There has been some confusion online about whether GPs and endos can continue to prescribe dessicated thyroid products such as Armour on the NHS; some doctors have refused.
1. Any GP *can* prescribe dessicated thyroid tablets on the NHS, provided that they are willing to take personal responsibility for the treatment. All dessicated thyroid products are unlicensed in the UK; this results in the prescriber being personally responsible for the safety of the treatment. Doctors can prescribe unlicensed medicines if they believe that no licensed product can meet requirements for an individual patient. Licensed products should always be tried first, unless there are exceptional circumstances which make this impossible.
2. British Thyroid Association (BTA) guidelines for the management of hypothyroidism recommend first-line use of levothyroxine. Levothyroxine treatment is safe and effective for many patients. Because dessicated thyroid tablets are not recommended by UK guidelines, your doctor may not wish to prescribe. On the other hand, guidelines are just that, guidelines, and not legal documents - there is flexibility with respect to whether your doctor chooses to follow BTA guidelines or not. Some GPs adhere to these guidelines rigidly whereas others are much more flexible. I do recognise that BTA guidelines are unpopular with the online community, but I felt it was appropriate to mention them here since they form the basis of most UK GPs prescribing decisions. As a result, if you feel that dessicated thyroid is the next medication which you would like to try, you may need to see several different doctors before you find one who is willing to prescribe.
3. Many doctors will not have heard of Armour thyroid, or other brands of NDT. Because it is not a licensed product in the UK, it cannot be found in the British National Formulary, or MIMS. In addition, students are not taught about dessicated thyroid at medical school. This may lead your doctor to believe that it cannot be prescribed. Although this is not the case, doctors need to be familiar with a product before they can prescribe it safely. Your GP may need to do some reading.
4. Some patients may have been told by pharmacy staff that they cannot obtain these medicines. In many cases, this was probably because they are not on the pharmacy computer system - most unlicensed imports are not. The pharmacist may therefore need to add Armour (or whichever brand is prescribed) as a new product. This is easy to do on most pharmacy systems. The pharmacy can then order via their wholesaler's special orders office or direct from an importer such as IDIS. The wholesaler's special orders office simply place an order with IDIS or another importer on behalf of the pharmacy. IDIS are one of the largest importers of specialist medicines into the UK. Direct ordering from IDIS is useful because IDIS can usually inform the pharmacy exactly when they will deliver the item. IDIS import common items in bulk, which are then stocked in their warehouse. If IDIS are out of stock, it may take much longer to obtain the product, but the pharmacy can try another supply if they have an account. If you are finding it hard to obtain a product, try an independent pharmacy. Independents can order from whichever company they choose, whereas the large pharmacy chains are restricted to a small number of head office approved suppliers.
5. *Some* importers require the words 'for hypothyroidism' to be written on the prescription. Your doctor can simply type this into the dosage instructions box when writing the prescription eg. Take ONE tablet in the morning, for hypothyroidism. It's probably easiest if you ask your doctor to do this when writing your first prescription. Similarly, other importers require a letter from your doctor. This sounds worse than it is. Your doctor does not need to explain why you need dessicated thyroid tablets specifically. The letter simply needs to have: something to identify you (eg. your name/DOB/address), similar information to identify the doctor (including their GMC number), a statement that the dessicated thyroid is necessary to treat your hypothyroidism, and the doctor's signature. The pharmacy will fax the letter to the supplier and should then file it away so that they can fax it again when you next get your prescription - this has always worked for me. It might be worth asking your doctor for the letter before you leave the consultation. It could be a bit more awkward to get one at a later date.
this is very useful for our members Bobbin2, can you just please clarify 'which' guidelines you are referring to in n.2?
Many thanks
Hi there,
I did hope members would find it useful.
In (2), I was referring to the guidelines from the British Thyroid Association, who recommend levothyroxine tablets as the standard maintenance treatment for hypothyroidism. The BTA have also released a statement listing the issues which they have identified with Armour, in which they say that they cannot recommend its use.
I do want to stress that I wasn't attempting to either promote or refute the BTA's stance in my post, I just wanted to make a few points about how Armour can be prescribed on the NHS, and how pharmacies can obtain it.
in reply to
I just had a look at the statement from the Royal College of Physicians, who appear to be singing from the same hymn sheet as the BTA.
