Hydrocortisone and Levothyroxine?

[Bramble83]

Just want to double check something please!

I have just been started on 25mg of Levothyroxine by my IVF clinic; we were due to do an embryo transfer this month, after our first cycle ended in a miscarriage, but further testing picked up that my TSH is 3.1, which they aren’t happy with.

I am super keen to get my TSH down as quickly as possible, as we can’t do the transfer until it’s down to below 1.5 and I’m super impatient!! As a result, I have been reading up on taking Levothyroxine and what I should and shouldn’t take it with, to make sure I absorb it properly.

I have Addison’s disease, so am on hydrocortisone every day.

My question is- can I definitely take it at the same time as my hydrocortisone, first thing in the morning when I wake up? Will it have any impact on me absorbing the Levothyroxine?

Thank you 😀

[HughH]

25 mcg is a low starting dose. A better starting dose for most people is 75 mcg. The problem with smaller amounts is that the body detects it and makes less TSH, so the thyroid makes less thyroid hormones and you can actually feel worse.

In the UK doctors use the BNF for guidance on prescribing medicine:

bnf.nice.org.uk/drug/levoth...

For Adult 18–49 years

"Initially 50–100 micrograms once daily; adjusted in steps of 25–50 micrograms every 3–4 weeks, adjusted according to response; maintenance 100–200 micrograms once daily, dose to be taken preferably at least 30 minutes before breakfast, caffeine-containing liquids (e.g. coffee, tea), or other medication."

[Bramble83 in reply to HughH]

Thank you.

I think they’ve gone for such a low dose as my TSH is only 3.1 and wouldn’t need treating if it wasn’t for the IVF and links to miscarriage.

I’m hoping the 25mg makes a difference in 6 weeks, otherwise our wait will be even longer for the next transfer 😞

[greygoose in reply to Bramble83]

Actually, you are hypo when your TSH reaches 3 - although they will not admit that in the UK. And, the amount you start on should not be dictated by your TSH level. A starter dose is a starter dose, regardless. And it should be at least 50 mcg. Starting with 25 mcg could actually raise your TSH.

[Bramble83 in reply to greygoose]

Oh! Well I didn’t know that at all! When it was first tested about a year ago it was 1.5, then it increased to 2, then 2.5 and then this latest test, obviously up to the 3.1

It’s really frustrating to have to wait 6 weeks, if it’s not going to bring it down, or could even increase it 😩

I might book in for a repeat blood test in 4 weeks and see what it’s done then and plead a bit ignorant that I thought it was 4-6 weeks, not 6!

[greygoose in reply to Bramble83]

It won't have taken full effect in four weeks. It takes six weeks. But, I don't really think your doctor knows much about thyroid. It's the IVF clinic itself that has prescribed that? I thought they would have known better.

Were all your tests done at the same time of day? Because the TSH is highest early in the morning - before 9 am - and drops throughout the day. If they're not all done at the same time of day, you can't compare them.

[Bramble83 in reply to greygoose]

Yep, it’s the IVF clinic and that’s the instruction they gave to the GP. I’d share the letter but not sure how to add a photo.

My GP is scared of me because of my Addison's 😂 so they just do whatever an consultant requests from them!

All the tests have been done between 8 and 9am.

[greygoose in reply to Bramble83]

I see. Well, what can I say? I'm sure they mean well. But small doses like that have a lot of drawbacks. If it were me, I think I'd go back now and say I'd been reading up on it and I'd learnt that low doses are not a good idea, and it will take longer to reduce the TSH that way, and could I have 50 mcg right away, please?

Did they also test your FT4 and FT3, or just the TSH?

[Bramble83 in reply to greygoose]

I think that’s a great plan- will try that next week and see how I get on.

I think they checked the others, but they just sent a letter to the GP, with me in copy and the only thing it said was about the TSH and trying to get my T4 to the mid to upper range.

When I had my last lot of results, which was over 12 months now, they looked like this:

FT4 15.3 pmol/L (12-22)

TSH 1.5 mIU/L (0.27-4.2)

Free T3 3.5 pmol/L (3.2-6.8)

I’m guessing that isn’t terribly helpful as now very out of date!

[greygoose in reply to Bramble83]

If your FT4 is below range, then you really do need to be on at least 50 mcg levo. You're not going to raise it much with only 25 mcg.

So, good luck, and let us know how you get on.

[HughH in reply to Bramble83]

"I’m super impatient!!"

