Full effect of changing the dose and jump-start - Thyroid UK

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Full effect of changing the dose and jump-start

ondrej41
ondrej41

How much time do a steady dose of T4 need to reach full effect on symptoms? It is stated 6 weeks, but I read posts here that for some people 2-3 weeks are enough to see final result after dose change. Given Levo's half-life period of 7 days, most of T4 - roughly 80% - will be accumulated in 3 weeks. So is it really needed to wait full 6 weeks?

And if patient feels great after 3 weeks on a steady dose, could this dose be too big for him after 6 weeks, because of the cumulative effect?

I've read Dr. Blanchard's book where he describes using the jump-start to speed up the accumulation of Levo in blood and to see final result quicker. To do this a patient should increase his dose of T4 by 50 - 100% for several days and then bring the dose back to slightly higher dose than before. Dr. Blanchard said that results of the slight increase will be seen in 2-3 weeks. Has somebody tried this method? Does it seem logical?

13 Replies
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helvella
helvellaAdministrator

I think there is some confusion here.

First, symptoms do not suddenly resolve the moment there is sufficient thyroid hormone in the body. Even with the best possible treatment it can take months or years for the symptoms to resolve as far as they ever will.

Second, the quoted six weeks is usually regarding blood tests. The effects of a change in dose cause the obvious thyroid hormone and TSH blood test results to change. Much of this change takes place quite quickly but the results typically are fairly stable after about six weeks. Until then, they can still be drifting and catching up with the change.

Third, quite a few years ago a Dutch paper compared two groups - one of which was treated conventionally with a fairly low starting dose, then slowly titrated up. The other group started on a much higher dose. Although the ones who started on the high dose seemed to reach their final dose more quickly, it wasn't obvious that there was much, if any, benefit to the patients in the end.

Fourth, if you are on only very slightly less than you really need, I am not convinced that a 50 to 100% increase in dose for several days is a good idea. I can see the logic when the current dose is some way below where you need to get to. Even then, speeding things up by a few weeks isn't that big an improvement.

Fifth, I am absolutely convinced that in some people, in some circumstances, some of the effect of a dose increase can be felt within a day. But even then, the cumulative improvement (at least, we hope it is an improvement) will take much longer build up.

ondrej41
ondrej41
in reply to helvella

Thank you for detailed reply. The reason I ask these questions - I do have only subclinical hypothyroidism and can feel dose changes in a matter of days, but if I'm given too big dose of T4, I will close down after a week or two and feel even worse than before (I thought I was a particular case, but it was quite normal for Dr, Blanchard's patients). Then I can drop the dose of Levo or stop it and I'm well again for several days, as long as levels of T4 are sufficient.

So the goal is to have right dose to be well for a long time and not to overdose. I feel stable and more or less OK on lower doses of T4, but for complete resolution of hypothyroid symptoms I need to get right levels of thyroid hormone, not too big and not small. And I must be very vary about overdosing, because if my levels are great after 3 weeks, I will have 20% increase of them after 6 wekks and this could lead to overdose.

So I presume the advice would be to wait 6 weeks (until accumulation of a steady dose will be reached) and to make only slight changes to a dose, taking into account my sensitiveness?

"First, symptoms do not suddenly resolve the moment there is sufficient thyroid hormone in the body. Even with the best possible treatment it can take months or years for the symptoms to resolve as far as they ever will"

I would agree and disagree:) I would say if levels of thyroid hormones are right for a person, he would have 100% of what is possible at the moment, but after months and years the maximum of his wellness can be increased. But I can be wrong, it's just my logic and experience, I'm still learning.

helvella
helvellaAdministrator
in reply to ondrej41

Feeling an improvement by stopping levothyroxine has often been reported. It appears to be a very short-term effect but can be extremely misleading.

I do agree with only making small changes and spacing them out.

I think you are saying what I think! For many, getting to their right dose allows their bodies to slowly recover. It is that slow recovery which means that complete recovery is fundamentally impossible in the short-term.

