I have hashimoto’s and have been supplementing with combination T3 + T4 therapy for around 12 months now
Prior to this I was on T4 only ( 100mcg per day ) my TSH results usually came back around 2 and my Free T3 was in the lower 30% of the normal range - generally I felt lousy and had v low energy.
So I gradually added some Tiromel brand T3 and reduced my T4
Tested every 6 weeks or so and adjusted - aiming for FT3 in the upper 30% of normal range.
I am more or less achieving this now - taking 50mcg Levo and 62.5mcg tiromel ( T3) per day for the last 5 months or so - and feeling better than I have for years - energy improving. All thyroid antibodies now also below test detection limits ( ie <9 or <10)
However, my latest TSH seems to have suddenly dropped v low (this is a bit odd as I tested it after 5 weeks of the above dosing and it was nowhere near as low as this) so seems to take a very long time to settle.
I would say that you haven't got the balance of Levo and T3 right.
Taking T3 lowers TSH, often suppressing it, so don't worry about the low TSH.
When on combination hormone replacement we have to find the levels of FT4 and FT3 that suit us individually. I need both FT4 and FT3 in balance around 70% through their ranges. Some members are fine with FT3 in the upper part of range and FT4 in the lower to mid point of range. There are a few members that take T3 only as that's best for them.
If I were you I'd experiment with adding some Levo to get your FT4 into range and take it from there. You may have enough natural conversion that a higher FT4 will also raise your FT3 so be prepared to tweak doses of both to find the right combination for you. Only change one thing at a time though, and leave 6-8 weeks between dose change and testing.
When testing last dose of Levo should be 24 hours before blood draw, and last dose of T3 should be 8-12 hours before blood draw even if this means adjusting timing and splitting dose the day before if necessary.
When testing we should not disrupt the dosing regime at all! Only concern is to avoid testing within 3-4 hours of a dose. The test should indicate our levels under a consistent regime, we want to know what the effect of the dosing regime is as it is! If someone takes 125 levothyroxine at 6am the blood test would have to be at 05:59 to give 24 hrs space if that is important (which is doubtful) skipping a whole dose will likely disrupt whatever the tested levels are from what they usually are..... levothyroxine has an immediate effect on thyroid homeostasis because it’s a big dump of free t4 that the healthy thyroid would never deliver, so suddenly stopping that if someone has stabilised on it every day will affect free hormone levels and maybe tsh too. What is the objective of fiddling with the dose just to accommodate a blood test? Where is the evidence for it? I would want to know my levels exactly as they are under my normal & consistent regime tested at the same time of day each time the test is run.
I'm not remotely fussed that my TSH is low - it's just what happens when you take lio There's a HUGE difference in having low TSH because you are on lio and having a low TSH (and over-range free T4 and free T3) when you're not on thyroid meds ... albeit that it seems too subtle a distinction for many doctors
I'm on combo therapy and like both frees to be high in range, but various people on this forum eg greygoose just take lio and have no discernable free T4 in consequence - so it's very much a question of getting your dose to what you personally like.
Basically, you don't want your free T3 going over-range in the long-term - but beyond that my understanding is that it's about what works best for you. Do you feel well? You're taking quite a lot of T3 meds - it's possible that more levo and less tiromel would result in higher free T4 and not much difference in free T3 - but if you're happy and feel tip-top I wouldn't change anything x
These results are fine. TSH will respond to your liothyronine dose, 10 mcg liothyronine has about the same effect on TSH as 30 mcg levothyroxine.
I am surprised at your fT3 and TSH given you are taking 62.5 mcg Tiromel. This is a fairly large dose, equating to around 190 mcg levothyroxine. Thus,I would expect a high fT3 and suppressed TSH. Did you leave a long time between your last dose of Tiromel and taking the blood?
It’s possible you are being supplied with substandard liothyronine although Tiromel is so cheap it wouldn’t be profitable to fake it. I suppose it is always possible that the supplier has not stored it correctly.
your tsh should be next to 0 if you are taking t3 - this means that you do actually convert t4 to t3 and you don't need to take t3 (although some bodies only do so intermittently so you may need a few tests to see if and when you convert eg. my pregnant daughter converted when pregnant but not before). If I got these results I'd be increasing t4 and finding out if I need t3.
