Hi
If a patient could reduce his TSH from 13 to 8,7 with the addition of only 12.5 mcg T4.
Now the patient add additional 12.5 mcg T4 + 12.5 mcg T3
Will this dose adjustment be enough to bring the TSH down to less than 1?
Please advice
Thx
T3 capability : Hi If a patient could reduce his... - Thyroid UK
T3 capability
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Blueskyyy
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diogenesRemembering
Sorry, it's not simple arithmetic. Each of us responds in our own unique way re TSH response to doses of T3 and T4. It is in the final analysis a matter of trial and error.
Yes
But I refer to the same patient, so I don’t want to extend this estimation to every other patient.
12.5 mcg T4 has reduced the TSH 4,3 points
So another 12.5 mcg T4 + 12.5 mcg T3 can bring the TSH to less than 1 ?
It really doesn't work like that. Plus, it's best to take symptoms into account first and foremost, rather than worry about achieving a specific TSH number.
Yes
That’s too, but again there should be some arithmetic involved in the TSH adaptation.
I don't think so. You want to make it simplistic, but it's far too complex for it to work like that. We are not machines 
It isn't that simple. I have been on 100mcg levothyroxine at different times over the last 4 years. Jan 2018 on that dose my tsh was 0.68 and ft4 18. 3 months ago I went back up to 100 mcg again and this time tsh is 0.19 ft4 19.the ranges are the same for both sets of tests.
Ok. But your FT4 didn’t change a lot.
My TSH was higher when my free T4 was 18 than when it was 12
Was FT3 the reason of high TSH?
My TSH went to its highest ever of 0.669, so not what you'd call high. Free T3 was the same. The pituitary gland is a strange animal
12.5mcg per day? Is that dose correct?
12.5 mcg dose increase.
So total = x mcg + 12.5 mcg
So what’s the total? I personally don’t see that increase being enough to bring the TSH in line. If my TSH were that high I’d be increasing by 25mcg per day for 6wks and the retest. Mine was once 14 and I added 25mcg per day. I didn’t retest because I didn’t know any better but I felt better so just went on with life.
1st dose : 100 T4 => TSH 13
2nd dose : 112,5 T4 => TSH 8,7
Current dose: 125 T4 + 12,5 T3 => TSH ? To be tested in 6 weeks
Will the TSH get normalized ?
You have now introduced a different drug without any reference to ft3 and ft4. TSH as a measure of thyroid function is extremely unreliable in thyroid disease due to so many different factors. Do you convert ft4 to ft3 in an optimal manner. Do you have optimal levels of vit d, vit b12, iron, folate and selenium? Do you have a genetic mutation that inhibits conversion? All of these factors will influence the answer. It is not a linear conversion. Ideally you need a minimum of TSH, ft3 and ft4, with ranges to even begin to untangle your answer. If you are hypothyroid due to hashimoto’s it will also depend on whether your thyroid is being actively destroyed at the moment inhibiting thyroid function further. The answer is to increase medication then repeat full blood test 6 weeks later, but also to see how you feel. Bottom line, if you feel better then the dose increase is right for you. Blood results are a guide not a goal, we know being over range for ft3 and ft4 can cause problems, but reduced TSH on its own doesn’t tell us so much in hypothyroid disease.
Thx
I know what you mean, I can assure you that my FT4 is perfect 18,6 (12,1 - 20.2)
FT3 is 4,6 (3,8 - 6,7)
These values were with 112.5 T4.
Only the TSH is still high, probably because I have hashimoto and the dose must be very high to lower TSH.
This time I take 125 T4 + 12.5 T3 and I hope that will be enough to lower the TSH
These results were from just on Levothyroxine
FT3 was still probably too low.
On just Levothyroxine many people need FT4 above range in order get high enough FT3
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)."
Hi SD, I have just noticed that the T3 measurement stated in Dr Toft's article is serum total and not free - it works out at 58% through the range used. Do you know if that would be a different percentage in an FT3 measurement? I'm confused.com 😊
Scotland seems to test total T3...Weird I know.
