Increase levothyroxine or try anti depressants? - Thyroid UK

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Increase levothyroxine or try anti depressants?

Hj101
Hj101

Hi everyone, this is my first post, I hope someone can advise me! I recently visited the doctor due to having ongoing exhaustion, mild depression and a range of other random symptoms. My first blood test showed a TSH level of 6.27 and after lengthy discussion the doctor agreed to trial me with 25 micro grams (or milligrams I’m not sure) of levothyroxine. She also suggested anti depressants which I turned down at the time as I felt my symptoms fit hypothyroidism and I would prefer to try one treatment at a time. I’ve been on the medication for 2 months now, after numerous trips back to the doctors they also eventually told me that I had a B12 Deficiency too which they are treating with tablets. I returned to work this week and after struggling with brain fog more than expected I went back to the doctors. They informed me that I have high thyroid antibodies but my TSH is now “fine” at 4.12 so as I’m still tired the only treatment they will offer is now anti-depressants. Am I wrong to think an attempt at more levothyroxine would be a good idea? I’m happy to take the other medication if needed but don’t want to muddy the water, if my thyroid is the problem surely we should be treating that? Any advice/explanations of what seems to be going on would be helpful.

22 Replies
oldestnewest

TSH of 4.12 is not "fine" you definitely need an increase of Levo and probably another increase after that, the aim is to get TSH to 1 or below, do you have T4 and T3 results ?

SlowDragon
SlowDragonAdministrator

Your GP is incorrect, your thyroid levels are NOT fine.

The aim of thyroid hormone replacement with Levothyroxine is to bring TSH down to around one and FT4 towards top of range and FT3 at least half way in range. Levothyroxine is not a medication by a replacement hormone, for one your body is no longer making

Also unless you are elderly, frail or have heart disease the standard starter dose is 50mcgs and then dose is increased in 25mcg steps until TSH around one and symptoms improved

Ask for 25mcg dose increase in Levothyroxine

Official NHS guidelines saying TSH should be between 0.2 and 2.0 when on Levothyroxine

(Many of us need TSH nearer 0.2 than 2.0 to feel well)

See box

Thyroxine replacement in primary hypothyroidism

pathology.leedsth.nhs.uk/pa...

Dr Toft, past president of the British Thyroid Association and leading endocrinologist, states in Pulse Magazine,

"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)."

You can obtain a copy of the articles from Thyroid UK email print it and highlight question 6 to show your doctor

 please email Dionne at

tukadmin@thyroiduk.org

As you have also been diagnosed with low B12 this is further confirmation you are under medicated

Essential to test vitamin D, folate and ferritin too. Can you add results and ranges if you have had them tested

It's very likely the cause of your hypothyroidism is due to autoimmune thyroid disease also called Hashimoto's diagnosed by high TPO and/or TG thyroid antibodies. Have these been tested? If not request they are

Private tests are available. Thousands on here forced to do this as NHS often refuses to test FT3 or antibodies

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

Medichecks Thyroid plus ultra vitamin or Blue Horizon Thyroid plus eleven are the most popular choice. DIY finger prick test or option to pay extra for private blood draw. Both companies often have money off offers.

All thyroid tests should ideally be done as early as possible in morning and fasting. When on Levothyroxine, don't take in the 24 hours prior to test, delay and take straight after. This gives highest TSH, lowest FT4 and most consistent results. (Patient to patient tip, GP will be unaware)

If antibodies are high this is Hashimoto's, (also known by medics here in UK more commonly as autoimmune thyroid disease).

About 90% of all hypothyroidism in Uk is due to Hashimoto's. Low vitamins are especially common with Hashimoto's. Food intolerances are very common too, especially gluten. So it's very important to get TPO and TG thyroid antibodies tested at least once.

Depression and brain fog are classic sign of being hypothyroid.

Link about thyroid blood tests

thyroiduk.org/tuk/testing/t...

Link about antibodies and Hashimoto's

thyroiduk.org.uk/tuk/about_...

thyroiduk.org.uk/tuk/about_...

List of hypothyroid symptoms

thyroiduk.org/tuk/about_the...

NHS guidelines saying standard starter dose is 50mcgs and that most patients eventually need between 100mcg and 200mcg Levothyroxine.

beta.nhs.uk/medicines/levot...

HiddenThis reply has been deleted
helvella
helvellaAdministrator
in reply to Hidden

I'm not sure I am quite understanding that.

Are you saying that there is a gender difference in levothyroxine need? [1]

Or are you assuming that men have greater mass than women?

And are you able to give even a very approximate meaning of "many"? If there are 1,000 men in the UK who need 300 to 350 micrograms, that could be counted as "many". Against what?, approximately 100,000 hypothyroid men, it is only 1% so might not usually be regarded as "many".

[1] Yes, I am aware that female hormonal levels can and do affect thyroid requirements. Hence commonly distinguishing between menopausal and non-menopausal women.

HiddenThis reply has been deleted
helvella
helvellaAdministrator
in reply to Hidden

I think I understand even less now! :-)

Your daughter and husband are BOTH on 5 gains. So no gender distinction!

Also, taking a small sample who possibly have a specific extra issue and applying to the general population of the hypothyroid really isn't on. We have endos to mis-apply statistics so egregiously.

