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hypothyroid symptoms.  Free T3 and free T4 are reliable evidence, etc.

So I guess the point of bringing this all up is that while we've talked about TSH as unequivocally a measure of therapeutic outcome, I think it still needs to be looked at very carefully because certainly the literature is conflicting with what we've heard today, and I think we need to look at it more closely.

DR. KIBBE:  Thank you, Larry.

Wolfgang?

DR. SADEE:  Yes.  I have some concerns about TSH measures to assess bioequivalence, and although I do not doubt that it's probably one of the better measures to titrate a patient, what we have to consider first is the relationship between the dose and the effect.  And in this case, it is a very steep dose-response curve and that was already alluded to by their saturation phenomena, but also the steepness of the curve implies that very small changes cause very large changes in the TSH level and the coefficient, which is a measure of how steep the curve is, is probably up to 5 or 10 as an exponential.

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