There are massive long term problems if your hormones are not right. I personally lost half my colon, my gall bladder and had to have a total hysterectomy, although I may just be unlucky....
I don't understand ,cazlooks, when you say" this means you do actually convert T4 to T3 and you don't need to take T3" ? could you explain what you mean here, i don't understand your thinking.
I'm not aware of any connection between FT4/3 levels and conditions which would lead to loss of colon , gall bladder, hysterectomy , could you tell us what you think the connection is .
" if i got these results i'd be increasing T4 and finding out if i need T3"... i do agree with you here, ie. why not increase Levo before trying to add T3? When TSH was still around 2 and FT3 was only 30% at this point, then possibly a higher dose of Levo might have provided enough T3 . But without checking garz' history i don't know if a higher dose of Levo had been tried previously.
Edit ... also could you explain "some bodies only do so intermittently my daughter converted when pregnant but not before" ...It sounds like you are saying she had 0 FT3 before pregnancy , but conversion of T4 to T3 is surely not an 'all or nothing' process, as presumably 'nothing ' would result in death, since T3 is the active hormone.
as I understand, and you should do your own research, t4 is a form of thyroid that can only be used in a limited capacity in the body. Thyroid stimulating hormone (tsh) is the hormone which converts t4 to its usable form t3 when needed. If you don't convert you don't have the t3 when you need it. If you can convert sometimes then your tsh is only working intermittently. If you are taking t3 then your tsh is not needed as the t3 is already in your body when needed, and so your tsh will be 0. If you have a tsh higher than 0.1 then you are converting t4 to t3. If your tsh production is failing to produce all the time (as with pituitary problems) then you may get a tsh read out higher or lower each time you test, then you need to take t3 consistently to override the failures. It's very complicated, and most doctors and some consultants don't know how this works. Find one that does. cx
Hi, thanks for trying to explain where you are coming from. I can see several holes in your logic here though..... for example , How would you explain hyperthyroid results with supressed (0.0)TSH which is known to be caused by too much thyroid hormone being produced ? there is T4 to T3 conversion going on there for certain , and 0 TSH.
TSH causes the thyroid gland to increase it's production of T4 and some T3, which you don't mention , and also it has an effect on the deiodinases which are what actually convert T4 to T3 .When TSH is supressed there is different dieiodinase activity and so less conversion of T4 to T3, however some still happens. When TSH is higher there is more deiodinase activity to convert a higher proportion of T4 to T3.
I think you are misundertsanding the role of TSH somehow. It does not turn conversion on and off in such a black and white way . If this was the case then everyone with a supressed TSH would die, since T3 is the only way thyroid hormone can have an action on cells ,because as you correctly say T4 is the Storage /transport/inactive form and must be converted to T3 in the cells by deiodinase activity causing the removal of one iodine atom from the T4.
"your tsh should be next to 0 if you are taking t3 - this means that you do actually convert t4 to t3 and you don't need to take t3".
I´m sorry, but I don´t understand this statement. How do you know that you are converting T4 to enough T3 when on a T3+T4 combo; I thought the only to tell how well you are converting is to do it when on levo only?
wow - thanks for all the helpful comments - that was a great response!
to clarify a couple of points mentioned.
test draw was at 8am - 12hrs from last T3 and 24hrs from last T4 supplementation
results are fasted - if that makes a difference ( always do my tests this way now for consistency )
also stopped all B vitamins aroudn 5 days before - as previously found Biotin in particular distorts the test results dramatically ( seemed to decrease FT4 and increase TSH significantly - and result in under diagnosis and under medication - it seems its well known effect and many labs now advise stopping biotin / B vitamins at least 2-3days before testing)
i had read that the triomel brand is perhaps less strong in terms of potency than other brands - but its the only one i can get reliably and since it is raising my T3 significanly i am OK with it if i have to take a bit more. i am comfrtable it is not counterfeight. the mecication is in date and i have used the same supplier for some time and they are very reliable.
regarding my general health - I have been diagnosed with Chronic Lyme disease by IgM and IgG antibodies and have been struggling with my general health for 5-6years now.
i was super fit and healthy then sudden random complex health issues struck without explanation and it took over 4 years to get a diagnosis.
