Questions about adding T3 to levothyroxine for ... - Thyroid UK

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Questions about adding T3 to levothyroxine for the first time

Zazbag profile image
36 Replies

Hello everyone,

I have been given a private prescription for liothyronine (2 x 2.5mcg per day) which should hopefully arrive in a couple of weeks.

I'm currently on 150mcg levothyroxine which I take at night. I prefer this as it means I can eat/drink tea as soon as I wake up, and I noticed I feel more alert in the mornings when I have taken it the night before.

My private endo has asked me to taper down my dose of levo over the next two weeks, so 125mcg this week, then 100mcg next week, before starting lio. She has also asked me to start taking levo in the morning with the first dose of lio, she said it's important to take them together. Then she said to take the second dose either around the 3pm slump (tbh this doesn't happen to me) or around bedtime, whichever I prefer.

Can anyone advise on whether I need to start taking my levo in the morning, whether it's important to take both the levo and lio at the same time? Since I no longer trust doctors I thought I would ask you guys whether there's any sense in this as I really would prefer to keep taking it at night if I can as I feel it fits into my schedule better. And regarding the second dose of the day, should I just take it when I personally feel I need an energy boost?

Also does lio need to be taken on an empty stomach like levo? Away from caffeine? Other supplements? Low dose naltrexone?

Thanks in advance!

36 Replies
Hashihouseman profile image
Hashihouseman

Ok usual caveat of how individual we are in all this but in my experience of combination replacement dosing I would drop 25 levothyroxine and then wait a few days until some symptoms suggest deficiency then take half the liothyronine as soon as you wake preferably 1-2 hrs before normal waking/rising with half your total levothyroxine, taking the rest of your levothyroxine before bed as usual, perhaps with a quarter of the liothyronine, leaving the other quarter for midday or thereabouts. That said, Levothyroxine is better split into as many doses as you can without popping it all day too close to food and drink. Liothyronine is also better split dose, 2.5 is too much for me in one go and I actually split my 5 mcg liothyronine into 4 together with 4 doses levothyroxine starting 10pm then whenever I wake in the night then at the crack of dawn then midday..... it’s not as much of a nuisance as it sounds and feels much more normal than one big dose of levothyroxine which is totally unphysiological, whatever the endocrinologists say! I substitute 25 levothyroxine with 5 liothyronine, dropping 50 levothyroxine seems too much for 5 liothyronine unless you are way over free T4 on testing? Incidentally I have experimented with many dose proportions and combinations at different times and I would say that theoretically equidistant dosing of liothyronine isn’t as good as finding your body’s own rhythm, e.g. taking the daytime dose at midday (after a waking dose at 6-7am) is better than if I wait until 3pm for the liothyronine to space it out more evenly!

Hashihouseman profile image
Hashihouseman

By the way, liothyronine is not like caffeine, it’s not meant as a stimulant and Shouldn’t be used as such, if you’re getting too much Ft3 either from too much liothyronine and levothyroxine together or too closely spaced liothyronine doses it will feel unpleasant, kind of rushing in the head maybe tinnitus and edgy with raised pulse. Apart from that you can take it whenever you like, it’s not affected by food and drink. You may have to experiment with different levothyroxine doses to get the right combination with liothyronine and it may take 6-8 weeks for your body to figure out how to balance the t4 and t3 you will be supplying, there may be some disruptions and inconsistencies in symptoms while you settle into a dose regime.

NWA6 profile image
NWA6

Hey 👋 No need to change your Levo routine and do you really need to decrease? I doubt it. Also 5mcg per day? 😬 I doubt you’ll see any improvements but it’s a start.

It it were me, don’t change how much Levo you take and how you take it, Levo and Lio do not need to be taken together. I’d probably also take the 5mcg of T3 at once and at night.

What’s your last blood test?

Zazbag profile image
Zazbag in reply to NWA6

Hey, I have replied to the thread with my recent test results, just to say that the 5mcg lio is meant as a starter dose, she wants to taper me up gradually... She wants me to come in for a blood test after 4 weeks on on 5mcg lio + 100mcg levo and I guess she'll up my dose if it looks like I need it... I am willing to try a different approach though if others here think this isn't the best way of going about it...

NWA6 profile image
NWA6 in reply to Zazbag

Levo is good as it stands. No need to lower. I think you’ll crash even with added T3.

Your T3 is ‘ok’ and I say this not to mean it’s ‘good’ it’s obviously not optimal but the added T3 5mcg could potential do you well, although 10 would probably be better but yes obviously most people like to work up gradually so that they find their sweet spot.

So I wouldn’t lower T4 and I would add another 5mcg after 5-10 days, not 4wks. You’d only need to wait weeks if you were messing with your Levo.

NWA6 profile image
NWA6 in reply to NWA6

Or you could do alternate days with Levo. 150 one day, 125 the next.

