TSH levels after total thyroidectomy. What should they be?

[Mazzer]

I have a reading after 8weeks on 100mcg levothyroxine at 9.29. Free 3 at 3.44 and free4 at 15.8. Feeling a bit rough.

[SlowDragon Administrator]

What was reason for total thyroidectomy?

If it was for thyroid cancer they like to keep TSH suppressed around zero

Anyone adequately treated on levothyroxine is likely to have TSH well under one

Please add ranges on these results (figures in brackets after each result)

Clearly TSH is far too high

Are you taking levothyroxine early morning or last thing at night ?

Levothyroxine is an extremely fussy hormone and should always be taken on an empty stomach and then nothing apart from water for at least an hour after

Many people take Levothyroxine soon after waking, but it may be more convenient and perhaps more effective taken at bedtime

verywellhealth.com/best-tim...

No other medication or supplements at same as Levothyroxine, leave at least 2 hour gap.

Some like iron, calcium, magnesium, HRT, omeprazole or vitamin D should be four hours away

(Time gap doesn't apply to Vitamin D mouth spray)

If you normally take levothyroxine at bedtime/in night ...adjust timings as follows prior to blood test

If testing Monday morning, delay Saturday evening dose levothyroxine until Sunday morning. Delay Sunday evening dose levothyroxine until after blood test on Monday morning. Take Monday evening dose levothyroxine as per normal

Many people find Levothyroxine brands are not interchangeable.

Which brand of levothyroxine are you currently taking

Many patients do NOT get on well with Teva brand of Levothyroxine. Teva contains mannitol as a filler, which seems to be possible cause of problems. Teva is the only brand that makes 75mcg tablet. So if avoiding Teva for 75mcg dose ask for 25mcg to add to 50mcg or just extra 50mcg tablets to cut in half

Are you currently taking Teva?

Teva, Aristo and Glenmark are the only lactose free tablets

dropbox.com/s/6h3h0qi4eqwi6...

Teva poll

healthunlocked.com/thyroidu...

Once you find a brand that suits you, best to make sure to only get that one at each prescription.

Watch out for brand change when dose is increased or at repeat prescription.

academic.oup.com/jcem/artic...

Physicians should: 1) alert patients that preparations may be switched at the pharmacy; 2) encourage patients to ask to remain on the same preparation at every pharmacy refill; and 3) make sure patients understand the need to have their TSH retested and the potential for dosing readjusted every time their LT4 preparation is switched (18).

Has your GP/ endocrinologist seen these results

They should increase levothyroxine dose by 25mcg and retest in 6-8 weeks

Essential to test vitamin D, folate, ferritin and B12 if not been tested yet

Frequently necessary to supplement to maintain optimal vitamin levels

[Mazzer in reply to SlowDragon]

TSH 9.29 (0.27 - 4.2)

Free T3 3.44 ( 3.1 - 6.8)

T4 15.8. ( 12 - 22)

Tested first thing in morning before next dose.

[SlowDragon Administrator in reply to Mazzer]

Ft4 is only 38% through range

Ft3 only 8.11% through range

Helpful calculator for working out percentage through range

chorobytarczycy.eu/kalkulator

Aiming for Ft4 at least 60-80% through range

Ft3 at least 60% through range

Currently poor conversion and under medicated

Have you had thyroid antibodies tested before thyroidectomy

[Mazzer in reply to SlowDragon]

Yes through the roof. Still very high but decreasing post operation. Diagnosed with Hashimoto by Endo several years ago. Unmedicated as told “in normal range”

[Mazzer in reply to Mazzer]

Brilliant thank you for your help. Very useful

[SlowDragon Administrator in reply to Mazzer]

So even though you don’t have thyroid you likely benefit from strictly gluten free diet

Hashimoto's frequently affects the gut and leads to low stomach acid and then low vitamin levels

Low vitamin levels affect Thyroid hormone working

Low vitamin levels tend to lower TSH, in effect hiding how hypothyroid you may be

Poor gut function can lead leaky gut (literally holes in gut wall) this can cause food intolerances. Most common by far is gluten. Dairy is second most common.

According to Izabella Wentz the Thyroid Pharmacist approx 5% with Hashimoto's are coeliac, but over 80% find gluten free diet helps, sometimes significantly. Either due to direct gluten intolerance (no test available) or due to leaky gut and gluten causing molecular mimicry (see Amy Myers link)

Changing to a strictly gluten free diet may help reduce symptoms, help gut heal and slowly lower TPO antibodies

While still eating high gluten diet ask GP for coeliac blood test first or buy test online for under £20, just to rule it out first

healthcheckshop.co.uk/store...?

Assuming test is negative you can immediately go on strictly gluten free diet

(If test is positive you will need to remain on high gluten diet until endoscopy, maximum 6 weeks wait officially)

Trying gluten free diet for 3-6 months. If no noticeable improvement then reintroduce gluten and see if symptoms get worse

chriskresser.com/the-gluten...

amymyersmd.com/2018/04/3-re...

thyroidpharmacist.com/artic...

drknews.com/changing-your-d...

restartmed.com/hashimotos-g...

Non Coeliac Gluten sensitivity (NCGS) and autoimmune disease

ncbi.nlm.nih.gov/pubmed/296...

The predominance of Hashimoto thyroiditis represents an interesting finding, since it has been indirectly confirmed by an Italian study, showing that autoimmune thyroid disease is a risk factor for the evolution towards NCGS in a group of patients with minimal duodenal inflammation. On these bases, an autoimmune stigma in NCGS is strongly supported

ncbi.nlm.nih.gov/pubmed/300...