My own experience of dispensing Armour thyroid is limited to a couple of patients, since it is rarely prescribed in the UK. One responded well but the other reported feeling unwell and was switched back to levothyroxine. Many pharmacists in the UK will never have dispensed it, which can lead to problems when a prescription is presented.
in reply to
from what i have read, NDT is a miles better treatment for hypothyroidism , as it has all the hormones we need, not just the one that we get in levothyroxine? it was what they used up to the 60s, so why oh why are we getting this crap they call a cure shoved on us called levothyroxine? its RUBBISH and clearly doesnt do the proper job... i would love to be put on NDT but my docs are clueless and rigid.
Hi Bobbin2 - thanks for your post I am one of the lucky ones, as my GP is prescribing me Armour thyroid on the NHS. I don't think he would have done this though, if my endo (one that he had chosen for me), hadn't prescribed it for me first on a private prescription. My (wonderful) GP saw the amazing improvement in my symptoms and told me he would fight the PCT on my behalf if necessary. This was a year ago, and so far it hasn't been necessary.
I believe my independent pharmacist has to obtain my Armour from IDIS as this is the MHRA (hope I've got that right) directive. This is a shame for the NHS as I found IDIS to be much more expensive than Pharmarama, where I used to get my private prescriptions from.
Excellent that you're doing so well on Armour thyroid PCTs have sometimes questioned the prescribing of unlicensed medicines, usually when prices were particularly hideous. Some importers add massive marks up to the cost of medicines. Armour is less expensive than many unlicensed medicines. In spite of all this, doctors still retain the ability to prescribe unlicensed medicines where there is no licensed alternative which has been effective for the patient.
There are numerous licensed importers in the UK, IDIS is simply of the largest and most well known. The MHRA does not direct pharmacies to buy from a specific importer, so long as the importer is licensed it is fine.
I expect that your pharmacy does not have an account with Pharmarama, they are much less well known than IDIS. I also think it is likely that Pharmarama would charge your pharmacy more than they charged you! Because there are no price controls on unlicensed imports, importers can (and do) charge whatever they think they can get away with. The NHS has to pay the pharmacy the price that it was charged. For private prescriptions however, Pharmarama have an incentive to be competitive in order to attract customers.
UK prices for most licensed branded and generic medicines are among the lowest in the developed world - the NHS benefits from this a great deal. Unfortunately, this 'cheapness' does not extend to unlicensed imports! It's fair to say that the NHS does pay through the nose for unlicensed medicines, but such products account for only a tiny proportion of the total drugs bill.
Thanks for the info - you are very knowledgeable Yes I expect you are right that my pharmacist doesn't have an account with Pharmarama. I did suggest to them that the price might be cheaper, but they told me that the MHRA had told them to use IDIS, or that was my understanding Sounds like Pharmarama might charge them the same or more though
The MHRA doesn't tell pharmacies which supplier to order from, it sounds like your pharmacy may have got confused. The most that the MHRA might do is to provide a list of licensed importers, but most pharmacies rarely contact them. IDIS do seem pretty reliable, so they are generally a good company to go to for supplies, particularly as they have a lot of medicines already in stock. This can make them pretty fast.
Hi Clairebear! If you get this please could you PM me with this information too - I'd like to get in touch with your private endocrinologist and get him to prescribe it to me too. Please help! I am so ill on Levothyroxine! Thanks!
I am desperately trying to find a Dr or endocrinologists who will look into my hypothyroidism as I am struggling terribly at the moment and as much as I think my GP is great she will only go by the results of the blood tests Which seem either just below or at the lower end of the scale, and not how I actually feel. She has referred me to a neurologist for "my array of unusual symptoms" (not so unusual if you know the symptoms of hypothyroidism!?) and an Endocrinologists that i insisted on but I want to try and find one that is more thyroid friendly and uses more of a holistic approach and knows a bit about NDT and T3 and doesn't just write my symptoms off as being depression, age, tiredness etc. I live in Yeovil Somerset so Bristol wouldn't be too far, I hope you don't mind me asking but would it be possible for you to give me the details of your GP and Endocrinologists please?