You need to be patient with this for the following reasons:

Your IVF doctors feel that thyroid is important for a successful outcome, but it takes time to get it right. Regardless as to amount of the "starter dose" it is exactly that. From the starter dose you gradual increase until you get to the amount you need (the maintenance dose) and this takes time. You will see in my previous reply that the maintenance dose is 100 to 200 micrograms once daily. This is the amount most people need to fix their thyroid problem and starting at 25 mcg it will take a long time to get to this sort of level.

It would seem logical that if you are just a little bit low of thyroid hormones then all you need to do is add this little bit and everything will be ok, but that is not how it works. The body has control mechanisms to regulate the thyroid hormone levels, so when you add that little bit, the body detects it and makes a bit less - often resulting in no overall increase. That is why the maintenance levels are 100 to 200 mcg, which is close to a full replacement amount - ie they body is making very little of its own.

You mention that you do a lot of exercise and this has implications for your thyroid hormones. The active thyroid hormone is T3, which stimulates metabolic activity in almost every cell in the body. It gets used up as it does this and the more you exercise the more gets used. You will want to remain fit but it may be worth reducing your level of exercise. You could ask the clinic about this.

[Bramble83 in reply to HughH]

Thanks for taking the time to explain, i’m very clued up on my Addisons but clearly don’t have the first idea about thyroid!!!

I’m going to try and find out what the other values were, from the IVF clinic today for this round of tests but even before my TSH was elevated (it was 1.5 then), my endo commented that my T3 was at the lower end. At that time my T3 was 3.5 (3.2-6.8)

Could that be to do with the exercise???

I’m not used to having set amounts of medication I can take, as with Addison’s you just self medicate and have an open prescription; the more I exercise the more I can take if I need it.

Would they ever let you do this with thyroid meds?

The HC was also a super quick fix and within about 2 days of starting on it, I had my life back and all my symptoms literally disappeared overnight. I guess I’d figured the Levo would be the same!!

I’m slightly loathed to reduce my exercise as the fitter I am, the better I feel with my Addison's and clearly that has a much bigger impact on my life.

I guess I hadn’t really thought anything of the thyroid diagnosis and it was more just tick a box and move on; I’m starting to realise it might not be quite that simple.

I really appreciate you taking the time to explain to me- thank you.

[SeasideSusie Remembering]

Always advised here is to take any other medication 2 hours away from Levo to avoid any chance of absorption being affected. There are some that need longer.

Some people take their Levo at bedtime, or in the early hours of the morning when they need a regular bathroom visit, that keeps it away from everything.

[Bramble83 in reply to SeasideSusie]

Thank you.

How important is it that you take it at the same time each day?

The difficulty I have is that I take hydrocortisone every 4 hours, so trying to keep the Levo 2 hours away from that and away from food is a bit of a challenge. I also take HC as the last thing before bed.

Maybe just before my lunch? Would that be okay?

[SeasideSusie Remembering in reply to Bramble83]

How important is it that you take it at the same time each day?

I don't think it's essential to stick to exactly the same time. I take mine when I need a bathroom trip at night and that could be anywhere between about 3am and 6am, so I just take it then. It's not a quick acting hormone, it's a storage hormone so I wouldn't worry too much.

Maybe just before my lunch? Would that be okay?

Levo should be taken on an empty stomach, one hour before or two hours after food. I know it can be very difficult when you have to regularly take other medication. But if yo can't leave the advised time gaps then do what you can, if absorption of Levo does become affected then it will show in your test results and hopefully your dose will be adjusted to compensate for this.

[greygoose in reply to Bramble83]

I have is that I take hydrocortisone every 4 hours

Is that through the night as well as the day? Or just the day. If it's just through the day, then set your alarm in the middle of the night, have your levo and a glass of water ready, and just take it then. Would that be possible?

[Bramble83 in reply to greygoose]

No, last dose is as I go to bed at around 11pm and next one is as soon as I wake up at 6am.

I’m slightly loathed to set an alarm for the middle of the night, as I don’t sleep terribly well anyway, but if that’s the best option, I might have to go for that.

[greygoose in reply to Bramble83]

If you don't sleep very well, then surely there is a moment when you're awake enough to take a tablet. It doesn't have to be the same time every night, just two hours away from your HC.

[Bramble83 in reply to greygoose]

Will give it a go, if it doesn’t matter if it varies by an hour or two, so long as it’s suitably away from everything else.

I’m so used to taking HC, which has to be at very specific times, I wasn’t sure whether or not I could be a bit more relaxed with the thyroxine.

Thanks for your help 😀

[greygoose in reply to Bramble83]

You definitely can be more relaxed with levo. Thank goodness!

