Advice needed on levo dose

[activelazy]

Having suffered from sub acute thyroiditis nearly 2 years ago, I have come a long way before being able to convince my GP to give a trial of thyroxine in March this year. My results were in range but despite a good level of FT3 and FT4 my TSH was high. Dropped from 6.3 to 2.7 in a year (without medication). I have negative antibodies of both types, luckily.

On advice here, I pursued my doctor to help me bring it down to 1 - my original level before being ill was 1.08. I have only one such reading.

From 25 MCG, I moved to 50 MCG 13 weeks ago. Things seemed to improve. I have less nervousness than before. My blood tests on 3rd Aug are:

Tsh 1.4 (0.3-4.5)

FT3 5.4 (3.1-6.8)

FT4 20.1 (11-22)

My symptoms keep coming back though. Sometimes weak arms, or weak legs, sometimes pain in hands and feet. Some days, I will feel low and nervous. Symptoms come and go every few days but there are definitely some symptoms at any given point. Nervousness is always accompanied by mild palps.

I asked here before the importance of being on a TSH of 1 or below. Most responses favoured the argument of '1 or below'.

Since my GP listened to me originally, I have convinced her that we need to keep working on our joint plan of achieving a TSH of 1. After discussing this with the other doc in surgery who is clinical lead on thyroid, she has once again agreed to increase the dose by another 25 MCG.

My prescription now is 50 + 25. I am currently taking 50 and just wanted to check with you guys once again if it's ok to go ahead with the increase.

My free T3 has never moved. Only this last time moved to 5.4. Before this it's been 5.3.

Please advise or give opinion.

Thank you

[shaws]

This is the recommendation of Dr Toft who was President of the BTA. It was in an article in Pulse Online - doctors' online magazine.

"6 What is the correct dose of thyroxine and is there any rationale for adding in tri-iodothyronine?

The appropriate dose of levothyroxine is that which restores euthyroidism and serum TSH to the lower part of the reference range – 0.2-0.5mU/l.

In this case, free thyroxine is likely to be in the upper part of its reference range or even slightly elevated – 18-22pmol/l. Most patients will feel well in that circumstance.

But some need a higher dose of levothyroxine to suppress serum TSH and then the serum-free T4 concentration will be elevated at around 24-28pmol/l.

This ‘exogenous subclinical hyperthyroidism’ is not dangerous as long as serum T3 is unequivocally normal – that is, serum total around T3 1.7nmol/l (reference range 1.0-2.2nmol/l).

Even while taking the slightly higher dose of levothyroxine a handful of patients continue to complain that a sense of wellbeing has not been restored. A trial of levothyroxine and tri-iodothyronine is not unreasonable. The dose of levothyroxine should be reduced by 50µg daily and tri-iodothyronine in a dose of 10µg (half a tablet) daily added."

It is fine to add the extra 25mcg. One doctor who was very much against the way we are now diagnosed these days stated that our doses were now too low as we used to get between 200 and 400mcg (NDT) and for many patients the modern guidelines put them in a parlous situation.

[activelazy in reply to shaws]

Thank you Shaws. I will add it from tomorrow. Feel safer after hearing from you.

[shaws in reply to activelazy]

Bearing in mind I'm not medically qualified.

[Clutter]

Activelazy,

Targetting TSH <1.0 is just a guide and if that is the only measure taken will generally indicate that T4 and T3 levels are adequate. FT4 and FT3 levels are far more important than TSH. Your FT4 is almost top of range and FT3 is just shy of the top third of range which usually indicate aoptimal dosing even if TSH is slightly >1.0.

Increasing dose to 75mcg will probably push your FT4 over range but it is unlikely to send FT3 over range and will almost certainly reduce TSH. Some people do need FT4 over range to deliver high enough FT3. Read Treatment Options in thyroiduk.org.uk/tuk/about_...

However, having FT4 top of range and over range can make one feel overmedicated. Nervousness and palpitations can be a sign of overmedication so if these get worse you may want to reduce dose.

You thyroid levels are currently good so I wonder whether the weakness in arms and legs and pain in your hands and may be due to something else? I suggest you ask for ferritin, vitamin D, B12 and folate to be checked as low/deficient levels are common in hypothyroid patients and can cause musculoskeletal pain, fatigue and low mood similar to hypothyroid symptoms.

[activelazy in reply to Clutter]

Thank you Clutter. Very recent vit D 89, ferritin 74, b12 >1500 and folate 21. Other than folate, all needed correcting. And I did it.

Thyroid is the only one I am not sure about. All I know is that my FT3 has been above 5 always. You have seen and commented before and agreed that it's worth trying thyroxine. You will recall if you see my previous post of thyroid trend.

The only reason why I want to try a bit of increase is that that I may be one of those people who need a little bit high FT4. I fully appreciate that I should be prepared to reduce the dose of things go worse. At 50 MCG, I am not worse for sure.

Shall I go ahead then?

[Clutter in reply to activelazy]

ActiveLazy,

Only way to tell if you do better on 75mcg is to try it If you start to feel overmedicated on 75mcg reduce to 50/75mcg alternate days.

[activelazy in reply to Clutter]

Great. Thank you