HiddenThis reply has been deleted
helvella
helvellaAdministrator
in reply to Hidden

It is not a matter of forgetting, just commenting on what you said in your response. :-)

Yes - there are many formulas for calculating required doses of levothyroxine. All are based on weight as a component of the formula, if not. All far too simplistic and incapable of reliably defining a good dose for the individual.

If the amount required is greater in men because they are, overall, more likely to be heavier than women, fine.

That is what I was trying to understand. Is that the case? Or is there some other reason for men seeming to need more than women?

Thank you so much for the helpful information, I’m glad I’m not being stubborn for no reason!

Serum ferritin is 32ug/L and serum folate is 6.7ug/L. Serum free T4 is 8.9pmol/L.

Vitamin D has not been tested as far as I’m aware. In terms of antibodies I believe they have been tested but the doctor was reluctant to provide me with results, just said that thyroid antibodies were high which “confirms hypothyroidism” and means that nobody will “take my medication away”. I think she has made a decision that I am irrational to be honest and therefore won’t really engage with me. She repeatedly tells me that my neurotransmitters are not working and therefore the only treatment relevant is anti-depressants.

Thanks again for your advice so far.

That's her subjective opinion as there is no scientific objective test for performance of neurotransmitters. But you do have a scientific objective blood test that shows that your TSH is too high (and free T4 too low) and that you need an increase in levo. Try to see a different doctor.

helvella
helvellaAdministrator
in reply to Angel_of_the_North

Fully agree.

I'd possibly ask which neurotransmitter(s) are "not working". That is because the various available anti-depressants operate on different neurotransmitters. As Angel_of_the_North said, there is NO scientific objective test so it will be, shall we say, difficult to answer.

A very brief summary (gathered from webmd.com/depression/how-di... ) identifies which groups of anti-depressants work for which neurotransmitters. If you don't know which neurotransmitters are "not working" how can you rationally select which anti-depressant is required? Further, if one or more neurotransmitters are actually "not working", why will increasing the quantity magically resolve the issue?

If she cannot identify which neurotransmitters are "not working" the only approach is to try each group and see if it helps. Of course, select the wrong group and it might actually make things worse!

Selective serotonin reuptake inhibitors (SSRIs)

Serotonin and norepinephrine reuptake inhibitors (SNRIs)

Norepinephrine and dopamine reuptake inhibitors (NDRIs)

Serotonin antagonist and reuptake inhibitor (SARIs)

Tricyclic antidepressants (TCAs) Like reuptake inhibitors, tricyclics seem to block the reabsorption of serotonin and epinephrine back into nerve cells after these chemicals are released into a synapse.

Monoamine oxidase inhibitors (MAOIs) These drugs seem to work a little differently. Monoamine oxidase is a natural enzyme that breaks down serotonin, epinephrine, and dopamine. MAOIs block the effects of this enzyme. As a result, the levels of those neurotransmitters might get a boost.

Also it doesn’t look like T3 has been tested.

Do you know what your B12 levels were? Tablets - particularly the strength your doctor is likely to have prescribed - often aren’t sufficient to raise levels much. How deficient were you?

B12 was at 171, which the doctor described as borderline, and came up to 309 in the next blood test (after only taking the b12 tablets for 1 day)

HiddenThis reply has been deleted
Hidden
Hidden
in reply to Hidden

Hj101 Please don't allow yourself to be pushed down the antidepressant track. Before even considering them be sure you have a proper complete thyroid workup following SlowDragon's guidelines above). Then take the time needed to start proper meds and slowly bump up doses until you are feeling better. Don't forget the optimum vitamin levels also. After getting your thyroid situation sorted out-and it can be a slow process- I will bet the odds are you won't need antidepressants. Too many of us have had our hypothyroidism undertreated for years and have trustingly taken antidepressants prescribed by doctors well versed in 'quick fixes' from their point of view. Many of us,I believe, were left wondering why we didn't feel better on the antidepressants. Easy answer: because the problem was our thyroid all along. Don't mean to be so adamant but prescribing antidepressants for hypothyroidism is a real button pusher for me. Browse around the site and read posts by others who have been on this detour for years. PS meant to send to Hj101. Sorry for the mistake. irina

Hj101
Hj101
in reply to Hidden

Thank you, I’m really glad I posted on here and found the support I needed to continue saying no to the anti-depressants. I completely agree with what you say and just couldn’t go against my gut feeling. I will continue to push for proper thyroid treatment.

Hidden
Hidden
in reply to Hj101

Good. Stick to your guns. You are in charge of your treatment decisions. Your doctors work for you!. Take care. irina

Hello, can you see another GP at the practice? I’ve just changed mine as the one I was seeing clearly knew nothing about hypothyroidism. Just labelled me tired all the time, low mood, sounds like yours is similar.

I was considering changing practises as I’m not able to choose who I see at this one, maybe seeing a different gp is a good idea after seeing the responses here. I was really starting to doubt myself before posting here.

Hidden
Hidden

Hi Hj. I just sent you a reply and accidentally posted to reallyfedup123. Please check my reply to her. Sorry for mistake-my computer skills are sometimes lacking. Take care. irina

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