Most people seem to need FT3 at least half way in range, if not higher
Personally I need FT3 near top of range but that's probably to do with my having Heterozygous DIO2 gene
Thanks SD, it was just a thought- I just didn't know if it would make a difference as I've been drip feeding my GP with Diogenes and Dr Toft's articles re testing FT3 and FT4 more important than keeping my TSH in range and I don't want to embarrass myself 😊
Gingernut44
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).*"
*He recently confirmed, during a public meeting, that this applies to Free T3 as well as Total T3.
"Unequivocally normal" can really mean anywhere within the range, not necessarily the exact level that he is quoting.
I am the same as SlowDragon. I take a combination of Levo and T3 and I need both FT4 and FT3 at approx 75% through range to be optimally medicated.
Thanks SeasideSusie I think I probably fall into the same category as yourself. At my last blood test, my FT3 was just under 43% through the range and my FT4 was 94% through range with a TSH of 1.18. I still feel terrible, lethargic and still gaining weight but my Dr is so concerned about over medicating me that he's only prepared to prescribe 100 mcg x 4 and 75 mcg x 3 per week. I decided to try NDT and started with half a grain for one week and I am now just at the end of the first week on one whole grain (2 weeks in total) but I'm feeling even more lethargic than I was on Levo and I think it's because my T4 is lowering. I might have to rethink my strategy and go for an addition of some T3 to my Levo. Perhaps I'll put up a new post about titrating with NDT. ☹️
Probably not much. The point about using FT3 rather than T3 is that a minority of patients have either very low amounts of the proteins that carry the total T3 around the blood or have very high amounts. The T3 reservoir size reflects this. Two people with a) a low amount or b) a high one could have the same FT3 but total T3 different by a factor of 4 or more. The large majority are normal(ish) so the relation between total and free T3 isn't so distorted. But even in the "normal" population the transport proteins can differ by a factor of two so the relationship between T3 and FT3 is still affected. FT3 is always demonstrably more accurate in diagnosis than total.
diogenes
Many thanks for your explanation which I am doing my best to understand 😊
That looks like poor conversion to me and obviously wasn't perfect if you didn't feel well and bounding with energy. Why are you so obsessed with TSH? It should make you feel better by increasing your free T3, but you might need a small decrease in levo also. No way to know until you've been on a stable dose for 6-8 weeks
I would suspect that there is something wrong with the test assay in that case, that is interfering with TSH results - see if it can be done by a lab that uses a different assay type.
Personally I didn’t get on well with trying to ‘normalise’ my TSH, when it was high my FT4/3 were way put of range, when it was lowered to 1ishy my FT3 was still very low, barely in range. I felt like crap. So I started looking at my history and realised that my FT3 was always low and I was a poor convertor so I added T3. Now I’m amazing, best thyriod/mental health of my life.
If you really want to know what’s going on and how to become well you need to know your Ft’s. Do you know them? I just don’t worry about my TSH anymore, that result is useless to me.
TSH is a pituitary hormone and has little direct correlation with Levothyroxine and especially with T3
Naturally we don't dump a once a day dose of thyroid hormones in the gut. Naturally bloods would have slow steady dose throughout 24 hours
TSh is especially unreliable if have autoimmune thyroid disease (Hashimoto's)
Adding almost any dose of T3 will suppress TSH, even if still under medicated and hypo with low FT3 and/or low FT4
FT4 and especially FT3 are always the most relevant results
But how do you feel - if you cant get a blood test once a week you cant use blood tests to drive Levothyroxine. So rather than worry about TSH this and that, go on how you feel. You should be at least 36C - maybe 37C at midday. Take more if your not. You shouldn't have a head ache, you shouldn't feel like your brian's in a fog. You should be able to stand on one foot with your eyes closed for 15 seconds. You should feel like doing daily aerobic exercise. If not you have your Levothyroxine wrong. Nobody else including the GP/Endo can get your thyroid supplement fine tune right, you have to fiddle with it until you get there. There will be some crash and burn but in the end you will get it right and understand your body and hopefully feel normalish.