My GP was happy to prescribe any desiccated thyroid for me a few years ago (i.e. not just Armour), but the PCT put a stop to it I don't know how things will pan out with the demise of PCTs, but I suspect cost will still be cited as a reason to refuse to prescribe. I would be interested to know how much the NHS gets charged for Armour, Erfa and Nature-Throid. I feel sure the cost must be high, but how high in comparison say to T3? A few years ago, when Armour was out of production, my local independent pharmacist told me that IDIS were charging an extra £5 per bottle for Nature-Throid over Armour.
The cost of dessicated thyroid products depends greatly on which importer is used, and sometimes on specific arrangements/discounts with the pharmacy. The is no fixed price which can be quoted.
PCTs could only advise GPs not the prescribe. Such advice could not be enforced but some GPs may react to the pressure and stop prescribing.
My PCT said they would no longer fund desiccated thyroid, which is why my GP stopped prescribing it. He was not personally concerned about the 'unlicensed' aspect.
How misleading of them to say that. They cannot actually make that decision.
The pharmacy will be paid for ANY medicine which has been prescribed by a doctor, PROVIDED that it is not on the list of disallowed medicines found in the NHS Drug Tariff, often called the 'blacklist', or 'list of items not to be prescribed'. This is a list of medicines which are never allowed on NHS prescription, and applies to all pharmacies in England and Wales. Blacklisted medicines can be prescribed privately, or bought OTC if applicable Armour thyroid is not blacklisted. The pharmacy would be paid and the money would come out of the GP's drug budget in the usual way.
The situation is different with respect to dressings and medical devices which, unlike medicines, are only allowed on prescription if they are on a special list in the Drug Tariff of permitted products.
in reply to
The above applies to GPs prescribing, and community pharmacies dispensing. It does not apply to hospital dispensaries, which have their own rules on what is and isn't allowed.
Thank you for this information. I have just seen an Endocrinologist who has agreed to me starting NDT. I have been on Levothyroxine for years and have not done well on it at all. It is only through this website that I discovered NDT can be prescribed in the UK so I am also very grateful for that! The Endo told me I would probably have to pay for the NDT though I have no idea how much that will be! It is really useful to have this information. ?? I am due to see my GP this week to get things organised so you couldn't have posted at a better time for me.
Your GP will probably be willing to prescribe it for you if it has been recommended by your specialist. If your GP feels that they are not able to prescribe it due to lack of knowledge, they should ask your endocrinologist to write your prescriptions.
You should not have to pay for this medicine, it is covered by your medical exemption. NHS regulations stipulate that GPs should only issue 'private prescription' (where you pay the full cost) under specific circumstances. These include:
1. Patients who have been seen privately, rather than on the NHS.
2. Medicines which are not allowed on the NHS. This only applies to a few products, and does not apply to NDT.
3. Medicines which are only allowed on the NHS in specific nationally agreed circumstances. If criteria are not fullfilled, a private prescription can be written. An example is Viagra.
I also wanted to say a bit more about the PCT mentioned above who said they did not 'fund' Armour thyroid. Forum members may have seen on the news that patients have been denied highly specialist cancer medicines because the PCT refused to pay. All such medicines are supplied through hospitals, never on green GP prescriptions (form FP10). PCTs have sometimes refused to fund medicines not approved by NICE. Most of these products cost tens of thousands of pounds and may produce a small increase in life expectancy.
In contrast, it is not possible for a PCT to 'not fund' a medicine which can legally be prescribed on a green GP prescription. They can advice/tell doctors not to prescribe but that is it. Your doctor is responsible for your care and should prescribe what he thinks is in the best interests of your health, using licensed products first, and possibly unlicensed products if there is no suitable licensed product which has been effective for you. There are certain medicines which cannot be prescribed on green GP prescriptions at all, the blacklisted products I described above. NDT products are not blacklisted. Your GP can check his copy of the NHS Drug Tariff to confirm this. The blacklist, which is Part XVIIIA of the Tariff - 'Drugs, Medicines and Other Substances not to be ordered under a General Medical Services Contract', is desperately in need of an update. Most listed medicines have long since been discontinued by the manufacturer.
Lloyds chemist stock Armour, they keep a stock in their distribution centres. I don' t have a problem now, Boots used to take sometimes months to get it but Lloyds get it within the week.
Lloyds pharmacy use AAH as their primary distributor. AAH are a very major pharmaceutical wholesaler in the UK. They are owned by the same company that owns Lloyds pharmacy, the Celesio Group.