The obtained results suggest that the gluten-free diet may bring clinical benefits to women with autoimmune thyroid disease

nuclmed.gr/wp/wp-content/up...

In summary, whereas it is not yet clear whether a gluten free diet can prevent autoimmune diseases, it is worth mentioning that HT patients with or without CD benefit from a diet low in gluten as far as the progression and the potential disease complications are concerned

restartmed.com/hashimotos-g...

Despite the fact that 5-10% of patients have Celiac disease, in my experience and in the experience of many other physicians, at least 80% + of patients with Hashimoto's who go gluten-free notice a reduction in their symptoms almost immediately.

[SlowDragon Administrator in reply to Mazzer]

Have you had 25mcg dose increase in levothyroxine since this result?

Bloods should be retested 6-8 weeks after EACH dose increase

Likely to need additional dose increase

Do you always get same brand of levothyroxine

Obviously need to continue working on improving low ferritin

Did you get coeliac blood test

Are you now on strictly gluten free diet

[SlowDragon Administrator]

For full Thyroid evaluation you need TSH, FT4 and FT3 tested. Also EXTREMELY important to test vitamin D, folate, ferritin and B12

Low vitamin levels are extremely common, especially if under medicated

Ask GP to test vitamin levels NOW

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

List of private testing options

thyroiduk.org/getting-a-dia...

Medichecks Thyroid plus antibodies and vitamins

medichecks.com/products/adv...

Thriva Thyroid plus antibodies and vitamins By DIY fingerpick test

thriva.co/tests/thyroid-test

Thriva also offer just vitamin testing

Blue Horizon Thyroid Premium Gold includes antibodies, cortisol and vitamins by DIY fingerprick test

bluehorizonbloodtests.co.uk...

If you can get GP to test vitamins and antibodies then cheapest option for just TSH, FT4 and FT3

£29 (via NHS private service ) and 10% off if go on thyroid uk for code

thyroiduk.org/getting-a-dia...

monitormyhealth.org.uk/thyr...

[Mazzer in reply to SlowDragon]

I had the thyroidectomy because I had a sub sternal goiter. The bloods were done by Medichecks. Vit and minerals all fine D is fine. Taking in the morning on empty stomach. Levothyroxine is Morning Star. Now on 125mcg. Retest at 8 weeks.

Thanks

[SlowDragon Administrator in reply to Mazzer]

So vitamin D is over 80nmol

Active B12 over 70

Folate at least half way through range

Ferritin at least half way through range

[Mazzer in reply to SlowDragon]

Yes except ferritin 48.4 range = 13- 150

[SlowDragon Administrator in reply to Mazzer]

Never supplement iron without doing full iron panel test for anaemia first

Eating iron rich foods like liver or liver pate once a week plus other red meat, pumpkin seeds and dark chocolate, plus daily orange juice or other vitamin C rich drink can help improve iron absorption

List of iron rich foods

dailyiron.net

Links about iron and ferritin

irondisorders.org/Websites/...

drhedberg.com/ferritin-hypo...

This is interesting because I have noticed that many patients with Hashimoto’s disease and hypothyroidism, start to feel worse when their ferritin drops below 80 and usually there is hair loss when it drops below 50.

Thyroid disease is as much about optimising vitamins as thyroid hormones

Masses of post on here discussing low ferritin

[SlowDragon Administrator in reply to Mazzer]

Taking in the morning on empty stomach. Levothyroxine is Morning Star. Now on 125mcg.

Presumably you mean Northstar levothyroxine ?

100mcg Northstar is Accord

25mcg Northstar is Teva

(Yes annoying and catches many out)

Many people find Levothyroxine brands are not interchangeable.

Many patients do NOT get on well with Teva brand of Levothyroxine. Teva contains mannitol as a filler, which seems to be possible cause of problems. Teva is the only brand that makes 75mcg tablet. So if avoiding Teva for 75mcg dose ask for 25mcg to add to 50mcg or just extra 50mcg tablets to cut in half

Teva, Aristo and Glenmark are the only lactose free tablets

dropbox.com/s/6h3h0qi4eqwi6...

Teva poll

healthunlocked.com/thyroidu...

Once you find a brand that suits you, best to make sure to only get that one at each prescription.

Watch out for brand change when dose is increased or at repeat prescription.

academic.oup.com/jcem/artic...

Physicians should: 1) alert patients that preparations may be switched at the pharmacy; 2) encourage patients to ask to remain on the same preparation at every pharmacy refill; and 3) make sure patients understand the need to have their TSH retested and the potential for dosing readjusted every time their LT4 preparation is switched (18).

Levothyroxine is an extremely fussy hormone and should always be taken on an empty stomach and then nothing apart from water for at least an hour after

Many people take Levothyroxine soon after waking, but it may be more convenient and perhaps more effective taken at bedtime

verywellhealth.com/best-tim...

No other medication or supplements at same as Levothyroxine, leave at least 2 hour gap.

Some like iron, calcium, magnesium, HRT, omeprazole or vitamin D should be four hours away

(Time gap doesn't apply to Vitamin D mouth spray)

If you normally take levothyroxine at bedtime/in night ...adjust timings as follows prior to blood test

If testing Monday morning, delay Saturday evening dose levothyroxine until Sunday morning. Delay Sunday evening dose levothyroxine until after blood test on Monday morning. Take Monday evening dose levothyroxine as per normal

[SlowDragon Administrator in reply to Mazzer]

Sorry only just seen you got 25mcg dose increased

Are both tablets same brand of levothyroxine

Northstar 25mcg is Teva.....NOT same as Northstar 100mcg which is accord

So bloods due to be retested about now