Currently you’re on 1050 a week

150/125 would lower it to 975

OR

150 six days a week making it 900

You really can play around with these doses and how you take them.

I take 150 Mon - Friday and 100 Sat/Sun (this is so I’m not given Teva 25mcg tablets and I don’t have to half the 50mcg tablet)

Pick a dose and stick to it for 6wks. Add your T3, feel the change or not add more T3 and then do a blood test 6wks AFTER you’ve settled on a dose, this will be the most accurate.

Some say don’t mess with Levo at the same time as adding T3 or optimising Vits. Pah! Get on with it I say 😂 Unless you know or find out that you’re super sensitive to changes then who’s got time to wait around! You’re off to Jordon soon and you need to get this done! 🤗

Zazbag profile image
Zazbag in reply to NWA6

Aw bless you for remembering that hah, yeah I am really anxious to get myself sorted on the right treatment before I go, I hope I can.

Zazbag profile image
Zazbag in reply to NWA6

Oh ok! One thing I'm confused about is whether my bad moods since increasing to 150mcg are because I have too much FT4 now and not enough FT3, or whether it's just because I don't have enough FT3 in my system. I really haven't felt good in terms of mood or energy level on 150mcg and I suspected it was because the extra FT4 was maybe generating rT3, which would mean I should lower the dose...?

NWA6 profile image
NWA6 in reply to Zazbag

I know nothing about Rt3 😬 if you suspect that the higher in range FT4 was a mood changer then yes drop but I do worry about going below 74% range, who knows we are all so bloody individual! 😂 it makes this shot complicated to advise! (Which is why I suspect Docs would rather ignore us that work with us).

I’d go for the 150 six day’s a week, that’s a drop of 150 a week which might be enough to lower but not drop you down too low.

My FT4 was 20/21 (12-22) once and I was an anxious wreck! And yet FT4 is ‘inactive’ not that inactive if it causes me jittery, anxious, cryey moods. Anyway my FT3 has never changed, always 0% through range no matter high or mid range FT4 (low FT4 dies result in below range FT3 for me)

What do you think? You’ve got a lot of advice from everyone. What’s your gut feeling?

Zazbag profile image
Zazbag in reply to NWA6

Yeah it definitely has made me feel very tense and emotional and easily angered/irritable. I was already quite irritable when I was undermedicated but this has pushed me into being completely unreasonable at times and I am finding it hard to control my responses to things, which normally, even when I am irritable, I can still do. I have read that this can be down to too much FT4.

And yes I imagine there's an element of apathy from doctors because proper treatment is actually quite an involved process for some patients, and doctors don't have the time/resources/knowledge to meet the requirements. Hence the institutional gaslighting.

I see, yes that sounds similar to what I'm experiencing, except I'm also being very angry. This is very new to me and quite peculiar. I've felt like I've had constant extreme PMS mood swings since the 150mcg dose increase, that's the only way I can describe it. But it's actually even worse than PMS. I have heard that if your FT4 is too high, your body converts some of it to reverse T3, which blocks T3 receptors and stops your cells from being able to use your FT3, so even when your FT3 looks decent, it can be causing symptoms. I don't know how much of a scientific basis there is for this but I've heard it from multiple sources. I did find a paper recently which stated that:

"In hypothyroid patients, L-T4-replacement that is sufficient to maintain a normal serum TSH is accompanied by a serum T4 that is higher than in normal individuals and may not result in an appropriately normal serum T3 concentration."

pubmed.ncbi.nlm.nih.gov/169...

It doesn't talk about symptoms though or reverse T3.

I really have no idea what the best way to proceed is, but I think I will continue taking 125mcg for now and add in the lio as soon as I receive it. I agree with you that it's better to just get on with taking it and see what happens. I know too much T3 can be dangerous, but I'm only adding in 5mcg a day, and my FT3 is less than two thirds through the range right now, and that will go down with the lower dose of levo, so I really don't think it poses much risk. And since it has a short half-life, if I feel bad I will stop taking it and the effect will go away within a day or less, right?

Batty1 profile image
Batty1 in reply to Zazbag

I had issues with hiddeous Mood swings when I was on T4 only when they added the T3 my moods improved a lot.

Zazbag profile image
Zazbag in reply to Batty1

This is so reassuring! Did you reduce your levo dose when you added the T3 or just keep it the same? I'm wondering whether I need to lower my levo or whether the addition of T3 will stop the symptoms I'm having...

Batty1 profile image
Batty1 in reply to Zazbag

When you take T3 its going to lower your TSH and most doctors go by the TSH when it comes to dosing and will reduce your meds. Your doctor wants you to lower the T4 meds because your TSH is already low and that T3 she gave you will lower it more. Try to drop T4 to 125mcg and see how you feel, Im sure you won’t have no earth shattering feelings and retest in 6-8 weeks or whenever your scheduled.