When obtaining Armour, Lloyds are other pharmacies have 2 main options. They can order via their wholesaler's special orders office or direct from an importer/specials supplier.
If AAH pharmaceuticals stocked Armour in their depots, it would arrive on a same day or next morning basis. AAH and other major pharmaceutical wholesalers do not generally stock unlicensed imports however. What normally happens is that AAH's special orders office order Armour from one of the various importing companies (who order it in bulk and keep a certain amount of stock - an example is IDIS). To speed up the process, IDIS generally send the product direct to the pharmacy via a carrier such as DHL. Some importers may send the product to the wholesaler's warehouse first, who then deliver it to the pharmacy - this tends to a be a bit slower.
The other possibility, as mentioned above, is that your Lloyds pharmacy are ordering direct from their chosen importer/specials supplier. This is probably what they meant when they said their distributor keep it in stock.
My experience of dealing with IDIS is that they are efficient and deliver quickly to the pharmacy. Their customer service staff are also helpful. I can't remember how much Armour cost the last time I ordered it from them, which was about 2 years ago. I have a feeling it was about £60 for a tub but I could have remembered that completely wrong, and it could have changed since then anyway! All importers of unlicensed medicine add substantial mark-ups before selling to pharmacy. After all, they are businesses.
You are probably aware that there was a shortage of Armour in the USA a while back. I don't know the exact time frame but I think it was a couple of years ago. UK pharmacies did experience delays in obtaining Armour during this period, but no pharmacy should be taking weeks to obtain it at the current time, unless there is a new supply problem which I am not aware of. This is not likely because the manufacturer's Armour thyroid website states that it is in stock.
If any members find that their pharmacy is taking weeks to obtain a product, they should ask their pharmacist to chase the medicine with the supplier. I once ordered a 'special order' medicine and it didn't turn up for ages. I then found that the supplier had misplaced it and forgot to send. On chasing it, it arrived the next day.
Wholesalers who can order Armour via their special orders office include:
1. AAH pharmaceuticals (used by Lloyds and many independents).
2. PHOENIX Healthcare Distribution (used by Rowlands and many independents, especially Numark pharmacies).
3. Alliance Healthcare (used by Boots and many independents).
4. Mawdsley-Brooks (used by independents).
Importers and special order companies who sell Armour include:
1. IDIS.
2. Quantum Specials.
3. Pharmarama.
There are more, but these are some of the main ones.
"2. UK guidelines for the management of hypothyroidism recommend first-line use of levothyroxine. In general, levothyroxine treatment is very safe and is clinically effective for most patients. The long term safety of Armour is less well established" ( levo treatment is very safe & effective for most patients ) hundreds of thousands of patients would totally disagree with that which is why they seek out NDT's it's just that UK folks are less familiar with NDT's as are doctors in the UK & Armour you say is less well established- is true in the UK--HOWEVER in the US it is and was used exclusively effectively for decades till a couple of pharmacists created a cheaper and unquestionably less effective treatment called levo--which does not provide T4 T3 T2 T1 and calcitonin in that combination which is the patients choice for a symptom free life not just lab results--one would like to suggest reading not only of UK forums but US ones specifically ( stop the thyroid madness ) which sites usage of NDT's esp. Armour and sites medical statistics on both points. For those of us that live with such crippling symptoms of hypothyroid would only wish that the medical profession would, regardless of where in the world they reside would come to factual agreements & begin to treat their patients with respect and care for their well being regardless of cost or disputed lab test results, the adjustments from country to country as to recommended levels are staggering-how is a sufferer esp. with brain fog meant to sort out all these opposed opinions, as well as those of us diabetics being told eat carbs---no don't eat carbs!! we need medical clarity & that may mean intense research shared between countries...
Thank you for your post. I totally agree that all patients must be treated with care and respect.
I am not here to support or refute the BTA's guidelines. I am not an endocrinologist. I began posting on this forum to provide additional information about the availability and supply of thyroid medicines in the UK - for the benefit of members.
As you know, levothyroxine (T4), and in special circumstances liothyronine (T3) are the licensed thyroid hormones available in the UK. As such, UK doctors will always use them first-line. NDT can be prescribed as an unlicensed medicine if the specialist feels that it is appropriate, after a trial of the licensed treatments. I cannot do anything to change this, which is why I made reference to the BTA guidelines which our doctors normally follow. As I said, I am not here to support such guidelines, or to refute them. I am here to provide information about prescribing, pharmacy, and supply.
