Hillary Clinton looked and (if you ignored the content) sounded great in the first debate.  She was relaxed, alert, confident, and was still perky at the end.  She seemed like the smiling, waving woman who strode out of her daughter’s apartment 90 minutes after her collapse on September 11.

You don’t recover from pneumonia in 90 minutes, but that’s more than enough time for most medications to take effect.  Was Hillary given some drug or drugs after her collapse, and did she take the same medications before the debate?

Thanks to Wikileaks, we know that in August 2011, an aide sent Cheryl Mills an article on “decision fatigue.”  “Wow, this is spooky [sic] descriptive,” Hillary wrote back.

Two months later, Clinton asked foreign policy advisor Jake Sullivan to look into the stimulant Provigil (modafinil).  She was told it was used to treat excessive sleepiness caused by narcolepsy, work-shift sleep disorder, Parkinson’s, Alzheimer’s, and MS, enjoyed a following among students and truckers, and was being tested by the military of several countries.  Sullivan mentioned that it was preferable to broad stimulants like amphetamines and caffeine, which affect the entire central nervous system.  Your heart doesn’t race, there are no tremors, you don’t feel or look high.  Though a schedule IV controlled substance, modafilin also appears to be non-addictive.*

[*Sullivan was not correct in describing how the drug works.  It does not slow the release of GABA, but interferes with the protein that removes another neurotransmitter, dopamine, from synapses.  Thus, like caffeine and amphetamines, it increases dopamine levels, but through a different mechanism. ]

Not surprisingly, Dr. Lisa Bardack doesn’t mention prescribing Provigil or any other dopamine reuptake inhibitor in her “Healthcare Statement” of July 2015.  Hillary’s medications “include Armour Thyroid, antihistamines, Vitamin B12, and Coumadin,” Bardack writes, and she takes no other medications “on a regular basis.”

Coumadin (warfarin) poses serious bleeding risks, and though it remains the most widely prescribed anticoagulant and is indicated for venous thrombosis, not many physicians would claim that a patient requiring lifelong warfarin, and with Clinton’s history of clotting, was “in excellent health,” as Bardack’s 2015 letter concludes.  (This is downgraded to “healthy” in the 2016 letter, though most physicians would be reluctant to conclude even this of a patient who has had a chronic cough for nine months, has a history of falls and needs assistance with stairs, and has had recent episodes of dyskinesia [her spasmodic head movements].)

The problem of maintaining the appropriate dosage of warfarin is compounded by the fact that hypothyroidism decreases sensitivity to oral anticoagulants.  It would be interesting to know how often Clinton undergoes INR monitoring (the test for blood clotting).  Some research indicates tests should be performed weekly.

The use of Armour Thyroid has also raised questions.

The most frequently prescribed medication for hypothyroidism is Synthroid, levothyroxine, the synthetic equivalent of the hormone thyroxine (T4).  Armour Thyroid, an extract of desiccated porcine thyroid, contains both T4 and a second hormone synthesized from iodine, triiodothyronine (T3), in a ratio of about 4:1, the same ratio as they are produced in humans.  T3, however, is about four times as potent as T4, has a faster onset, and shorter half-life (1 day vs. 5-7 days).  It provides some patients with a little buzz.

This could explain the results of a 2013 study which revealed that whereas there was no difference in the control of the symptoms, 49% of patients preferred desiccated thyroid extract, 19% levothyroxine, and 23% had no preference.

Some endocrinologists and other physicians worry about the over-prescription of natural thyroid.

A physician who wishes to remain anonymous has written to me:

Armour thyroid has gained additional following in recent years, particularly among “alternative” medicine practitioners.  Not all practitioners of alternative medicine follow accepted guidelines for diagnosis of hypothyroidism.  Some may regard low-normal (but still normal) free T4 or free T3 levels to be indicative of hypothyroidism if symptoms of fatigue are present, even with normal TSH.  Others will diagnose hypothyroidism clinically, as for example using morning body temperature as a surrogate for thyroid hormone homeostasis (e.g. https://en.wikipedia.org/wiki/Wilson%27s_temperature_syndrome#Patient_death_and_medical_license_suspension).  There are a great many ways for an alternative medicine physician to inappropriately diagnose hypothyroidism. Different examples (e.g. Wilson’s Temperature Syndrome) can be individually criticized.

The danger of inappropriately prescribed thyroid extract is that it can induce hyperthyroidism and suppress the production of TSH, thyroid stimulating hormone, secreted by the pituitary.

