Shaky/shivering after starting Armour? - Thyroid UK

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Shaky/shivering after starting Armour?

soupybp
soupybp

Daughter asked me to check with you folks regarding some symptoms she is having. Refresh - labs show hypothyroid and low vitamin D. She started vitamin D3 5000IU on October 15 and Armour thyroid 30 mg on October 18. She takes it daily at 6am on empty stomach with water and waits to eat/take remaining meds (lithium/vitamin D) until later in the morning.

Since about Saturday, Nov. 3, she gets a period of feeling shaky or shivering that lasts 30-60 minutes in the timeframe of 6-9pm. She doesn't feel hot or cold at those times. It isn't something so severe that is visible by looking at her.

I think it is reasonable for her to think that it is related to the thyroid med with this starting up about 2 weeks in an no other med changes happening. I am planning to call the doc about it, but I agree with her that having a bit more education from you folks on the topic may be beneficial to that discussion.

21 Replies

If she started on 18th October, she's due for an increase in dose. These new symptoms could just be that her dose is now too low. :)

soupybp
soupybp in reply to greygoose

That's what I was wondering. If I understand correctly, the dose kicks in, the thyroid kind of sighs in relief and puts its feet up on the desk, then then levels end up being too low. Is that a correct general gist?

Doctor had asked for repeat labs at 6 weeks before making further change so that things were settled in, and I have seen conflicting information as to whether first check/changes after first starting meds should be at 2 weeks or 6 weeks. Right now we have other testing going on, so it would be easy to do a repeat (we are in the US, and we have met our insurance deductible for the year) if he felt it was necessary before increasing. Are labs necessary before increasing?

We do have the following new results:

folate - 17.3 (>4.5)

B12 - 820 (200-900)

ferritin - 38.1 (20-324)

lithium - 0.4 trough (0.5-1.5 therapeutic range)

<- this is an issue

greygoose
greygoose in reply to soupybp

That's the general gist, yes. :)

Testing six weeks after a change in dose, and before another change in dose, is necessary for T4 only. When taking Armour, you can increase by 1/4 grain every two weeks until you reach 1 whole grain, and then hold for 6 weeks and retest. So, she can in crease now without retesting.

Her folate and B12 are good. But her ferritin is rather low - should be at least mid-range. It might be a good idea if, next time you're testing, to get a complete iron panel done.

I don't know anything about lithium, I've never seen that tested for before.

soupybp
soupybp in reply to greygoose

Thanks so much. Very useful.

She is taking lithium for bipolar disorder treatment. Regular serum level monitoring is required. Her level has dropped below the low end of therapeutic - I don't know for sure if that could be related to initiation of thyroid treatment or vitamin D supplement.

Hidden
Hidden in reply to soupybp

Hi Lithium is very thyro toxic. I am wondering if he hypothyroidism is due to its use. I sometimes think that there are too many correlations between bipolar, under an over active thyroid disease and mania and depression.I am not suggesting she stop the lithium but I wonder if a discussion with psychiatrist about using an alternative mood stabiliser might be helpful. She might also want to avoid fluoride. The vitamin D is great for all sort including depression, may be because it boosts thyroid function.Do you know if she has antibodies?

soupybp
soupybp in reply to Hidden

She had had issues with multiple mood stabilizers (which leads me to think that the underlying problems were perhaps more likely thyroid/adrenal/sex hormone and not bp). She has also had strong undesired reactions to multiple antidepressants. Bipolar runs in my husband's family, but I am beginning to wonder if it isn't actually a thyroid problem that runs in his family...

July 2018 antibodies:

TPO 11.4 (0-31.0)

Tg <10.0 (0-60.0)

greygoose
greygoose in reply to soupybp

Well, lithium is bad news for thyroids. It can reduce production of thyroid hormones:

verywellhealth.com/lithium-...

On the other hand, bi-polar can be a hypo symptom. Does she know what her levels were before she she started the lithium?

soupybp
soupybp in reply to greygoose

Lithium was recently started (mid-August). My research indicates it typically takes much longer than that to see thyroid effect. She has been on Seroquel off and mostly on since April. Short stint on Depakote in July. New psych is doing a careful review of test results before deciding course of action.