Do you have any evidence that Desiccated Thyroid contains T2 or T1? Or how much?
Do you have any evidence that porcine calcitonin works in safe and effective ways in humans? Or how much is present in any desiccated thyroid product?
Do you have any long-term safety comparisons between levothyroxine and desiccated thyroid? To be meaningful for small differences, this would require considerable effort and would need to compare otherwise similar patients.
I am well aware that some people do very, very much better on desiccated thyroid than levothyroxine. (And such people might be very willing to accept the possibility of greater risk because of the benefits they perceive.) But that is simply an observation. I am not convinced that the frequently-mentioned attributes which are speculated to be the reasons are actually validated in any scientific way.
You might also be interested to know that the first synthesis of levothyroxine was achieved in the UK by Harington and Barger:
yes Harington and Barger did-- and allot of us feel this is not something to be celebrated--T4 alone is what has come out of their 'achievement' for so many sufferers- many having to wait way too long if at all to be prescribed T3 as well, it is for those i made my comments & to answer your other queries--those were not my assertions but from hundreds of thousands of sufferers, the research HAS all been done & as i stated the web sites and books are all available for those who do the research, the first port of call would be - ( stop the thyroid madness ) references to all your questions are available, the book is i admit hard going-but any confusion that might arise could easily be cleared up within the forums of STTM, p.s. no aggressive tone was or is intended so i repectfully request the same from your self, my intention was to clarfify the statements made by bobbin2 The long term safety of Armour is less well established" this is a med that had and is used succesfully in the US for decades and the UK has forgotten it's use since the two harington and barger came up with a cheaper less effective treatment.. old time docs are more aware of this fact and expense has ruled the roost since i'm afraid-- i have been waiting for the second best treatment of T4 PLUS T3 for way too long and symptom suffer and hence my annoyance towards medical professionals who are slow to help us in real terms rather then relying on lab test results, hopefully you can sympathize for the many of us in that particular boat.
I am afraid that, despite doing a lot of searching, I have never found evidence to convinces me that desiccated thyroid contains any more T2 and T1 than any other organ.
Indeed, it looks to me as if there has been a misapprehension which ricochets around time and again.
The thyroid does manufacture and contain monoiodotyrosine (MIT) and diiodotyrosine (DIT). I think someone (or some people) have taken MIT to be T1 and DIT to be T2. A very easy mistake to make. And a very difficult one to correct.
(I know that I have specifically read this in at least one place that should have got it right but I do not wish to embarrass anyone by saying where.)
T2 is a metabolite of T3 and rT3. I can see no reason to expect there to be any more T2 in the thyroid than in any other tissue in which T3 and/or rT3 are metabolised.
Of course I could be wrong. And I would welcome a good reference that shows where I am wrong.
I do not know if this is a temporary issue, but searching on STTM:
i would like to suggest the revised edition of the book ( stop the thyroid madness ) as the reference points on these items as they are explained in full detail with all the evidence one could ever get their heads around, it is a long and hard slog of a read, which i for one can only take in small doses, the online forums are a bit short in exact details as i suppose they would be- to drive one to purchase the book.
could i also refer to mary shomon approx.half way down -reference to natural desiccated thyroid "that these drugs, which provide T4, T3, T2, T1, and other thyroid hormones and nutritional elements, more closely resemble human thyroid hormone than the synthetic drugs, and report that their patients feel better on them." link to page- thyroid.about.com/od/hypoth...
specific response for the promotional use of natural desiccated thyroid versus T4 in relation to T4 T3 T2 etc. the quotes are here for one.. "Unlike T4-only meds (Synthroid, Levoxyl, generic levothyroxine, Eltroxin, Oroxine, Levothyroid, Levaxin or Euthyrox,etc)…desiccated thyroid is natural and gives you exactly what your own thyroid would be giving you: T4, T3, T2, T1 and calcitonin. Chapter One of the revised STTM book details what each of these hormones are." link : stopthethyroidmadness.com/n... the simplistic theory being that the synthetic T4 does not provide the total body need-to alleviate the myriad of symptoms that are endured despite lab test results.. there is also a long term study on-going NDT versus LEVO in relation to success or failure of patients symptoms - perhaps the first of it's kind.in Baltimore Maryland--suggests to me that maybe the medical profession might finally be listening to patients who want a better quality of life, rather than just getting by or worse.
well said, and the proof is in the pudding? thousands of patients cant be wrong.. and there is always a risk with ANY long term use of a drug... i would love to take my chances .... shorter life but better quality would suit me fine ....