What disturbs the anonymous physician, and others, like Dr. Ted Noel, is a statement from Dr. Bardack’s September 2016 letter, in which she declares that Clinton “has remained stable for many years on Armour thyroid to treat her hypothyroidism (a low T3 level).”

According to the American Thyroid Association and the American Association of Clinical Endocrinologists, a low T3 level is not recommended as a test for diagnosing hypothyroidism:

"RECOMMENDATION 10: Serum total T3 or assessment of serum free T3 should not be done to diagnose hypothyroidism. Grade A, BEL 2… Recommendation 10 was upgraded to A because of many independent lines of evidence and expert opinion.“ (p. 25/1012)  (https://www.aace.com/files/final-file-hypo-guidelines.pdf#page=25).

"Serum T3 measurement, whether total or free, has limited utility in hypothyroidism because levels are often normal due to hyperstimulation of the remaining functioning thyroid tissue by elevated TSH and to up-regulation of type 2 iodothyronine deiodinase  (https://www.aace.com/files/final-file-hypo-guidelines.pdf#page=12).

The manufacturer of Armour Thyroid recommends testing T4 serum levels as well as the TSH suppression test, and warns about interactions with oral anticoagulants.

Hyperthyroidism is associated with a prothrombotic state.  The patient is more likely to develop blood clots.

There’s been speculation that the deep vein thromboses Clinton suffered in 1998 and 2009 may have been induced by frequent air travel, even though neither as First Lady nor as Secretary of State would Hillary have been confined to a cramped coach seat.  On the other hand, it’s very unlikely her cerebral venous sinus thrombosis (CVST) of 2012, though it was discovered shortly after Hillary’s concussion, could have been caused by the fall.  She would have to have sustained a skull fracture.  But could the CVST be associated with a hypercoagulable condition resulting from the thyroid extract?

The physician asks, “Is Secretary Clinton medicating, with thyroid hormone or other medications, to overcome fatigue or in an attempt to increase mental performance?”

He or she then asks the following questions:

• What were Secretary Clinton’s TSH, free T4 levels, free T3 levels, and symptoms at the time or her first (original) diagnosis of hypothyroidism?
• Who made Secretary Clinton’s first (original) diagnosis of hypothyroidism?
• When was Secretary Clinton’s first (original) diagnosis of hypothyroidism made?
• What were Secretary Clinton’s TSH, free T4 levels, free T3 levels, and symptoms at any time since diagnosis when she was not taking thyroid medication?
• What are Secretary Clinton’s TSH, free T4 and free T3 levels now and at all times while she was taking thyroid medication?
• Was Clinton taking thyroid medications near the time of her cerebral venous thrombosis?
• What were Secretary Clinton’s TSH, free T4 and free T3 levels at the time of her diagnosis of transverse sinus thrombosis, and in the weeks thereafter? What did her coagulation studies and coagulation factor studies show at that time?
• What were Secretary Clinton’s TSH, free T4 and free T3 levels at the time of her diagnosis of any other venous thrombosis, and in the weeks thereafter?

The physician believes that “over-prescription of thyroid medications by practitioners of ‘alternative’ medicine is fairly common these days.”  It has even been prescribed off-label for weight loss.  Dr. Bardack is not a practitioner of “alternative medicine,” but was Clinton nonetheless “abusing” thyroid medications?  And did iatrogenic hyperthyroidism (caused by the thyroid tablets) contribute to the cerebral venous sinus thrombosis?  Information about Hillary’s TSH, T4, and T3 levels at various times would help answer this question.

There remains controversy over the effectiveness of the standard criteria for diagnosing hypothyroidism, and a patient with a low-normal T4 result may benefit from a thyroid supplement.   There has also been a long and sometimes impassioned debate about the merits of natural vs. synthetic thyroid hormones in the treatment of hypothyroidism.

Interestingly, for her other patients Dr. Bardack does not hesitate to prescribe the synthetic hormone.  In fact, the number one drug prescribed by her is levothyroxine sodium (generic Synthroid) and number eight is Synthroid.  For her specialty in NY, the first ranks number four with other physicians, the second, number thirty.  (It’s possible Armour Thyroid was originally prescribed by someone else, and Dr. Bardack agreed to continue the medication.)

At least we cannot exclude the possibility that, whether or not it played a role in the December 2012 CVST, Clinton preferred Armour Thyroid to Synthroid because of its effects as a stimulant, and that both in her daughter’s apartment on September 11^th and before the September 26^th debate, she was given the drug and/or modafilin.

Any endocrinologists or other physicians, or patients with hypothyroidism, who have opinions on this question are invited to contact the editor.

Jay Michaels (as Josh Michaels) is the author of the novel Outlaws.