Introducing T3

[Caesard]

Hello and a warm thank you for all the wonderful contributors of this community.

I am coming back here for your advice and similar experiences about managing the introduction of T3 alongside T4, to combat the horrid effects of hypothyroid state after the TT for Basedow-Graves (+ later TED)

Surgery undergone in dec 2013, started with 100 mg T4 and upped incrementally to 175mg. For a while, until end of 2015 it worked rather well, main un-subsiding symptoms being brain fog, poor concentration, energy and focus and overall fatigue while the usual test were within range (TSH normal but always higher than 2, FT4 near the upper limit, FT3 hardly reaching medium scale, usually staying in the lower third of the scale) No mineral or other significant tests performed until this time mark

I have managed to function reasonable good, loose some weight (about 20% of maximum total weight) run a semi-marathon for the first time in my life and kept the boat sailing. But wasn't anymore the multitasker I used to be and, especially in terms of professional life, sharpness and whits I know that it was sub-optimal to say the least.

In the beginning of 2015, unchanged treatment (175 mg T4) and all other constant depression appeared, some insomnia issues and even increased fatigue. I've managed somehow to contain depression and avoided those bloody treatments the psychiatry o easily recommends. I was fairly convinced those symptoms have a physiological cause and not a psychological one (that was not entirely true but I will come to that)

I've started another effort and decided to take he matter in my own hands as the endos I was seeing referred to my endo situation as stable and normal, given the circumstances. I've found this challenge not an easy one, being half witted, tired, lacking focus and memory and with the overall life crumbling down around me but - and here I mention again this wonderful community - I have slowly understood that I may be right and I was standardly but poorly treated for my now chronic hypothiroidy.

Identified an vit D moderate deficiency (not far from severe threshold) that has solved another issue, bone and joint pain (running/sports with a limp ankel is not a cookie...); 2000 IU D3/day appears to have solved that in more or less a month - I am currently talking 2000 IU vitD daily, for the entire cold season.

Long story short, decided to try adding T3 and convinced an endo that it's time to have a mixed T4/T3 run, as against T4 only (Euthyrox 175 mcg) since 2014, after TT (Basedow-Graves + later TED) does not relieve some of symptoms (energy, clarity, brain fog) though test results are quite good.

Moreover, another endo I've managed to reach (an university professor, one of the best local figures in the area) understood instantly the issue and admitted that's a fairly known problem for a group of patients, due to a polymorphism of the DIO2 gene and related enzymes involved in T4 to T3 conversion. He emphasized that in such cases (DIO2) the lack of T3 impairs neural function (central nervous system and brain activity)

Visiting this doctor I was armed with all the possible test, including an RT3 test (came back normal though)

starting point, AUGUST 2016, 175 T4

MINERALS/VITAMINS

vit D 33 [20-50]

Folic acid

4.75 [2.7 - 16.1]

B12

245 [191 - 663]

CA (ions) 4.2 [3.6 - 5.2]

CA (serum)

9.98 [8.4 - 10.2]

Ferritin 292 [30 - 400]

Iron 101.32 [59 - 193]

Mg 2.36 [1.6 - 2.6]

K 4.43 [3.5 - 5.1]

Na 141 [136 - 145]

Se 85.7 [50 - 120]

ENDOCRINE MARKERS

Cortisol (a.m.)

312.3 [ a.m. : 138 – 690 p.m. : 69 – 345]

iPTH 29.74 [15 - 65] (Parathormon intact)

FT3 4,78 [3.1-6,8]

TSH 1,92 [0,27-4,2]

FT4 21,4 [12-22]

RT3 normal

FT3 FT4 and TSH have historically fluctuated wildly, on the same amount of T4 it happened that FT4 would rise, TSH would rise and FT3 will lower

I was recommended to change the 175 T4 into 100 T4 / 20 T3 combo Novothyral 100 (available on prescription in my market) in the evening and 50 mcg levothiroxine in the morning. First two days I've started with half of Novothyral in the evening (50 T4 / 10 T3) and 100 T4 in the morning, thinking to start small and to avoid any heart rush.