I seem to have created a bit of a stir. This has surprised me slightly because I have mainly provided information designed to help sufferers obtain NDT when their doctor has recommended it.
>Do you have any evidence that porcine calcitonin works in safe and effective ways in humans?
I have no idea about porcine calcitonin, but salmon calcitonin has been used in medicine, mainly for osteoporosis, Paget's disease and the hypercalcaemia of malignancy.
Calcitonin is a polypeptide hormone. If given orally, it is mainly broken down by protease enzymes in GI secretions - this is the same as what would happen if insulin was given orally. As a result, calcitonin was formulated as a nasal spray and an injection. The nasal spray has just been withdrawn from the market due to an associated with an increased risk of cancer. The injection remains available for short-term use.
>I am hoping that if there is any calcitonin in Armour, that it is not harmful though
I think it's very unlikely. Because calcitonin is a polypeptide (like a tiny protein), the digestive system treats it like all other proteins when taken by mouth ie. most of it is broken down by enzymes into its constituent amino acids, which are then absorbed. Pharmaceutical companies did attempt to develop calcitonin in tablet form a few years ago. They used a special carrier to reduce the amount that was broken down in the intestine and increase the amount that was absorbed. This required fairly complex technology but did allow some of the dose to be absorbed. In contrast, I can only assume that if calcitonin is present in NDT, all (or at least most) of it would not be absorbed intact, but as individual amino acids that would then be used by the body in the same way that it uses proteins in the diet. As a result, it would not result in any hormonal activity.
Although companies were looking to produce a tablet/capsule form of calcitonin to replace the unpopular nasal spray, development has been discontinued now that the nasal spray has been withdrawn from the market for safety reasons. Short-term use of calcitonin injection remains safe and effective for hospital use. It was the long-term use of the nasal spray which caused a problem. Treated patients would have had higher than normal levels of calcitonin in the body. It's usually the case with most hormones that if the blood level is abnormally high or abnormally low on a long time basis, problems may arise.
Hi Clarebear, it's Jules from the thyroid group from the old days in Knowle with Sally
Wanted to say hi and wondered if you could pm me please? I've been studying naturopathic medicine for the last three years in a quest to get to the bottom of this thyroid nonsense! qualify in September and raring to help others but wanted to pick your brains about something.
Hope all is well
Jules X
in reply to
thankyou for your help.. i really didnt realise i could get NDT on nhs .... its just finding that special doctor that will help... i now know when i ask for it that i cant be fobbed off with being told, its not available in the uk!
There are no NICE guidelines for hypothyroidism and the BTA were in with the RCP when it came to writing their statement, not guidelines on hypothyroidism.
Armour thyroid is one of a few natural desiccated thyroid (NDT) USP products on the market. Armour always seems to be clumped together to be an umbrella name for desiccated thyroid products.
Hopefully with more patients using NDT and recovering their health and more trials taking place, then hopefully more GPs/Endos will prescribe.
I think the NICE question is because although NICE came to adopt the CKS data, there has never been a formal NICE guideline on thyroid (except for one eye issue).
bobbin if you wouldn't mind my addressing a point from your post on nice --the paragraph was; "A recent randomized controlled trial (RCT) suggested that TSH levels are suppressed more by bedtime dosing of levothyroxine than by morning dosing, although quality of life measures were unaffected [Bolk et al, 2010]. This RCT has multiple methodological problems. It is, therefore, not possible to determine whether morning or evening dosing with levothyroxine has a clinically significant effect on TSH levels and symptoms of hypothyroidism."--- ok my question is, can one assume it's ok to take 50mic in the morning and 50mic in the late evening, to cover all bases? i am currently on 50mic and want to increase to 100 to see if any symptoms can be alleviated at all & if it seems to wane throughout the day, does morn & eve make sense to you? thank you in advance, for you seem aware of the levothyroxine med. sky
I saw that too. I was surprised because levothyroxine has such as long duration of action (several days) that I wouldn't have expected evening vs morning dosing to affect TSH, or symptoms for that matter. Indeed, it did not seem to affect quality of life measures.