TSH, antibodies, fT4, and T3 results were from early/mid July.

TSH 6.81 (.3-3.8)

fT4 0.91 (.8-1.8)

Total T3 102 (80-200)

fT3, rT3 were from mid October.

fT3 2.71 (2.3-3.8)

rT3 9 (8-25)

There was limited testing prior to that in April before she was put on any psychiatric meds:

TSH 2.05 (.3-3.8)

fT4 1.26 (.8-1.8)

I know, missing key info - but taken with the symptomology of persistent depressive state, heart arrhythmia could be subclinical levels, especially with the recently identified Ehlers-Danlos hypermobility type diagnosis.

Interestingly, in November 2015, went to gp because daughter was sleeping 12-14 hours per day, extremely fatigued, not eating, depressed. Again, limited testing done:

TSH 2.89 (.3-3.8)

fT4 1.06 (.8-1.8)

I know that she wasn't on any meds then...

Hypothyroid runs in husband's family (haven't gotten answer as to if it is Hashi's - but MIL has rheumatoid arthritis too...). Based on what I have learned, I strongly suspect there is undiagnosed hypo in my mom and brother and probably me.

In April when daughter ended up in psych hospital, psych encouraged us to see endo. Prior to that the geneticist that diagnosed the EDS recommended endo eval. Endos in our area will not take kids. Pediatric endo clinic in our area will not accept patient without referral. Psych and geneticist would not write referral - said get from gp. GP would not write referral as "he could handle it" but didn't do anything. A friend recommended the Catholic fertility clinic in the area because we were seeing more psychotic type symptoms at time of period. They told me that her psych symptoms could be a result of thyroid/adrenal/sex hormone issues/imbalances...maybe.

greygoose
greygoose in reply to soupybp

More than likely, I would say.

Has she only ever had the one antibody test? You cannot rule out Hashi's with just one negative test. Sometimes people with Hashi's never develop high antibodies.

I think you should report your doctor for negligence.

soupybp
soupybp in reply to greygoose

I am hopeful that we are on the right track. Daughter is still hopeful too, but sick and tired of feeling no joy in life.

At this point, she has only had the 1 antibody test. Since they haven't been checked since July, I will ask GP for an order for repeat of the test for us to include in one of her upcoming draws. I need to request the full iron panel too.

Right now, gp knows I am working with a new psych and the specialist ob/gyn and am researching on my own. He is giving me any lab order I ask for. He knows that he didn't do right on this one. As long as I can play doctor through him to get to the information I need, I will keep him on...

greygoose
greygoose in reply to soupybp

Well, that's one good thing, anyway! You could ask for an ultrasound on the thyroid, too.

I think you're on the right track, too. :)

soupybp
soupybp in reply to greygoose

I'm holding off on the ultrasound request pending the results of the progesterone/estradiol blood test series we are running (ends Tuesday). I expect that if these levels are off kilter in a particular way, the ob/gyn may order pelvic ultrasound to check for abnormalities, and I would try to get them scheduled together.

greygoose
greygoose in reply to soupybp

OK, but it wouldn't be at all surprising if her sex hormones were off kilter. When one hormone is, the others often are. They are all inter-linked.

Hidden
Hidden in reply to soupybp

It is clear that she has been hypo for a while re thyroid. Hopefully the ndt increase will start to help and maybe a path to her feeling much better all round. I presume if she is bipolar she get elated at time too.Sometimes in the recent past in uk pyschatrist were diagnosing bipolar because somebody was severely depressed on a few occasions but did not ever experience the highs. I think just in my experience as a pshc nurse that there is limited benefit to mood stabilisers for nasty depression if there are not both the highs and lows.

soupybp
soupybp in reply to Hidden

She has had some periods of high energy, high creativity but I am not sure that it was mania. She has periods of more mixed states - the depression turns into whirlwind feeding itself to a frenzy of bad thoughts.

In recent initial consult with new psych (2.5 hours!!), it seems that there was a definite shift in her that she saw in herself at about 4th grade...6-12 months before her first menstrual cycle occurred.

