Letter from endo to GP - advice needed

[Jules_Essex]

Brief history is that I've been hypo and on levo since I was 21 (I'm now 40). Only saw an endo for the first time a couple of years ago and was diagnosed with hashi's and since then other autoimmune issues - lichen planus and possible antibody negative sjogren's syndrome.

I switched last year to an endo in London who was on a list of good endos and I thought he wasn't too bad but I saw him before Xmas and he ran loads of bloods (my local hospital will only test tsh and not T4 or T3 which is astonishing!!!) and he's written to my GP with the results but I'm not overly happy. Here's the main body of the letter (hope it's okay to post it here):

'Results of blood test undertaken at that time are now back

which show acceptable renal and liver function, apart from a slightly elevated ALT of 50 IU/L, normal <40, with a normal glucose of 5.1 mmol/L. Free T4 is normal at 11.1 pmol/L, normal range 9 to 23, with free T3 of 5.1 pmol/L, normal range 2.5 to 5.7, with a low TSH of 0.03 mu/L, normal range of 0.3 to 4.2. Vitamin D was good at 99.8 nmol/L, normal range being 70 to 150, and full blood count was unremarkable along with acceptable iron studies, although transferrin saturation was within normal, it was towards the lower end of this at 22%, target being 16 to 55%.

Vitamin B12, C-reactive protein and ESR levels were normal, with thyroid peroxidase antibodies being negative.

Overall, these results suggested good vitamin B12 and vitamin D levels and that no change to her supplementation with these is needed at this stage, but her iron levels are towards the lower end of our target range, even though they are within normal, and with her current symptoms suggest she would benefit from increasing her iron intake, using a suitable over-the-counter supplement, which should be taken at a different time to both her T4 and T3 therapy, to avoid any interaction.

Her current thyroid hormone levels suggest slight over treatment at this time, and I would therefore reduce her Levo-thyroxine from 100 mcg to 75 mcg daily at this stage, keeping the Liothyronine at its current dose. I would suggest a further blood test is undertaken in six to seven weeks’ time, to see the effect of this change'

Basically I'm really not happy to reduce my T4 - it's not high in range anyway and I've always had suppressed TSH since adding T3 in a couple of years ago and I thought it was pretty standard that T3 reduces TSH to an abnormal level? I've written back and asked if he'll reconsider asking to reduce my T4 dose as I'm not happy to do that really.

I'm just wondering what others think and if there's anything else you notice about the results?

[shaws]

I am assuming that your blood tests were not taken first thing a.m. Therefore our TSH drops throughout the day and won't be 'accurate'.

It doesn't matter if he agrees or not - he should have discussed this with you first. You should have the privilege of deciding your dose. This is an extract of a doctor who only took blood tests for the initial consultation and thereafter treated his patients till they were well.

Read the first two questions/answers.

web.archive.org/web/2010112...

This is an excerpt from the following link:-

"Dr. Broda Barnes was right when, long ago, he wrote that circulating levels of hormones don't measure what's most important. What’s most important is (1) how the patient's tissues are responding to a dosage of thyroid hormone, and (2) the physiological and clinical effects on the patient of that dosage.

"Our model of assessment (within metabolic rehabilitation) is taken from behavior modification, in which I was trained in the early 1970s. Using this model, we make multiple measures of how tissues are responding to a particular dosage. We repeat the measures at short intervals and post the results to several line graphs. By inspecting the graphs, we can see how the patient’s tissues are responding to the present dosage. We carefully consider the graphed data in view of the patient's and our collaborative judgment of how he or she is responding to the treatment. We can then intelligently adjust the hormone dosage (and any other features of the patient's treatment regimen) until he or she achieves optimal metabolic health—all without regard for the blood levels of the TSH, free T3, or free T4. We know from hundreds of trial runs that this systematic behavioral approach enables us to control the metabolic status of patients more precisely than with any other method.

"I concede that you can do some fairly good tweaking of a patient's clinical status by adjusting dosage according to free T3 blood levels. This is so because the free T3 blood level appears to better correlate with the metabolic status of tissues than does the TSH level. Despite this, if you don’t carefully and systematically assess a patient's tissue responses to any particular thyroid hormone dosage, you’re not focusing on what's most important—the patient's physiological and clinical responses to the hormone. These responses are the pure essence of what patients seek, and it's what our systematic approach—which ignores blood hormone levels—provides."

So, to specifically answer your question: No, we don't finally have a blood test that matters—not unless a doctor's goal is to treat another lab value rather than his patients.

web.archive.org/web/2010122...

[Clutter]

Jules_Essex, I can't agree that you are over replaced as FT4 is very low in range and FT3 is good, but not near top of range. I read it that your endo wants your TSH higher but I think reducing Levothyroxine to 75mcg is likely to drop your FT4 below range and lower FT3.

Your vitD is good but I would have liked to see the B12 result.

_______________________________________________________________________________

I am not a medical professional and this information is not intended to be a substitute for medical guidance from your own doctor. Please check with your personal physician before applying any of these suggestions.

[Jules_Essex in reply to Clutter]

Thanks for the replies Clutter - I totally agree, my T4 is very low in range so I can't see how cutting it will help change my TSH as it's only ever been suppressed since I've been on T3 anyway so I honestly can't get my head round it!

The other issue I have is that my local hospital will only test TSH anyway so even if I reduce my T4 I'll only get a TSH result from them so won't know how cutting it has affected my T4 levels (I'm guessing it may well make them go below range). I really don't want to be trekking back to London just to get my T4 checked again in 6 weeks as it's a full day out of work to get there and back!

[Clutter in reply to Jules_Essex]

Jules_Essex, unless your endo has requested TSH, FT4 and FT3 I think you need to. It's no good seeing TSH has risen if FT4 has dropped under range.

[Jules_Essex]

Sorry I haven't explained that properly - my endo is in London but my GP in Essex so when the GP writes on the blood form to test TSH, T4 and T3 the local hospital will only test TSH whatever the circumstances or whatever medication you're on which is insane!! So basically the only way I can ever get T4 or T3 tested is to go back to London and get it done by the endo which is just a total pain for me to go all that way for a blood test.