Splitting levothyroxine into divided doses is uncommon but I have seen it done occasionally and wouldn't anticipate any problems so long as the total daily dose is appropriate to your needs. Standard advice is to tell patients to take levothyroxine on an empty stomach to ensure consistent absorption. Some pharmacists tell pts to take it first thing in the morning with water, and to eat breakfast about 30 minutes later. In order to find out whether it made a difference to you, you'd need to do a little experiment on yourself - taking 50mcg twice a day for a couple of months then 100mcg once a day for a couple of months, comparing your symptoms in a diary. When people are unwell, it's very common for fatigue to be worse at certain times of day, but due to levothyroxine's very long duration of actions, it's unlikely to be cause by the levothyroxine wearing off. For those of liothyronine treatment (T3), it's very different because T3 has a shorter duration of action.
50mcg of levothyroxine is generally too low to treat hypothyroidism, but it is occasionally adequate. 100-125 mcg is much more likely to be effective. Finding the right dose for *your* body can certainly require patience... + repeated blood tests + repeated assessment for symptoms of hypothyroidism, or much more rarely hyperthyroidism if the dose was far too high.
I hope this is helpful. Do not hesitate to ask any more questions.
The responses are interesting and varied. Quite a number of people have switched and found it beneficial. (I started taking mine at bed-time and have never tried it in the morning - so I have no point of comparison.)
From memory (and I shall try to look this up), the T3 peak after taking T4 occurs usually around 48 hours after ingestion.
well thank you bobbin2-- your reply was extremely helpful, i now have the tools to take my situation to hand, as my gp had been on extended leave i am now much more confident what to do.. thank you very much,
Thank you so much, Bobbin2, for taking the time and trouble to give us so much info on effective doses of thyroxine and accessing Armour, and all the regs.....
I'm going to copy all of it to a document for future reference!
You have also taken me on further in understanding Calcitonin.
You must be very busy, so thanks again for your time and attention in all this.
Admin - does crucial info like this importing and availability of Armour from Bobbin stay in any kind of filing system on here, or does it get more difficult to access on this blog as time brings lots more contributions?
Thanks Susanne. I actually just edited my post. I added a point about getting a doctor's letter and edited point 2, which seemed to be upsetting people.
Great, Bobbin, I'm pasting it all to documents....I trained as a nurse, and then for a while privately taught self-help, and I still give advice to friends and friends of friends....not as much as you do, though.....as I'm retired now.
If you're interested in the subject of innovative use of T4 and T3, see Dr Skinner's retrospective survey of treatment of quite a large number of his patients.....roughly a third were refered with suspected: hypothyroidism, a third with suspected ME/ chronic fatigue and roughly a third with depression.....he found it didn't matter which category they came under, the pretty well all improved greatly on T4 or T4/3/or Armour.....as a GP this could help you and your 'challenging' patients a lot.....
Interesting info thanks. According to my doc who refused to let me have any other natural drug rather than Levo sodium - she tells me that it is down to new clincal commissioning groups in Devon (formerly PCT) and gps have to go by their guidelines. Also told that the allergic reactions i think i get with Levo, essential tremour, anxiety, lack of sleep etc over many years can also come from Armour due to porcine hormone in it and that they are writing to patients to tell them to come off natural one! Whatever happened tocpatient choice. I still feel this all down to the
Money re pharmacy and free lunches in hospitals for suppliers ofcLevo and other drugs.
I already have symptoms from Levo as far as I am concerned but it seems I just have to put up with them now.
Have been told i can see an endo but they will probably tell me the same since CCG are their bosses too!
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I am one of the lucky ones, as my GP is prescribing me Armour thyroid on the NHS. I don't think he would have done this though, if my endo (one that he had chosen for me), hadn't prescribed it for me first on a private prescription. My (wonderful) GP saw the amazing improvement in my symptoms and told me he would fight the PCT on my behalf if necessary. This was a year ago, and so far it hasn't been necessary. 
Sounds like Pharmarama might charge them the same or more though 
Armour on NHS- is there a way?
Urgent supply of Armour Thyroid needed
Does anyone here in the UK take NDT (Natural Dessicated Thyroid - or Armour)?
how is Armour Thyroid working these days...?
Prescribed NDT on NHS now doctor refusing to prescribe. Help!
