I am very new to this "world" so apologies for this question which may have been asked and answered multiple times in the past.
During an investigation for recurrent miscarriage, I discovered of having anti-TPOAb (I have not been told the value, just that is slightly raised) despite having normal TSH (1.7 mIU/l) and free T4 (15.5 pmol/l) levels, and I have been prescribed 25mcg of Levothyroxine daily.
I have been told to take it in the morning, with a sip of water, and to wait at least 30 minutes before eating or drinking anything. I usually wait between 30 and 60 minutes (it depends on the day), and I then have my breakfast, when I also take part of my daily supplements, that is 1000 IU of vitamin D3, 100 mcg of vitamin B12, 400 mcg of methyl folate, and 200 mcg of coQ10.
I am now wondering whether taking these supplements 30 to 60 minutes after the Levothyroxine may generate issues. Also, is there anything regarding supplements and thyroid/levothyroxine I should be aware of?
Many thanks for your help!
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MofM
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Yes, it will generate issues, it will stop the absorption of your levo.
The majority of supplements/medication should be taken at least two hours away from thyroid hormone.
Vit D, calcium, iron, magnesium and oestrogen should be four hours away from your thyroid hormone.
I don't agree with the way you were told to take your levo - splitting hairs a bit, here! lol - but it would be much better to drink a glass of water, rather than a sip, to make sure the tablet goes all the way down to your stomach. And, waiting a full hours will likely give you better absorption than 30 minutes.
When are you going back for a retest? On that day, make sure you get an early morning appointment for the blood draw, and fast over-night. Leave a 24 hour gap between your last dose of levo and the blood draw.
Yes, on my Levo packet from the GPs instructions it says to take 30 mins before food or caffeine drinks. I take mine during the night (I set an alarm) so stomach is empty for 4 hours either side of my meds.
I would never be able to do that! If I wake up I will never be able to go back to sleep. But perhaps taking it in the evening is a better choiche. Thanks a lot for your feedback!
Unfortunately I have to as I take gaviscon advance literally just before I go to bed for acid reflux then in the morning I take omeprazole, so I need quite few hours either side of my Levo. However I thought the same as you and didn’t expect to be able to get back to sleep but surprisingly I do. I put my glass of water by my bed and my tablet next to it, alarm goes off, I take it and normally go back to sleep pretty quickly 😊
I should try! I also take omeprazole (but only when I have a reflux "crisis" and never for more that 5 days). I need to remember to take it four hours before/after levothyroxine... So many things to take care of!
So I have been doing this all wrong for 5 weeks now
Well, I guess better to gain some wisdom later than never.
Thanks a lot for your answer, it is very clear and helpful. I will now move the vitB12, methylfolate, and co-Q10 later on in the morning (to be at least 2h after the levothyroxine) and start taking the vitD after lunch, when I am also taking a preconception multivitaminc (which includes extra Vit D, calcium, iron, and magnesium). This will be 5 to 6 hours after the levothyroxine, so it should be fine, right?
I have noticed many people take their levothyroxine in the evening, and I am now wondering how many hours you should fast BEFORE levothyroxine -- perhaps taking it in the evening will make my life easier.
I have already gone back for a retest, and it was at lunch time, so 5h after the levothyroxine, and likely after I had some fruit. Well, good to know for next time. I should have joined this forum weeks ago!!!
I am also taking a preconception multivitaminc (which includes extra Vit D, calcium, iron, and magnesium). This will be 5 to 6 hours after the levothyroxine, so it should be fine, right?
Actually, taking a multi-vit is rarely fine. They are very bad things to take, for all sorts of reasons. For example, it's doubtful you need the calcium. One should always get it tested before supplementing because calcium supplements are not easily absorbed and tend to build up in the arteries.
However, if it also contains iron, the two will bind together and you won't absorb either of them. So what a waste of money! And, to top it off, the iron will probably block the absorption of all the vitamins. Iron should be taken on its own, two hours away from everything except vit C.
And, if the multi contains iodine - which they usually do - that is absolutely wrong for you because you are hypo. Iodine in excess is very bad for you, and as you need very little, it's easy to over-dose. You will already be getting about 16 mcg from your levo. Plus what you get from food. Thyroid hormones are made from iodine, and the iodine is recycled in the body. Which is why you need so little daily.
I have noticed many people take their levothyroxine in the evening, and I am now wondering how many hours you should fast BEFORE levothyroxine
Depending on how large a meal you have in the evening, 2 to 3 hours should be good.