Mildly elevated TSH showed up fairly early on - into the 5-6 range - but not skly high - antibodies were initialy 150ish - but now undetectable
i belive this is a form of autoimmunity triggered by the lyme infection ( this phenomenon is quite well documented )
it turns out i was still active and doing things like 4hrs mountain bike rides in the hills with a TSH of 6 that the GP failed to follow up on till after i became very ill with lyme and they re-ran alot of tests so i didnt think the Hashimoto's was holding me back a huge amount initially.
but i have read recently in books by lyme experts that some people will not recover from Lyem unless they get thier thyroid hormones in teh ideal range - and so that has sent me down the path of combination T3 and T4 therapy.
i am feeling better recently - but its all relative, as i still have a long way to go - and i am doing a lot of diet and lifetsyle interventiosn to support my bodies recovery.
i dont really want my T3 to reduce belw where it is - so i think i may try increasing the levo dose only and see where that gets me - maybe to 75mcg a day ...?
is there a known relationship to calculate a best estimate of what dose it should teake to get in teh middle of teh range or just above ?
I thought that might be the case,...... so pleased to hear you are feeling better than on levo alone...... my two 'penneth..... if you feel well carry on on your current dose, your TSH is not low enuf to be a problem ,your Ft3 is not above range, and as far as i know there are no risk at all from low T4 in this situation.
NHS guidelines use this study as part of their evidence of risks of low tsh, but it seems they only read (parts of !) the conclusion, not the full results in detail. And so manage to use it to say something it doesn't say at all .
Right - so i'm now comfortable in terms of what i am trying to achive - but i sat down to try to work out how much T4 to add i was a liitle suprised to see that becuase my FT4 is less than half its target value ( assuming i would like to get it to aroudn middle of the normal range )
and this wuold suggest doubling my dose of levothyroxine - whilst keeping the Triomel dose about the same ( becuase i dont want to reduce my FT3 much if at all - in fact if it went up a little bit more it get into the top 30% of the range and at least on paper thats where i would like to be )
this would mean taking 100mcg of Levothyroxine plus 62.5mcg of Triomel daily
this just suprised me as the GP had me on 100mcg of levo for years = my TSH was usually aroudn 2 or just over
does this make sense ?
i know i am likley to get a bump in FT3 also from the T4 converting - but that seems to be an unknown quantity at the moment - so can only guess as to its size - and have some headroom in FT3 anyway.
i know there are rules of thumb in terms of TSH suppression - but since we have established that its not really a primary indicator - that would not seem to be of much use here.
so are there any rules of thumb that apply to conversion that can be applied to get in the ballpark or is it really pure trial and error ?
unfortunately I don't think you can use such a mathematical approach to dose in= results out :).... that would be too easy .
doubling T4 dose would probably be too much. If you want to raise T4 just be patient and increase dose by a small amount 12.5 or 25mcg at most ,and retest after 6 weeks.
Boring i know ,but remember the hare and the tortoise.
but there must be some approximate rules in play - at least for the same individual - all other things being equal
for instance - I looked back at the relationship bwtween 2 different LEVO doses and resulting FT3 levels (when i was only taking Levo )and found that there was about 0.0408 FT3 for each microgram
using some simple math you can then work out a roughly how much the 62.5mcg of T3 must be contributing to the FT3 in my mosty recent tests - which works out to be in the region of 0.0549 FT3 per microgram
using that relationship you could calculate a rough theoretical dose of each to achive a given FT3
something like this:
(62.5 * 0.0549) + (50*0.0408)=FT3
if you use the same formula and try different dose combos you then get the below results
( in the form: Triomel dose/Levo dose/ resulting FT3 expected)
62.5/50/5.47 this is a cross check on current - gives good approximation of current results
62.5/100/7.51bit high - so need less Trio dose
50/100/6.824good but still poss a fraction high
25/100/5.452OK - but poss just a fraction low
37.5/100/6.138 - this looks good
i doubt its super accurate - but it fits with expectation - ie just doubling levo will lead to too high a FT3 -
the optimum might be something like 37.5triomel / 100levo = FT3 6.1
i am not expecting my body to work like a perfect mathematical model - just thinking it might just get me where i want to go with fewer steps and less tests - as the cost certainly adds up
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There's a HUGE difference in having low TSH because you are on lio and having a low TSH (and over-range free T4 and free T3) when you're not on thyroid meds ... albeit that it seems too subtle a distinction for many doctors
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