James
Thx
I feel great, i have more energy.
My basal temperature is between 36,10 and 36,35
Yesterday my Temperature was 36,48 in the evening. Although, I must lower TSH as it’s required for pregnancy.
If you’re going to want to get pregnant I’d definitely be looking at FT Health rather than TSH and all the vitamins and minerals. If you feel good then maybe those FT’s are optimal. Look at getting all your ducks in a row and not just TSH.
Hi
My FT4 is 18.6 (12.2- 20.2 )
FT3 is 4.7 ( 3.7 -6.8)
Tsh 8.7
So your TSH is high because your FT3 is low so your conversion is not very good so your pituitary is working hard to try, responding to that low FT3.
FT4 - 80%
FT3 - 32%
So it’s been a good idea to introduce T3. Levo is good enough at near the top of the range so I’d stick with that.
Your TSH will come down when you reach optimal levels of T3. Stick with knowing your FT scores though as a guide to being optimal esp for pregnancy. Maybe your TSH will remain higher and going for a low TSH will not be good for you? 🤷♀️ I don’t know, I’m guessing because if my TSH were that high my FT’s would be so flat and I’d feel awful but you say you feel good?
Ty Paula !
Yes I added T3 for two reasons:
1- increase FT3
2- suppress TSH
We were trying for 8 months to get a baby and it didn’t work, the TSH didn’t make it possible, despite that FTs were fine, I mean in range !
Btw, I added another 12.5 T4 so I am now on 125 T4 instead 112.5
Current T3 Dose is 12.5 mcg .
May I ask you how much T4 / T3 are you taking ?
Hey Bluesky. Like I said I wouldn’t have added anymore T4, it’s already high enough and not converting well enough to T3. Its your T3 that you need to concentrate on not t4 or TSH. If you want to get pregnant cut back on the T4 again and add T3. TSH doesn’t stop you getting pregnant lack of T3 does. Being ‘in range’ is not good enough, like I said yours is only 32% through range and you want to make it go up to the top of range esp as you are finding it tricky to get pregnant 😔
I’m on 125/150 Levo and 20mcg of T3. I suffered on Levo on and off for over 10yrs because my results were often ‘in range’ and my GP concentrated on TSH (which is only a stimulating hormone, it has no other function other than to stimulate your Thyriod to secrete more hormone)
I’d take enough Levo to bring my TSH down under 2 but my FT3 never changed. So the TSH value means nothing. When I added T3 I got my life back.
You mean 12.5 T3 isn’t enough ?
Should I take 20 mcg T3 ?
Btw, how high is your actual FT3 after taking 20 mcg T3 ?
Yes. Whatever amount of Levonyou are on to produce a result of 18 for FT4 is very good for combo treatment but your FT3 score isn’t even half way through raise. Increase your T3. I’m am not a cautious person so for me I’d just double it now. BUT if you are cautious or sensible 🤪 introduce another dose. For example I used to quarter my 20mcg tablet and take 1/4 in the morning with Levo and then 1/4 in the afternoon (about 7/8 hrs after the morning meds) and then 1/4 at bedtime. You could do this too. Now I just halve my tablet and take 10 in the morning. 10 at night.
What mcg are your tablets? How you proceed is individual. I had horrid Hypo symptoms caused by low (but in range) FT3. You don’t have any symptoms? (Apart from reproduction which may or may not be caused by Thyriod) what sort of person are you? Cautious then add another 1/4 of a tablet or gun ho, add the other half (if you are only taking half)BUT beware if it’s too much T3 you could have heart palpitations, feel sweaty/flushed, headache, panic attacks.
Or just add a 1/4 and a week or two later add another 1/4. All depends on how you responded when you first introduced T3.
