Can Levothyroxine cause acid reflux?

[Sinny1]

Hi, I’m new to this site. I started taking 50mcg of Levothyroxine in September and within a few weeks I started with burning stomach acid. Has anyone else experienced this?

[SlowDragon Administrator]

Welcome to the forum

Bloods should be retested 6-8 weeks after each dose change or brand change in levothyroxine

50mcg levothyroxine is only a starter dose

Important to increase dose up as fast as tolerated

Acid reflux is extremely common hypothyroid symptom due to LOW stomach acid

Have you had bloods retested?

The aim of levothyroxine is to increase the dose slowly upwards in 25mcg steps until on or around full replacement dose

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 and thyroid antibodies if not been tested yet

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)

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 down to £26.10 if go on thyroid uk for code

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

monitormyhealth.org.uk/thyr...

[SlowDragon Administrator]

guidelines on dose levothyroxine by weight

Even if we don’t start on full replacement dose, most people need to increase levothyroxine dose slowly upwards in 25mcg steps (retesting 6-8 weeks after each increase) until on, or near full replacement dose

NICE guidelines on full replacement dose

nice.org.uk/guidance/ng145/...

1.3.6

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.

Also here

cks.nice.org.uk/topics/hypo...

gp-update.co.uk/Latest-Upda...

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.

BMJ also clear on dose required

bmj.com/content/368/bmj.m41

bestpractice.bmj.com/topics...

[Nanaedake]

What type of levothyroxine are you taking and have you stuck to the same brand at each refill? If so, then you could try a different brand to see if it makes a difference.

[Sinny1]

Hi

Thank you for your replies. I have had very little interaction/advice from drs due to Covid. I have been told that my tsh was out of the range but ts4/3 are well within so I think that makes me sub clinical but no ones ever told me this. I had a retest at the end of October and my tsh was 3.95 and was told everything was in range. My blood test was at 11.00 though and I take my tablet at 7.00 so from what you’re saying I may have had a false reading?

I was put on omeprazole for a month which did help. Would this improve if I was low acid given that it suppresses stomach acid?

My symptoms in general aren’t too bad, I lost quite a lot of hair in the summer and I suffer badly from anxiety so not sure whether the acid is because I’ve been so anxious since I found out I had hypothyroidism. Is there a test that can be done to see if I do have low stomach acid?

[greygoose in reply to Sinny1]

I'm afraid neither SlowDragon nor Nanaedake are likely to see your reply, because on this site, you have to click on the blue reply button when replying so that the person is notified. I've notified them for you.

A blood draw at 11 am will give you a lower TSH than one taken at 9 am, yes. And, taking your levo so close to the blood draw will have given you a false high FT4.

Doctors rarely give patients full details of their results - they'd probably prefer yu didn't know too much, or they think you won't understand. So, always ask the receptionist for a print-out of your results which will give exact results and ranges. It's important to know. You should also know that results just being in-range, is not always good enough. It's where they fall within the range that counts. 50 mcg levo is only a starter dose, so you're more than likely under-medicated and need an increase of 25 mcg.

It's being hypo that causes acid reflux/low stomach acid, not the levo. And, omprazole could help even though your stomach acid is low, but that's a very bad thing to take, and best avoided, if you can. If you read the following article, you'll find a home test for low stomach acid:

healthygut.com/articles/3-t...

SlowDragon

Nanaedake

[Sandra600 in reply to greygoose]

How can omeprazole help if the problem is low stomach acid?

[Marz in reply to Sandra600]

Symptoms for low and high acid are similar - hence why I think greygoose agreed with your comment that the PPI helped but followed up with the caution !

[Sandra600 in reply to Marz]

Thanks for replying but you have confused me with someone else. I am worried about some of the advice given on here, I don’t see how omeprazole could help if the problem really is low stomach acid, surely it would make things worse?

[greygoose in reply to Sandra600]

I wasn't giving advice. I wouldn't advise anyone to take omeprazole. It's ghastly stuff! I was just saying that some people do find it does help even with low stomach acid.

What happens with low stomach acid is that the food is not digested properly, so can't pass on into the gut. It just stays in the stomach and ferments. Occasionally, it erupts, like a volcano, forcing what little acid there is up into the oesophagus. If you lower the acid even more, artificially, there will be next to none to go up into the oesophagus. But, I didn't say that was a good thing. We all know that it's very bad. But that's not what she asked.

However, I then gave her a link that will help her further. So, I really don't think you have cause to be concerned.