First dose of T3 introduced had an astonishing effect, after 1 minutes or so a slight buzz appeared into my ears but subsided in another five minutes but the clarity! Oh the clarity! Effortlessly perceiving the inner and outer environment! Never felt like that in four years since I got ill on Graves, though before thyroidectomy I suppose I've had high T3 levels due to overstimulated thyroid, regulated by anti-thyroid meds though.

After the first week taking the prescribed dosage and I was literally flying, excellent result, mental clarity, energy, even the pulse has decreased (wasn't too high anyway) and I was looking forward for the revamped potential. Second week brought some hyper signs and after two weeks on T4/T3 tests were:

end of September 2016, after two weeks on 100 T4 / 20 T3 combo Novothyral at night and 50 mcg T4 in the morning:

FT3 7.34 [3.1-6,8] high

TSH 0,147 [0,27-4,2] low

FT4 22,4 [12-22] high

TT3 2.26 [1.3 - 3.1]

My high cholesterol dissipated in the two weeks and losing weight seemed a piece of cake (pun intended); Celiac disease test taken, came back negative.

The professor cancelled the 50mcg T4 in the morning and remained on night time combo of 100 T4 / 20 T3.

In a few days I have started to feel worse and worse, clarity gone, energy worse, brain fog back again and after another three dreadful weeks have taken tests

mid October 2016, after three weeks on 100 T4 / 20 T3 combo Novothyral at night:

FT3 4.84 [3.1-6,8]

TSH 1.97 [0,27-4,2]

FT4 11.85 [12-22] low

TT3 1.63 [1.3 - 3.1]

Obviously I was under-medicated again but I wouldn't have imagined that reducing the T4 would have such a drastic impairment effect.

After his test (one week ago) I have reintroduced by myself 25mcg of T4 alongside the 100 T4 / 20 T3 combo Novothyral and have also changed the administration protocol, taking splitting both medicines, one half at night and one half in the morning. Somehow it works, feeling again functional but the clarity I've felt in he first week of introducing T3 is simply not the same. Just started a vitamin B complex (120 mg B1 +180mg B6 + 750mcg B12, in 3 daily doses) and continuing with the 200UI vit D3

I know I have written a lot but I wanted to leave a story behind for the fellow sufferers . However, I'm asking you once again your opinion on what do you think about this dosage, administration protocol and if you have any thoughts on how/what to adjust further.

Should I try adding some T3 instead of T4? My plan is to wait and see after a few weeks the test result after adding the 25mcg T4 but, alternatively, I do have available separately 25mcg T3 Unipharma Greece and also could change that 25mcg T4 into 25 T4 / 5 T3 Novothyral combo (quarter pill)

Of course I take full responsibility and understand this is not established medical advice but I need to learn from your experience and your opinions shall be welcomed.

Thank you again for being a great, helpful community

[shaws Administrator]

Yes, it is another sorry story but do you have a Gene Defect, i.e. DI02?

[Caesard in reply to shaws]

Apparently yes, judging on the symptomatology behind. This test isn't available in my country (I haven't searched too extensively though) but I will order from the UK, via UK Thyroid offer. Makes sense to establish that for sure, it is on my list but time and money are a factor these days, this bloody situation has stretched me out of both in the last few months.

[shaws Administrator in reply to Caesard]

O.K. that's fine Caesard. So, if you have the gene defect there's no point in taking T4 at all so it is T3 only you should be taking.

I don't know if you can source T3 in your Country .

[Caesard in reply to shaws]

Simple liothyronine is not available here, only combo with levothyroxine (Novothyral) but I can easily source it from Greece. Two days trip, 1300 km and I have a stash for a year at a decent price, at least until they will stop producing that too.

I was wondering about the reliability of DIO2 testing, do you have something on that? I have no info on that yet.

Also, if DIO2 polymorphism is confirmed, that would mean I don't need T4? AFAIK DIO1 still converts T4 in T3 inside liver and other tissue, the DIO2 is prone more on supplying the nervous system. At least that was what my endo explained, take it a face value as I haven't got the chance to verify the info yet.