Hidden
Hidden in reply to soupybp

Gosh poor girl so young as well to be that ill. I am sure this is thyroid and it sounds like theses creative periods are how she should be.High energy is not a problems as long as people are getting some reasonable sleep, eating and drinking well, looking after themselves and not upsetting everyone else other wise it is lovely to be creative. Some mindfulness might really help with this frenzy of bad thoughts.I have been using a mindfulness practice CD for myself and children by a Jon Kabot Zinn.The one I use is mindfulness meditation of pain relief. It has some really great stuff about the words we use in our thoughts. It is all very wise and lovely, very mature and aimed at adults but my children sit and listen with me.

shaws
shawsAdministrator

Usually when on NDT, we start at a dose equivalent to what we took on levo, always taking note of clinical symptoms and an increase in dose of 1/4 tablet every two weeks untiil symptoms are relieved. I will give you three chapters that one of our Advisers did (he is now deceased). Copy and paste the tinyurls below onto a new page. Keep a check on pulse/temp and if either go too high reduce to previous dose.

tinyurl.com/ycxpz565

tinyurl.com/ya5blrr2

tinyurl.com/y7ejh9sh

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

soupybp
soupybp in reply to shaws

Thank you so much.

Do not take vitamins tell dinner take with food, they say u fan take vitamins 4 hours after pill don’t wait all day, Armor is the only thing that I can take everything else gives me side effects that put me in the hospital so if she thinks armor as bad she’ll never be able to take this dynamic trust me just continue taking the stuff it is the least side effects if it’s not too harmful for just give it a month to month

She says the shaky feeling has subsided. Doc (ob/gyn) will not increase dose yet. Our follow up with him has been postponed until Dec. 17. I am going to take daughter for the follow up bloodwork on Dec. 1 like we were going to do before the appointment was changed - hopefully the results arriving to him will prompt a change in dose ahead of the appointment.

Did receive call from his office today that the progesterone/estradiol testing shows that her progesterone levels are quite low. He has prescribed a bioidentical progesterone for her to start taking in the luteal (ovulation to menstruation) phase. Hopefully that will help with the despondency/hopelessness/dissociation that worsens toward the end of that phase.

And he did take the time to call and talk to the psychiatrist so that they could coordinate properly on her care. Yippee for doctors working together!

Her eczema has gone absolutely nuts. I don't think it is entirely thyroid, though, given the timing of the worsening. I think that it is more likely a response to lithium. I expect that the lithium will be stopped in the near future. Psychiatrist does not want to reduce or eliminate it until he has in hand more medical reports and test results, especially while ob/gyn is making changes.

I got the chance to speak with the ob/gyn today after he received daughter's new lab results. He explained that he is aware of the typical dosing schedule for Armour; however, he wants to go a little more conservatively with her.

If she has bipolar disorder IN ADDITION TO the thyroid issue, in his experience a slower advancement of dosing is the least mood destabilizing in rapid cycling/mixed state comorbid BPD (I have seen some documentation in this regard from respected bipolar specialists). If the symptoms of bipolar disorder are actually thyroid based, it will just be a slower recovery for her. He really wants to avoid her ending up in the psychiatric hospital and missing more school due to destabilized mood.

With regard to ultrasound, he said that it would not change his plan of attack. He is planning to keep an eye on fT4 and fT3 levels and continue to increase dosage of Armour in a symptom-based approach (not TSH). He didn't feel the ultrasound was necessary based on his plan and things he has read; however, he said he is open-minded. If I find something that points to further benefit that could be gained, he would love to read it and discuss.

Based on how she is doing on the 30mg at this point, he is increasing her dose to 45mg. We will see him in just about 3 weeks and discuss a plan for the next increase at that time.

Also, after further discussion with the psychiatrist (and her eczema getting so bad she couldn't sleep), the lithium was decreased as well...which is likely to have the effect of improving her thyroid hormone metabolism. We will see him in about 3 weeks as well and expect the lithium to be discontinued if she continues to do well. After 5 days, the eczema does not look angry and she is significantly more comfortable.

We are still about 5-6 days away from trying the first round of progesterone.

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