Advice re combination T4 &T3: Hello, First post... - Thyroid UK

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Advice re combination T4 &T3

Hello, First post for me.

Appreciate opinions on starting combining T4 with some T3. Diagnosed with Hashimoto in Sept17.Started on 50mcg levo and now on 75mcg. Feel bit better but still symptomatic.

Tsh now 1.34 and T4 18. Gp can’t get Ft3 checked as local Hosp says ‘not necessary ‘!

I am thinking of trying small dose T3 which I will pay for privately and reduce levo at 4:1 ratio.

Has anyone tried this please?

18 Replies
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You really need to know your FT3, tested at the same time as FT4 and TSH.

You can do a home fingerprick test with Medichecks or Blue Horizon

medichecks.com/thyroid-func...

bluehorizonmedicals.co.uk/t...

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Thank u but the test is quite expensive :(

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15% off Medichecks thyroid tests this month (March 2018) with voucher code MED15.

Might help :)

healthunlocked.com/thyroidu...

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Medichecks frequently have it on offer for £29 on Thyroid Thursdays which would make it cheaper than using the MED15 code. Look out for it on Thursdays, their offers are posted on the forum or you could check their website.

What is the range for FT4? My lab's range is 7-17 and we often see 9-19 so if your range is either of those then you are high in range. So you really need to know your FT3 to see if you are converting well enough, if it's low then adding T3 would be beneficial, but if your FT4 result of 18 is only half way through it's range then increasing Levo is the next step rather than adding T3.

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Our range is 9-25.

Why should they differ in range from Hosp to Hosp?

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There is no standard range, each lab has their own range and I believe it's based on results from the local population of some such thing.

So with FT4 at 18 you are a smidgen over half way through the range. So you need to increase Levo for now and get your FT4 further up nearer the top of the range. If your FT4 is in the upper part of the range, FT3 low in range and TSH around 1ish then you know lthat you don't convert T4 to T3 well enough.

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My Tsh is at 1.34 at the min and it went from 2.95 to that with a 25 mcg increase in levo. My concern would be that further 25 mcg could drop it too low?

I really appreciate ur input.

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When taking replacement thyroid hormone, low TSH isn't important. TSH is a pituitary hormone not a thyroid hormone.

The pituitary checks to see if we have enough thyroid hormone. If we don't it sends a signal to the thyroid to produce some - that signal is TSH and if we don't have enough thyroid hormone TSH will be high. If we do have enough thyroid hormone then the pituitary doesn't need to send the signal so TSH will be low. Taking replacement thyroid hormone means that when there's enough the pituitary will detect this and won't send the signal and that's why our TSH will be low.

A lot of doctors don't understand this and give us scare stories of low/suppressed TSH will give us heart problems and osteoporosis, and insist our TSH stays in range and even denying an increase in Levo when TSH is at the top of the range.

I actually had this conversation with the nurse practitioner at my surgery last week when he said my TSH is suppressed. I said that FT4 and FT3 are only mid range though so I can't be overmedicated. He ended up by saying it was nice to have a conversation with someone sensible!

Check out Dr Toft's article in Pulse magazine where he says

"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)."

thyroiduk.org.uk/tuk/about_... > Treatment Options

Dr Toft is past president of the British Thyroid Association and leading endocrinologist. If you would like a copy of the article you can email Dionne at tukadmin@thyroiduk.org and it is question 6.

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That makes good sense to me but my Gp is one of those with limited understanding and locally they won’t test t3.

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Snap! My GP is TSH obsessed, as experienced by the majority of members. We can try and educate our GPs by offering them articles like the one Dr Toft has written, or we have to learn how to help ourselves which is why many of us do our own tests and either supplement our prescribed Levo with self sourced T3 or completely self medicate. If we left it to our GPs many of us would remain ill. It's our choice at the end of the day. I chose not to allow a pig of an endocrinologist ruin my life any longer, likewise I ignore my GP's obsession with TSH.

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Lu-ck,

You should check your FT3 level first. No point in adding T3 if your FT3 is high. You can order a thyroid home test via healthunlocked.com/thyroidu... If FT3 is not high then there is no need to reduce Levothyroxine dose when adding T3 because FT4 is just over halfway through range and isn't high.

If you choose not to check FT3 it may be better to increase Levothyroxine dose to see whether symptoms improve.

The goal of Levothyroxine is to restore the patient to euthyroid status. For most patients that will be when TSH is 0.2 - 1.0 with FT4 in the upper range. FT4 needs to be in the upper range in order that sufficient T3 is converted. Read Treatment Options in thyroiduk.org.uk/tuk/about_... Email dionne.fulcher@thyroiduk.org if you would like a copy of the Pulse article to show your GP.

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Thank u for ur advice. Will try boosting T4 to 100mcg but get flashes already on 75 in the evenings and don’t want that to increase?

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Lu-ck,

What are flashes?

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Hot sweats/ flushes!

Not v nice:(

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Lu-ck,

Could you be in peri-menopause?

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Been through menopause!!

I’m 62 but flashes similar in nature to meno.

Happens mostly in the evening.

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My late mother (who was hypothyroid) had flushes even in her 80s!

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Oh golly that’s not good!!

I didn’t have them prior to commencing the Levo.

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