[shaws Administrator in reply to Caesard]

This is from Thyroiduk.org. which might be informative for you.

thyroiduk.org.uk/tuk/testin...

I haven't had the test but think I have the gene defect as I was always very unwell on other variations but levo was the worst but am well on T3 only.

[Caesard in reply to shaws]

It is, thank you! I'm gonna test, it would shed some light, as otherwise doesn't seem like a regular conversion issue.

Two weeks ago I was getting worse and the only truly depreciated factor in tests was FT4, on T4 input reduction, while T3 meds were constant.

However, on T4 only wasn't really enough to function properly.

This background points out to a logic where there may be a DIO2 polymorphism, probably the faulty gene inherited from one parent and not from both parents. Makes sense, as in the mother's lineage there were thyroid and other autoimmune diseases while on father's not....While this context by itself is not necessarily related to a DIO2 gene issue, the genetic testing seems the way to go in order to clarify pharmacological approach to thyroid hormone replacement therapy after thyroidectomy.

[Clutter]

Caesard,

Did you take T4+T3 before the blood test when FT3 was 7.34?

[Caesard in reply to Clutter]

Yes, switched from 175mcg T4 only to 100/20 Novothyral and 50 T4. A couple of weeks later FT3 was 7.34 and then ditched the 50 mcg T4 which made me worse again (from either FT4 below min limit or overall FT3/TT3 decrease. .or both)

Reintroduced besides 100/20 Novothyral 25 mcg T4 and split in two equal doses and s much better but still not crisp and clear like after the first t3 pill. But decent and reasonable, though this short period pit some anxiety feelings in he mix. I've heard before low or high FT4 triggering anxiety...

What do you think about this approach?

[Clutter in reply to Caesard]

Caesard,

I was trying to establish whether you took Novothyral on the morning of your blood draw. T3 peaks in the blood for up to 6-8 hours and if you took T3 that will be why your FT3 was 7.34 which was very mildly over range.

You may have felt better with higher FT3 and 4.84 may be too low for you. You could try taking 25/50mcg T4 alternate days plus Novothyral daily.

B12 is very low in range. You might ask your GP to test intrinsic factor to rule out pernicious anaemia. If you don't have PA you can supplement 5,000mcg methylcobalamin daily for 8 weeks to raise B12 and then reduce to 1,000mcg daily maintenance dose. Take a B Complex to keep the other B vitamins balanced.

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

[Caesard in reply to Clutter]

Understood. No, I was not, there were at least 12 hours between T3 titration and drawn blood.

In respect to B12, absolutely, I have started a few days ago a B12 B6 B1 complex but I am thinking taking B12 shots and folic acid as that is borderline low too. Will discuss about pernicious anemia with the medic, thank you. However, I am sceptic about such a cause, this issues seem clearly related to the hormone substitution but will rule it out, in parallel with gene testing for DIO2 polymorphism.

what about that +25mcg T4 extra that solved the worsening state after ditching the 50mcg T4? I am thinking to wait a few weeks, test and then, depending on results, switching 25T4 to 25T4 / 5 T3 for a little bit more "horsepower"

This means ending up with 125 T4 / 25 T3 as against a 175 T4 starting point. Seems a little bit more but worth a test run.

[Caesard]

So, new tests results available.

Current dosage is 1 tablet Novothyral 100 (100 T4 / 20 T3) and 25 Euthyrox (T4) changed some 2 weeks ago.

Dosage taken in two splits, at night and in the morning.

Test results to be considered as the drawn blood was taken 5 hours after dosing (62,5 T4 and 10 T3)

FT3 6.26 [3.1-6,8]

TSH 1.52 [0,27-4,2]

FT4 16.71 [12-22]

TT3 2.21 [1.3 - 3.1]

Feeling good but only about 80% of what I've felt the first three days after starting with T3

Next move, instead of the 25 T4 Euthirox will introduce a quarter Novothyral (25 T4 /5 T3) taken in the morning; most likely the extra 5 T3 won't change the world but might send the FT3 to upper threshold and TSH below 1.

To me it sounds reasonable. Any thoughts? Thank you