Exactly what are your current vitamin results and ranges ?
Vitamin D
Folate
Ferritin
B12
Bloods should be retested 6-8 weeks after each dose increase in levothyroxine
Standard starter dose of levothyroxine is 50mcg
For full Thyroid evaluation you need TSH, FT4 and FT3 plus both TPO and TG thyroid antibodies tested. Also EXTREMELY important to test vitamin D, folate, ferritin and B12
Low vitamin levels are extremely common, especially if you have autoimmune thyroid disease (Hashimoto's) diagnosed by raised Thyroid antibodies
Ask GP to test vitamin levels
Recommended on here that all thyroid blood tests should ideally be done as early as possible in morning and before eating or drinking anything other than water .
Last dose of Levothyroxine 24 hours prior to blood test. (taking delayed dose immediately after blood draw).
This gives highest TSH, lowest FT4 and most consistent results. (Patient to patient tip, best not mentioned to GP or phlebotomist)
Private tests are available as NHS currently rarely tests Ft3 or thyroid antibodies or all relevant vitamins
My vitamins were not measured (apart from vitD that was just below threshold) but I am taking vitB12 because I am vegetarian (as suggested by my GP), and vitD and methylfolate because I am trying to conceive via IVF. For the same reason (IVF), I am also taking a preconception multivitamin, omega-3, co-Q10, vitE, and extra vitC.
I have been on different combination of this regime since January, apart from vitD which I have been taking since mid-2018.
Ferritin has never been mesured, but standard blood test I had after my multiple miscarriages ruled out anemy.
I have no hypothyroidism, just a slightly raised anti-TPOAb count, with a good TSH level (1.7 mIU/l), which class me, at least according to my current consultant (not endocrinologist), as having subclinical hypothyroidism and at raised risk of developing Hashimoto's. Being my THS levels below 2 mIU/l, I should not need any adjustment (levothyroxine) to improve my chance to conceive, but due to my multiple miscarriages the consultant felt it saver to have me on a low levothyroxine dose of 25 mcg (rather than the standard started dose of 50mcg, which is not needed since I have no hypothyroidism, or at least not yet).
My GP retested my after 4 weeks of levothyroxine (no increase is planned), but I am not sure what was mesured (TSH and free F4, most likely). I doubt she will ever test my vitamin level -- but thanks a lot for the links: I might do this privatly, even though I feel a bit unsafe in stopping supplementation for one week when I am so close to my IVF.
Do you think my level might be lower also if I don't have hypothyroidism and I have been supplementing now for quite a while?
If you are taking vitamin B complex, or any supplements containing biotin, remember to stop these 7 days before any blood tests, as biotin can falsely affect test results
ALWAYS get actual results and ranges on all blood test results
Frequently what is classified as “normal or fine “ just means within range
You need optimal levels
The problem with taking levothyroxine is it doesn’t “top up” you own thyroid hormones....it tends to reduce your own output as it will reduce TSH ...hence importance of taking enough
How do you define “optimal level”? I have been told these are when you “feel good”, but having always felt perfect I have very little way to decide what “optimal” is for me. I am not hypo and Anti-TPO level is low (36), therefore I can’t even say I have Hashimoto, albeit I can develop it in the future.
My TSH is already within the accepted range (below 2 mIU/l), so can you please explain better what do you mean with “it will reduce TSH ...hence importance of taking enough”? I am so new to this and I think I am missing some connections. Thanks!!!
As an example....if, when perfectly healthy, your own thyroid made the equivalent of 125mcg levothyroxine....and this metabolism is controlled by pituitary sending messages - TSH (Thyroid stimulating hormone)
Then as your thyroid starts to fail (usually due to autoimmune thyroid disease) ....you might get diagnosed when your thyroid has reduced output to roughly equivalent of 75mcg levothyroxine
Pituitary has noticed there’s a drop in thyroid hormones in the blood....(that’s Ft4 and, most importantly, the active hormone Ft3) ....so to try to make more thyroid hormone ...pituitary sends out stronger message to thyroid - TSH rises up
But with Hashimoto’s the TSH is often unreliable.