Im currently on 100mcg (T4) per day along with 10mcg (T3) I split my T4 into 2 doses and add 5mcg T3 with each dose and my Endo has just added an extra 50mcg T4 to take once per week week (I split this and take it a couple times a week).

T3 will definitely help with moods!

Zazbag profile image
Zazbag in reply to Batty1

Thanks this is really helpful!

Zazbag profile image
Zazbag in reply to Batty1

I've been on 125mcg of levothyroxine (down from 150mcg) for about 2 days and genuinely feel an improvement in my irritability. I feel a lot more relaxed compared to before. But I feel more sluggish. I'm hopefully adding in the T3 tomorrow, which I'm praying will give me the energy that neither 125 nor 150mcg of levo have.

Batty1 profile image
Batty1 in reply to Zazbag

It should help A bit but I wouldn’t expect earth shattering results.

Zazbag profile image
Zazbag in reply to Batty1

I'm expecting a steady improvement as the dose is titrated up.

McPammy profile image
McPammy

First thing to check is what was your latest T4 blood results. If above the range then reduce it. If not I’d leave it as is.

I didn’t reduce my Levo advised by my private Endocrinologist. It was at the top of the range. I introduced T3 5mcg twice a day. I take my T3 when I get out of bed. I take half my Levo at noon. I then take another T3 at 2.30pm and then other half of my Levo at 4.30pm. I don’t know why but I can’t take my full Levo dose in one go or I become very weak. It’s odd but this splitting of the Levo works for me.

I feel 100% better since starting T3. If I exercise regularly I need to increase my T3 and add a third dose of 5mcg. T3 for me is best spaced by 6/7 hours. It also has a short half life of 2/3 days. So best trying taking it the same time each day.

Have you had the DIO2 gene test to see if you have a faulty gene, meaning poor conversion from T4 to T3. I took this test and was positive. It’s good to know the reason why you are converting poorly if you can.

Ive lost over three and a half stone since starting T3 a year ago. I’m now full of energy and life after struggling on T4 for 11 years. I hope it works well for you also.

I think it would be too much to reduce levo by 50 mcg in two weeks. Usually, you decrease by 25 mcg (if labs suggest FT4 levels are out of range) and hold it there for 6-8 weeks. Decreasing by 25 mcg for one week and then by another 25 mcg does not make much sense. Your FT4 levels won´t have time to adjust and you risk ending up with too low FT4 after a few weeks. It´s often said that when on T3 FT4 levels don´t matter, but I have found that to be untrue. If my FT4 levels drop below 1 (my lab´s ranges: 0.7-1.5) I feel more hypo, regardless of my FT3 levels. So you should not decrease too much too fast or you risk missing your sweet spot.

As others have suggested, don´t lower levo unless necessary. Doctors seem to think you always need to do that if you add T3, but that depends on your FT4 levels.

Zazbag profile image
Zazbag

Hi everyone, thanks for your replies.

Here are my most recent test results, from 17th August. The first is from an NHS lab, the second is from Medichecks. I don't know why there's such a big difference between the two, because they both came from the same venous blood sample:

NHS:

TSH: 0.03

T4: 19.4 (74%)

FT3: 5.2 (56.8%)

Medichecks:

TSH: 0.023

FT4: 22.6 (106%)

FT3: 5.6 (67.6%)

I have felt better in some ways since increasing my levo to 150mcg:

Feet usually feel warm now (but not always)

Periods now 4 days with only 1 day of heavy bleeding (usually 8 days with 3–4 days of heavy bleeding)

Appetite has gone quite low and seem to be very slowly losing weight

But in other ways I feel worse/no improvement:

Headaches

Constant tiredness (but different feeling to fatigue, more like a worn out, exhausted feeling, I've been falling asleep a lot during the day which I don't normally do)

My hair is still falling out (but has been since February when I was 100mcg levo

Very irritable and easily frustrated/angered and tense (new feelings)

Moodiness and depressive feelings/suicidal thoughts (new feelings)

Still can't recover from exercise

Breathlessness (new feeling)

I told my doctor I think I have too much FT4 for my FT3 and she agreed that's probably what's happening.

The 5mcg per day is meant as a starter dose, she said I may well need 20mcg but she doesn't want to start me on that as she's afraid of making me hyper.

I don't know if it's related or a coincidence, but I dropped down to 125mcg last night and I woke up feeling very tired/sore headed. I had trouble sleeping last night though so it might just be because of that.

hipolion profile image
hipolion in reply to Zazbag

I think the levo dose is to much at 150mcg. You need about 125 levo and some T3

Zazbag profile image
Zazbag in reply to hipolion

Thanks, I think you're probably right. I'm going to stay on 125mcg and add in the T3 as soon as I have it.

Zazbag profile image
Zazbag

Also, has anyone here tried taking lio like this?