I am a bit cautious with T3, my heart pulse is 87 when I take my T3 dose.
I think higher pulse is dangerous
My T3 tablet is 25 mcg, I cut it in 4 pieces and take only two pieces per day.
Can you please tell me your FT3 before and after you started taking T3 ?
Blueskyyy sorry for the delay in replying I didn’t get a notification that you had replied 😬
Ok good info there, so you’re going to need to start slower than me 😬 cut in 1/4’s and take the extra quarter in the afternoon
I wear a watch all the time so I know my RHR, it was often under 40 before treatment - now that’s dangerous! Then it went up to 63 when I first introduced T3 and then up to 73 when I introduced another 5mcg and took the tablet all at once. Now back down to 63 because I’m splitting the dose again.
My FT3 before treatment has been around 3.5 (3.5-6.5) and not always tested as they rely so much on TSH tests (wrongly) now Id say it’s in the 5’s somewhere ( I don’t actually know for sure because I messed up my last bloods and got a false low but my symtoms are all good)
It is a delicate balance to find your personal number, there’s not a one size fits all.
Paula
Your FT3 was too low, mine before adding T3 was 4.7
I am taking 12.5 mcg T3 daily, I take 6.25 mcg in the morning and 6.25 in the afternoon.
I don’t think my body needs more than 12.5 mcg T3.
Yes mine was much lower. So the results you posted are not accurate? Are the results you posted after 6wks on combo replacement?
An FT3 of 4.6 is only 27% through range. That’s what you posted your FT3 as being. Is that after being on 12.5mcg for 6wks?
When one is trying to get pregnant that low a FT may be a factor. If you don’t think you need more T3 and yet you think you need more T4, when that is 80% through range then I don’t know how else to explain it 🤷♀️
What may happen when adding too much T4 is that it actually drives down the conversion and your FT3 will become lower. It will also drive down your TSH but I’ve already tried to explain why TSH is not a good indicator of thyriod health
Maybe another forum member is more eloquent than me 🤷♀️
Hi Paula
No, these results are before starting combi therapy.
So you are thinking of adding more T4 without knowing what your results are after 6wks of combo treatment?
Sorry it gets very confusing on the internet, it’s not like having a conversation. Still you seem sure of what you want to do. I wish you lots of success going forward and hope all will be well 🤗
Interesting question! I think the answer has to be, "Maybe, maybe not". I haven't tried T3, but the way my TSH has changed in just over a year since starting Levo suggests it's impossible to predict, even though there may be an individual pattern of sorts
On consecutive increases of 25mcg Levo, my TSH decreased a tiny bit to begin with (on a starter of only 25mcg) from 5.29 to 5.18. Then, on 50mcg it decreased to 2.99. Finally, on 100mcg it dropped like a stone to 0.01! On that occasion I had a private test as well, and on that one (same occasion, fasting and early morning) it was 0.18 only five minutes or so later! But I still had to accept a decrease of 75/100mcg on alternate days, even though I knew I still had hypo symptoms.
So the first drop was by only 0.11 (same reference range each time). The second one was by 2.19 and the third was by 2.98 or 2.81. Not quite exponential but the decrease increased each time!
But thankfully, over six months later, (that is quite a saga in itself) they were finally convinced that my hypo symptoms really had got worse and I'm now back up to 100, with hopefully a future increase if needed.
It might and it might not. TSH does what it likes according to the individuals pituitary response - and everyone had their own "perfect" level. What's more important is the free T4 and free T3 results and how you feel
As I previously said my FTs are in range :
FT4 18.6 (12.2 -20.2 )
FT3 4.7 (3.7 -6.8)
My TSH isn’t responding to T4, we added T3 to suppress TSH.