When GP starts you on 50mcg ....initially you feel a bit better ....as you have 75mcg from your own thyroid and 50mcg levothyroxine
But (here’s the bit GP may not understand)....levothyroxine doesn’t “top up” your own thyroid output.....well it does very briefly....but the pituitary very soon “sees” the levothyroxine in the blood....and TSH starts to drop
So at the end of week 6 ....TSH has dropped a lot. Your thyroid takes a rest ....has a holiday
So at this point you are now only mainly using the 50mcg levothyroxine....which is actually a dose reduction down from managing on 75mcg from your own thyroid before you started on levothyroxine
So you start to feel worse .....and are ready for next 25mcg dose increase in levothyroxine
Modern thinking ....and New NICE guidelines suggests it might actually be better to start on higher dose .....but medics may not have read these new guidelines ....and many patients can’t tolerate starting on more than 50mcg and need to increase slowly.
Starting on 50mcg and stepping dose up in 25mcg steps, retesting 6-8 weeks after each increase. But we still very often need to increase up to full replacement dose
Consider starting levothyroxine at a dosage of 1.6 micrograms per kilogram of body weight per day (rounded to the nearest 25 micrograms) for adults under 65 with primary hypothyroidism and no history of cardiovascular disease.
Traditionally we have tended to start patients on a low dose of levothyroxine and titrate it up over a period of months.
RCT evidence suggests that for the majority of patients this is not necessary and may waste resources.
For patients aged >60y or with ischaemic heart disease, start levothyroxine at 25–50μg daily and titrate up every 3 to 6 weeks as tolerated.
For ALL other patients start at full replacement dose. For most this will equate to 1.6 μg/kg/day (approximately 100μg for a 60kg woman and 125μg for a 75kg man).
If you are starting treatment for subclinical hypothyroidism, this article advises starting at a dose close to the full treatment dose on the basis that it is difficult to assess symptom response unless a therapeutic dose has been trialled.
A small Dutch double-blind cross-over study (ArchIntMed 2010;170:1996) demonstrated that night time rather than morning dosing improved TSH suppression and free T4 measurements, but made no difference to subjective wellbeing. It is reasonable to take levothyroxine at night rather than in the morning, especially for individuals who do not eat late at night.
Strongly recommend Getting full thyroid and vitamin testing privately after 6-8 weeks on this very small starter dose
Essential to test Ft4 and Ft3 and see where levels are within range
You may see levels of Ft4 fall as only on tiny dose
Any embryo is completely dependent on your Ft4 crossing placenta for first trimester. So important that Ft4 levels are high enough during early pregnancy. After first trimester the baby’s own thyroid has developed
Folate and B12 levels important before TTC early for neurological development
The BMJ article you linked says that “Subclinical hypothyroidism is a biochemical state where TSH is elevated above the reference range but FT4 and FT3 levels are within the reference range.” Therefore, according to the NICE guidelines I am not even subclinical (all my levels are within range).
Moreover, it says “Consider levothyroxine for adults with subclinical hypothyroidism who have a TSH of ≥10 mU/L on two separate occasions three months apart. ” and “Consider a six month trial of levothyroxine for adults <65 years old with subclinical hypothyroidism who have: a TSH level above the reference range but lower than 10 mU/L on two separate occasions [or]
Symptoms of hypothyroidism.” My TSH level were way below this and well within the reference range on the two separate occasions they have been measured, and I do not have any symptoms, so I start to understand what the consultant meant when he said that we may be “overmedicating”.
I also understand why monitoring is important: supplementing levothyroxine will interfere with my thyroid, potentially making me hypo instead of improving the picture (thanks for your explanation).
With “vitamin D was just below threshold“ I mean it was 71, with the suggested level being 75 (this was also specified in the lab report, never saw the 50 threshold anywhere, thankfully). She suggested 1000IU vitD3 because said that higher readings improve odds of conceiving/carry a pregnancy to term.
Please remember that do not have Hashimoto nor hypothyroidism— at least not yet, and I now hope that taking levothyroxine will not bring me there.
As per Greygoose below. I would also add that Vid D is fat soluble and should therefore be taken with the fattiest meal of the day, usually dinner. An oral spray is more easily absorbed and is not as constrained.
I usually have a very fatty breakfast, while my dinner is usually very light (a salad, or some fruit). I think I will move the vitD at lunchtime, along with my multivitamic.
Thanks for the tip regarding oral spray, I might switch to that since it gives me some freedom!
If your vit d is in an oil capsule, you don't need to worry about taking it with fat. But, I did forget to mention that when you are taking vit D, it will increase your absorption of calcium from food. So, to make sure that that extra calcium goes into your teeth and bones, you should be taking vit K2-MK7. Vit K2 is also fat soluble.
And, also, vit D and magnesium work together and therefore if you're taking vit d you should take magnesium or the vit d will deplete your magnesium levels.
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