Hi everyone. I have been having some health issues relating to chest pain and heart palpitations for most of this year. I' have been through a barrage of testing on the heart which seems to rule it out completely. Although I do have PAC's which come and go and may be managed with medication, I am waiting to take action on the PAC's until I see what comes of this current thyroid testing.
Given that most of my symptoms line up with hyperthyroidism and I take Levothyroxine for years now and switched from my American generic version to a German brand earlier this year when it ran out, I asked my GP to do a complete thyroid blood work up to make sure everything looked ok there. My results (German doctor/lab):
TSH Basal 2.68 [μlU/ml] Normal - 0.4-4.00
Free T3 - 3.3 [pg/ml] Normal - 2.0-4.2
Free T4 - 1.4 [ng/dl] Normal - 0.8-1.7
TPO - <15 [U/ml] Normal <34
ATG - 368 [U/ml] Normal <115 I'm told this is the antithyroglobulin antibody test
The only real information he gave me was that the ATG was high and I should go and have an ultrasound done on the thyroid. Beyond that I don't really know what this level means. All the other levels are in the range and the TSH, Free T3 & T4 are very close to the levels I had from a 2018 blood panel.
Does anyone have any insight to what this means?
Thank you!
-Paul
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Have you had your ferritin iron stores checked? Low is under 30, optimal is around 100. Chronic 'low ferritin without anaemia' caused my palpitations, and my chest pain is costochondritis.
I don't see that anywhere in my bloodwork. I don't think barrage testing is the German way. As a new patient to this doctor over the past year, and having had him prescribe me the thyroid and BP meds earlier this year, I would have expected him to check the thyroid function in my routine bloodwork that I had done in August. At least it would have been checked back home routinely.
You need an increase as that is only a starter dose. Re-testing after 6/8 weeks is key so dose can be adjusted. I suggest you read around the forum and other Posts/Replies for supportive information.
Bloods should be retested 6-8 weeks after each dose or brand change in levothyroxine
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
And especially if been left under medicated
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)
Is this how you do your tests?
Private tests are available as NHS currently rarely tests Ft3 or thyroid antibodies or all relevant vitamins
Palpitations and tight chest can be low iron/ ferritin
Come back with new post once you get full vitamin testing
See Gp for 25mcg dose increase in levothyroxine
Bloods should be retested 6-8 weeks later
Likely to need several more dose increases
our thyroid controls our metabolism
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
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 some GP’s don’t 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 many medics just don’t read 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.
Thank you for the really insightful replies Slowdragon! I have decided to have the ultrasound my GP prescribed performed by an endocrinologist. Hopefully from there they can take over treating my thyroid properly and doing the additional bloodwork you mentioned above. My GP is leaning towards generalized anxiety as my problem, but I don’t agree that it is the cause of what I’m experiencing right now. Hopefully I can put your good information to use. It’s definitely an adjustment for me here in Germany having to advocate for myself so strongly to get at least the minimum tests done that I should be getting. Thanks again!
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