deficiency:
http://forums.wrongdiagnosis.com/showthread.php?t=9948&page=1447

I highly recommend you join wrongdiagnosis and participate in this

conversation thread (it's turned into a support group). That your
serum B12 dropped so quickly might be a bit suspicious. There's a
possibility that you are predisposed to a genetic sort of problem with
B12 deficiency, something to do with autoimmune. Easy to deal with,
you just supplement.
Lots to follow when I have time!!!!