[Sandra600 in reply to greygoose]

I wasn’t implying that you were suggesting that the OP should take omeprazole, only that if it had helped her it was more likely that she had high stomach acid.

[greygoose in reply to Sandra600]

Well, I honestly don't think that's what I said, was it. And, if that was what I meant, why would I give her a link to an article about low stomach acid, and how to test for it? That just isn't logical.

[Sandra600 in reply to greygoose]

I never said you said that, I am saying it.

[greygoose in reply to Sandra600]

I wasn't suggesting it, either.

[Sandra600 in reply to greygoose]

To clarify, I am concerned that the assumption is that people on here always have low stomach acid, people can have high stomach acid too and if omeprazole helped the OP then maybe she has high stomach acid. Ideally, tests should be done at the start to ascertain whether it is high or low. I never implied or suggested that you were saying she should take omeprazole.

[greygoose in reply to Sandra600]

And to clarify even further, of course we know that some people can have high stomach acid - although hypos usually have low stomach - and I know it should be tested for but doctors never do that because they don't know about low stomach acid. And, that is why I gave her a link to a home test so that she could check.

So, I think we've covered all angles, now, and can safely drop the subject. Thank you for your concern.

[Sandra600 in reply to greygoose]

More than happy to drop it

[Marz in reply to Sandra600]

Sorry - yes you are right - I made a mistake in thinking you were the OP !

When stomach acid is low - food hangs around in the stomach for longer - delaying stomach emptying. Acid breaks down food into smaller particles before entering the duodenum. When food remains for too long in the stomach it can begin to ferment causing the fermentation to rise upwards from the stomach. The symptoms can be similar to high acid levels. Think of home brewed beer bubbling away !

Docs over prescribe PPI's to solve matters without further investigation it would seem. Lots of discussions on the forum regarding this issue 🌻

[Sandra600 in reply to Marz]

Thanks, I think that people should be tested to see if they have high or low stomach acid before treatment, I don’t think assumptions should be made either way.

[SlowDragon Administrator in reply to Sinny1]

Omeprazole is to treat HIGH stomach acid

Rare for any medic to consider low stomach acid

High and low acid have virtually identical symptoms but very very different treatment

Low stomach acid can be a common hypothyroid issue

Thousands of posts on here about low stomach acid

healthunlocked.com/search/p...

Web links re low stomach acid and reflux and hypothyroidism

nutritionjersey.com/high-or...

articles.mercola.com/sites/...

thyroidpharmacist.com/artic...

stopthethyroidmadness.com/s...

healthygut.com/articles/3-t...

naturalendocrinesolutions.c...

Ppi tend to lower Vitamins more

pulsetoday.co.uk/clinical/m...

gov.uk/drug-safety-update/p...

Hairloss linked to low ferritin or iron

Important to get thyroid tested as early as possible in morning before eating or drinking anything other than water and last dose levothyroxine 24 hours before test

TSH should be under 2

gponline.com/endocrinology-...

Replacement therapy with levothyroxine should be initiated in all patients to achieve a TSH level of 0.5-2.0pmol/L.

Aim is to bring a TSH under 2.5

gp-update.co.uk/SM4/Mutable...

Dr Toft, past president of the British Thyroid Association and leading endocrinologist, states in Pulse Magazine,

"The appropriate dose of levothyroxine is that which restores euthyroidism and serum TSH to the lower part of the reference range - 0.2-0.5mU/l.

In this case, free thyroxine is likely to be in the upper part of its reference range or even slightly elevated – 18-22pmol/l.

Most patients will feel well in that circumstance.

But some need a higher dose of levothyroxine to suppress serum TSH and then the serum-free T4 concentration will be elevated at around 24-28pmol/l.

This 'exogenous subclinical hyperthyroidism' is not dangerous as long as serum T3 is unequivocally normal – that is, serum total around T3 1.7nmol/l (reference range 1.0-2.2nmol/l)."

(That’s Ft3 at 58% minimum through range)

You can obtain a copy of the articles from Thyroid UK email print it and highlight question 6 to show your doctor

 please email Dionne at

[e-mail]

[Nanaedake in reply to Sinny1]

Just to say, I agree with Greygoose to always get a copy of actual results of all tests and ensure the results include the lab range. PPIs are not meant to be taken long term so you need to find a more permanent solution to gut health. Getting onto the right dose of levothyroxine will help and try a different formulation of levothyroxine. Sometimes the fillers can give trouble.

[Batty1 in reply to Sinny1]

My stomach acts up when I feel a little off.

[Dix7]

Yes! If I am getting too much that definitely happens! Never had it otherwise.