[Bramble83 in reply to greygoose]

Left it in the bathroom and took it when I woke up to pop to the toilet- worked great as think it was about 4am, so a long time clear of my nighttime HC and also my 6am morning dose.

Thanks so much for the suggestion!!! 😀

[greygoose in reply to Bramble83]

You're welcome.

[Barrister]

I take my T3 at 6 am and then my Hydrocortisone at 7 am. Previously, I took Hydrocortisone at 6 and T3 at 7 but decided to try it the other way around.

Clemmie

[Bramble83 in reply to Barrister]

Thanks Clemmie. So do you set your alarm an hour early to take the Levo and just go back to sleep, or do you just get up at 6am and not take your HC until 7am?

[Barrister in reply to Bramble83]

I don’t set an alarm because I seem to wake up naturally at 6. Sometimes I will doze off again and then wake at 7 but other times I will stay awake.

Clemmie

[Roxanne73]

I would take it at 7 am together with hc. I don't think a hc tablet will impare the absorption.

I take my ndt together with my hc in the morning.

Can I ask how much hc you are on?

I am on 25 mg but I don't think it's enough for me. I also suspect I have Addison's.

[Bramble83 in reply to Roxanne73]

Hi,

Thank you, a few people on the Addisons Facebook group said it’s okay to take at the same time, I just wanted to double check 😀

I’m intrigued; if you’re not diagnosed with Addison’s, what is it you’re taking HC for?

I actually only take 20mg a day but I do circadian dosing, so it’s spread out a lot across the day. What makes you feel like you need more than 25mg? Do you still feel poorly 😞

I guess it all depends on the individual; not sure if this helps but I’m 5ft 7 and about 60kg. I do a lot of sport / exercise so occasionally I up-dose with an extra 5mg but only if I’m doing an particularly long run or cycle.

[Roxanne73]

Many hypothyroid people have compromised adrenals because the adrenals have had to work harder to compensate for luck of sufficient thyroid hormone. It is common to take hc ( or adrenal glandulars) in the beginning of the treatment with thyroid hormones.

You are lucky to be doing fine on such a low dose, I thought people with Addison's would have to take around 40 mg.

Yes, I still feel tired but I have only started the thyroid hormone recently so I have hopes it will improve.

[Hidden in reply to Roxanne73]

20mgs is the average therapeutic dose for Addisons/adrenal insufficiency, 40mgs is considered a high dose

[Bramble83 in reply to Roxanne73]

Oh wow, that’s really interesting I had no idea people with thyroid issues would be prescribed HC.

How long do they get you to take it for?

Is there not a risk of causing secondary adrenal insufficiency from taking it?

20mg is pretty standard for Addisons, you might get some (larger men?) taking 25 or 30mg but 40mg would be considered really quite high by most.

I have always worked with my endo to take the least amount possible, as I know I will be on for life and want to minimise the amount I take, without having an adverse affect on my health. At 15mg I was okay but struggled to do all my sport (I run 3-4 times a week, play tennis, do long hikes at weekends etc). Generally though, I find the more active I am, the better I feel and just make sure I religiously give myself 8 hours of sleep a night 😀

I also eat a low carb, high fat diet as it seems to work much better for me and keep really well hydrated and take a lot of electrolytes 😀

Is your thyroid condition quite newly diagnosed?

[Hidden]

I also dose my HC according the circadian cycle, I take my Levothyroxine when I wake around 3am with my 25mgs of HC. As you are taking a smaller dose of HC then you are probaby fine to take them at the same time.

[Bramble83 in reply to Hidden]

Thank you. I tried it last night and left the Levo in the bathroom, so when I woke up in the night to go to the toilet, I just took it then, which I think was about 4am; so a longtime clear of my bedtime HC and a couple of hours prior to my morning dose.

Thanks for the advice 😀

Let’s hope it works now and brings my TSH down nice and quick, so we can crack on with the IVF!!!!

Out of interest, with Addison’s and hypothyroid, did you have any idea about the thyroid??? (or did you get diagnosed with that before the Addisons)

I am presuming I noticed nothing as with a TSH of 3.1 it’s barely significant, outside of the context of IVF.

Thanks for your help 😀

[Hidden]

I don't take 25mgs at 3am but 2.5mgs!! I had a pituitary tumour removed so am hypopit with secondary adrenal insufficiency, however the treatment is much the same so I'm hypothyroid due to the pituitary tumour removal. In my case they have to test T3 & T4 as I don't make a lot of TSH.

[Bramble83 in reply to Hidden]

I kind of guessed it was a typo 🤣

Ah okay, that makes sense. Was just trying to work out, if / how i’d ever notice anything thyroid related because of my Addison's 😀