Just a point to add to the above: simply considering the total of ingested med alone, does not take account of all the other pharmacokinetic factors such absorption, metabolism, elimination etc. because it isn't just stacking up ad nauseum, in your body - it's being used or expelled. So the effect is a little like pouring a litre of water daily into a 10 litre-capacity bucket with a hole in it.... the bucket will not be full on day 10. What is aimed for, is the steady state, which is when the rate of drug input is equal to the rate of drug elimination, and the rule of thumb is that steady state will be achieved after 5 half-lives (97% of steady state achieved). Knowing the steady state allows other calculations to be made, such as about average concentration of the drug for instance, and predicting the steady state concentrations for different dosings intervals or different dose levels. Such computations are generally what happens in say, in-hospital acute care; whereas in treating routine or chronic conditions in primary care, it's generally pared down to ensuring c6 wks before re-testing.

ondrej41
ondrej41
in reply to MaisieGray

I thought about factors you highlighted and see them like a constant - those factors are stable and doesn't change with time, it's the same rate of absorption if I take my dose every morning on empty stomach. As I wrote to Helvella, my biggest concern is to go above the optimum point with T4. I can feel changes to a dose quickly. Quite often I reached complete resolution of symptoms for a week and then felt very bad - so logically the bucket was overflowed too quickly; I'm more stable and predictive on lower doses. So basing on your wonderful informative message I see my goal is to reach wellness at a mark of 5-6 weeks where input=elimination and it's the only mark where I can make safe conclusions about if my dose is sufficient. And it also could mean that if I feel myself great after the first week or the second, the dose is too big for me. Because with time there will be a lot more input and levels will go above the point where I feel myself optimally

MaisieGray
MaisieGray
in reply to ondrej41

Those factors may be constant, but may not be optimal, of course. So for example, your absorption may be consistently poor because of gut issues, which will directly impact absorption of your oral meds, and also impact nutritional factors that themselves impact how meds are utilised. I'm not saying it is so, in your case; just pointing out that constancy isn't the same as fixed, nor good, of course.

Feeling good in the immediate or short term and then feeling bad, is a common experience; but I don't think it necessarily proves, as you say, that the bucket has overflowed too quickly. It seems to be possibly an effect of the negative feedback mechanisms in play between the thyroid, pituitary and hypothalamus, that can often resolve with a dose increase - which I understand, is the opposite to what you feel to be necessary. And is likely exacerbated by the fact, as Helvella says, that it can take a while for the impact of having had an inadequacy of thyroid hormone, to be resolved, which is separate from simply resolving the hormone shortage. As an aside, I suspect that there may also be a psychological effect in the short term, for some, in the early days of taking a med - a sort of placebo-type effect whereby we anticipate feeling better so we do, the sustainability of which, may be time limited for various reasons. In fact a study in the US gave study subjects pills that were clearly labelled "placebo", (placebo tests are of course, normally blind) and drummed into them that the pills were placebos, and they still reported feeling better taking them - such is the power of the mind. But I digress. It may very well be the case as you believe, that you need a lower dose than the next person, to be euthyroid. There's no way to second guess that; but it's great if you achieve that state, the how isn't important. But it isn't always, for everyone, a progression that we can make lineally, there are often plot twists that jolt us off our straight path left or right, or even present us with dead ends, so being receptive to things changing or not being as we thought them to be, is useful.

ondrej41
ondrej41
in reply to MaisieGray

I would say that bucket overflow depends not only on the amount of water you are pouring, but also on how much water have been in the bucket before. There are hypothyroid patients with Hashimoto and slightly elevated TSH and patients who unfortunately lost their thyroid gland, so logically the amount of dose for these groups, especially at the start, should vary. I'm not saying lower doses are for everybody, I'm speaking for myself and trying to learn how to be cautious - I do have thyroid gland and have always reacted relatively quick to dose changes. But what was a discovery for me is that symptoms of too much T4 and too little can be very close and they are often hard to distinguish. It's basically 2 possibilities - you start low (as for your body and your thyroid) and go slowly up or you start too high and you should go down with time.