"• For doses lower than 20 micrograms, the tablet should be allowed to dissolve/disperse in 20 mL of water for 10 minutes, in a small measuring cup.

• The patient should gently swirl the solution occasionally to aid the dissolution/dispersion. The patient should then swirl the solution for a few seconds prior to using a suitable oral syringe to withdraw the amount of liquid corresponding to the dose prescribed (5mL for a 5mcg dose; 10 mL for a 10mcg dose).

• The patient can then squirt the liquid directly into their mouth from the suitable oral syringe by gently pressing the plunger.

• Any remaining liquid should be discarded."

I've only heard of people cutting the tablet up.

endomad profile image
endomad in reply to Zazbag

Utter waste of t3 cut with pill cutter or knife, tiny difference in size won't make that much difference on such a small dose. I lmao that my Dr prescribed nearly double the amount of tablets so I could throw half away, utter nonsense. Keep your spare tablets you may need them later on x

Zazbag profile image
Zazbag in reply to endomad

It also seems like you wouldn't get an accurate dose as it's unlikely the lio would disperse uniformly throughout the liquid, and even if you used all of the liquid (which it tells you not to) some lio would stick to the container...

endomad profile image
endomad in reply to Zazbag

Just cut them, the water thing started 3 years ago obviously some bright spark came up with the idea prob on nhs funded research 😠 one min my local ccg said it's too expensive then with individual funding they had money to burn! I was getting 5 months tablets every 3 months! Bonkers

Zazbag profile image
Zazbag in reply to endomad

Huh? WTF is wrong with the NHS when it comes to hypothyroid treatment?!

endomad profile image
endomad in reply to Zazbag

😂😂😂😂f**k knows, it's a crap shoot, you couldn't make this shit up. Just when I think iv heard it all someone posts something and I just sit there with my mouth open.

Zazbag profile image
Zazbag in reply to endomad

Hahaha!

endomad profile image
endomad

We are all so different I take 75mcg t3 when I go to bed, my Endo is amazed I can sleep at all, I actually sleep better and the thinking there is poss stops me having adrenaline rush at 3am every morning. It has never had a stimulant effect for me. It is all trial and error, the Drs are guessing just as much as we are. It took about 9-12 months of detailed journal to find if I take t3 in morning I slept all day groggy all night, I am thyroid resistant. Keep detailed food mood meds supplements sleep journal so you can identify trends on how you feel but it's boring :) go by what Dr says as a start but you may need to tweak and change depending on how you feel xx

Zazbag profile image
Zazbag in reply to endomad

Thanks endomad, it's really useful to hear this perspective!

Angelic69 profile image
Angelic69

Why has he added T3?

Zazbag profile image
Zazbag in reply to Angelic69

Because I'm still having thyroid symptoms even though my dose of levo has been increased to 150 mcg, and my FT4 is quite high in the range. I actually feel worse now I'm on 150mcg, even though it has resolved some of my hypo symptoms (my feet are usually warm now and my periods are lighter and shorter) it has introduced some new ones that are making my life miserable right now (irritability, tension, anger, depression, my mood is all over the place, headaches, exhaustion (not fatigue though, a different kind of tiredness to hypo fatigue)). And my hair is still falling out. I'm hoping adding T3 will help.

Angelic69 profile image
Angelic69 in reply to Zazbag

When i had T3 added i did not get as exhausted but i was also less active anyway.

I still get irritable with T3 but cope better because im not so tired.

I too am suffering with hair loss whilst taking 125mcg Levothyroxine and 10mcg T3 but the hair loss did not begin until seven months into taking HRT by which time my TSH had increased to 2.39.

Hair loss can be due to androgens, low iron and B vitamins in addition to an immune response.

My personal journey to decrease my hair loss involved stopping my HRT which was probably increasing adrogens and reducing the effectiveness of my thyroid medications.

If you are like me in your thyroid symptoms your body may take longer than normal to remove waste products and things that are left rotting can cause a huge problem.

Are all your nutrients at the higher end of the ranges as this may indicate absorption difficulties or diet requirements.

Headaches can sometimes be relieved by increasing your water intake and can also improve brain fog.

Check all medications and supplements that you take for contraindications as you will be suprize at what can interfere with your thyroid health, like soy products.

Hope something i mentioned brings relief, kind regards and good luck.

Zazbag profile image
Zazbag in reply to Angelic69

Thanks for the suggestions. My vitamins are optimal and my ferritin was 53 at last test and climbing as I'm taking 420mg of FF a day. I'm only 33 so not on HRT or anything like that. I'm optimistic that T3 will help me, so I'm not going to worry about other things for the moment. I spent months trying other things and getting my vitamins optimal before deciding to try T3.

Angelic69 profile image
Angelic69 in reply to Zazbag

Did they check blood oxygen levels?

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