Let's hear The Evidence For and Against Combination #Thyroid Hormone therapy by Dr. Bianco #AACE2022 #Endotwitter. This conversation is controversial here are some of the main slides 
Patient's on Lt4 reporting a lot of residual symptoms in energy, cognition
Normal physiology the majority of thyroid hormone production is T4 (16:1 T4:T3) and gets converted peripherally to T3 (5mcg made in thyroid, 25mcg made peripherally)
there is a pt preference for combo therapy but most studies have not shown an improvement with combo therapy -- some think it may be b/c the right pts weren't recruited/studied
Latest study at #WalterReed by @HoangTdhdthanh showing that there may be some benefit with combo therapy in those with high residual symptoms but no benefit in those with mild/moderate symptoms
In those you do try combo therapy here are suggestions for therapy. Can consider checking T3 fasting and 2-3hrs taking dose to make sure peak is not very high
Safety data for T3? There are some retrospective studies looking at those on T3 long term and that it doesn't decrease mortality, morbidity, fractures compared to T4
In summary, it is not for everyone but there may be a subset of pts that may benefit from combo therapy.
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