I think it's not always right to explain the deviation from conventional point of view as a placebo (this is preciasely what most endos do - if something doesn't fit to what they study in medical college, than it doesn't exist. It's not good or bad, it's just not scientific approach to deny facts). Simply because using this approach we can explain every weird or unclear thing in the world with psychology, magic, random. It can be right in many cases, but not every case, we should prove it. Especially comparing individual case vs. statistics. And in the end of the day, thyroid hormone is not a sugar in tablet form, it's an important hormone which effects every cell of the body so we know it produces effects from the very first day someone takes it. Question is if patient starts to feel them now or later. As for me - I didn't expect anything from thyroid hormone treatment back then, I was just given some tablets to take it in the morning. I do believe that people with small hypothyroidism can feel effects earlier than people with TSH=50 or who lost all of their thyroid production.

And yes, I totally agree that linearity is often not working with thyroid hormones. It's just when the plot twists are so inclined that it simply says there is something else going on than just normal variation. It's good to be an unbiased scientist with thyroid hormones, because often not a fact but an explanation is what stops from understanding and making the correct decision.

Thank you for your post, it gives a lot of worth to think about.

MaisieGray
MaisieGray
in reply to ondrej41

To clarify, my reference was to 'a' rather than 'the' placebo effect. For myself, I find it frustrating and interesting in equal measure, that mention of psychological aspects to physical illnesses, including such phenomena as placebo effect, often results in knee jerk reactions, as if an insult or criticism has been given, or the person is being accused of pretence or an overactive imagination. But it isn't that at all - it's evidence, as I said, of the phenomenal power of the mind, and of its intrinsic interconnectivity with the body. Except perhaps in the case of say, severe brain injury, the two can't be separated, and there is always a psychological element to our behaviour and responses. As you say, it is erroneous for Drs to automatically discount a positive response to a med, as being solely a placebo effect; but equally it is wrong to automatically discount its presence.

I was a patient of Dr. Blanchard and have utilized the “jump start” method for dosage increase. I have found it to be effective.

Conversely, I’ve also done the reverse method (reducing or stopping dosage for 3 days then resuming at a lower dose) when I’ve been either over medicated or for the “seasonal change”. Dr. Blanchard believed that slightly more thyroid hormone was needed in the cooler months, slightly less in the warmer months. I have also found that to be true.

ondrej41
ondrej41
in reply to milkwoman

Yes, I have found reducing dosage is effective too. But it was hard to distinguish symptoms of too much and too little - Dr Blanchard describes similarity of the symptoms in his book too.

Could I ask how do you decide if you need an increase or decrease? And when using jump start method, how much time did Dr Blanchard need to make a final conclusion if dose is enough or not?

milkwoman
milkwoman
in reply to ondrej41

Yes, I have also found it difficult at times to distinguish between over and under medicated. The dose change would typically come as a result of blood test values in conjunction with reported symptoms. For me, I can feel the affects of a sausage change fairly quickly - in Bput a week I can usually tell if I am feeling better or worse. Dr B would also go by how I was feeling so no real time frame. He would say to let him know how I was feeling after the change and he would adjust as necessary.

Other times I would try an increase or decrease on my own if I felt things were out if whack. I can usually tell within a week or two if I’ve made the correct adjustment.

ondrej41
ondrej41
in reply to milkwoman

Yeah, I have the same experience with the 1-2 week intervals. Now I'm trying to figure out as for my body when I would reach the full effect of the dose, just little afraid of overmedication. Previously I started with too big doses as for my degree of hypothyroidism, I became to feel much better quickly, but then I just went above the optimum point and suddenly after great time I felt very very unwell and thought I need more.

The other thing is that Dr Blanchard advocated using only small doses of T3, I take more and really don't know if it helps me much since there is a clear need to establish good T4 balance whatever. T4 is felt more comfortable and natural, I believe. Could I ask if you know, maybe, what Dr Blanchard advised his patients who wanted to safely reduce their T3 dose?

milkwoman
milkwoman
in reply to ondrej41

From what I know, you can stop the T3 at any time. Of you think you may be over medicated, stopping T3 could do the trick.

I’ve tried T3 on several occasions and it doesn’t seem to work for me. I feel better on Levo only and feel I can manage the dose better. I just stopped a T3 transdermal cream (takes in addition to my Levo) and I’m feeling better.

Dr. B passed in 2017. I now see his predecessor. When I stopped the T3 cream, she had me do a jumpstart of Levo for 3 days, and then to only add in 50 mcg weekly. I think I still may be just slightly over medicated but I’m going to give it a few more weeks to settle.

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