Sorry Blueskyyy, I don’t mean to harp on but you’ve got to get your head around this 😬 Your high TSH is NOT stopping you from getting pregnant. You are absorbing the T4 that you are taking, your good FT4 result shows this BUT you are not converting that T4 medication adequately to produce enough FT3 which is the active and most important hormone. You are taking T3 to raise your FT3 that you need for your body to function at optimal levels. Not to lower your TSH Your TSH is high because your FT3 is low. Once your FT3 is raised your pituitary will stop sending out so much Thyriod STIMULATING hormone - TSH is only to stimulate your Thyriod and your body is NOT responding.
Paula
Every woman is different, some can get pregnant with high tsh, some can‘t, and others can get pregnant but they misscary later when their body isn’t able to fulfill the body‘s need of hormones.
Anyway, adding T3 is helpful to increase FT3 as well as inhibiting TSH due to its nuclear release properties.
Blueskyyy, a TSH of 8 is quite high. It may take a few dose increases to get it reduced. It's not something you can try to do in one go.
I have slowly increased my thyroid hormone dose since my TSH was in the hundreds. In my experience the closer your TSH gets to optimal, the smaller a change you will see in the TSH each time.
Here are some examples of my own TSHs. These are increasing the dose by the same amount each time:
>100 (.27-4.2)
50 (0.3 - 6)
15.89 (0.27-4.2)
2.7(0.3-6)
0.92 (0.27-4.2)
0.39 (0.27-4.2)
0.06 (0.27-4.2)
Can you tell us more about your therapy ?
My TSH evolution is :
64 when I was on 75 mcg T4
13 When I was on 100 mcg T4
8.7 when I was on 112.5 mcg T4
14.5 when I was on 112.5 mcg T4 (but was taking glutamine so TSH increased !)
Next TSH in few weeks, I am actually taking 125 mcg T4 + 12.5 mcg T3
I was taking NDT, Natural dessicsted thyroid. This is extracted from animal thyroid, and contains both T4 and T3. I was increasing by a quarter grain each time. This contains about 9.5mcg of T4 and 2.25mcg of T3.
Checking the figures actually I was wrong, the first increase was half a grain:
1 grain: >100 (.27-4.2)
1.5 grain: 50 (0.3 - 6)
1.75 grain: 15.89 (0.27-4.2)
2 grain: 2.7(0.3-6)
2.25 grain: 0.92 (0.27-4.2)
2.5 grain: 0.39 (0.27-4.2)
2.75 grain: 0.06 (0.27-4.2)
I'm giving the TSH here because that is what you asked about, but really the more important figure is freeT3:
1 grain: 2.4 (3.1-6.8)
1.5 grain: 3.4 (3.6 - 6.4)
1.75 grain: 4.18 (3.1-6.8)
2 grain: 3.8 (3.6-6.4)
2.25 grain: 4.64 (3.1-6.8)
2.5 grain: 5.13 (3.1-6.8)
2.75 grain: 4.89 (3.1-6.8)
As you can see, my freeT3 sometimes reduced after a dose increase, I'm not sure if this happens to everyone or if it's a complication of thyroid hormone resistance. My symptoms did improve every time, though.
You can also see that even when my TSH dropped below the range in the final result, my freeT3 was still only about halfway through the range, not near the top where most people will feel well. I still felt pretty rubbish at the time, and was very symptomatic.
If a doctor was evaluating my dosage on TSH only I'd have been told not to continue increasing. In fact I did continue to increase every 6 weeks, and continued to get improvement in symptoms. These results are from 2016 and I am still adjusting my dose today.
Well, i have no experience with NDT so I can’t help !
My FT4 has been always in upper half of range while FT3 was in two occasions at ~ 32% and one time was at 54%
See below :
TSH FT4 FT3 Dose
—————————————————-—
64 - - 75 T4
13 17.8 (12.2 - 20.1) 4.4 (3.8-6.7) 100 T4
8.7 22.3 4.6 112.5 T4
14.5 18.6 5.4 112.5 T4
All above tests were done with levothyroixn dose been taken 2-4 hours before blood workup so perhaps FT4 is falsely high (however for not more than 10-20%)
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