Hot flushes

[Fenioux]

I have Hashis .... are really bad hot flushes a symptom of hypothyroidism? I thought I had finished with those in my early sixties but they have returned in avengeance in my mid 70s.

[SlowDragon Administrator]

Looking at previous posts....are you still on Lansoprazole (PPI)?

PPI tend to lower vitamin levels, especially B12

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

webmd.com/heartburn-gerd/ne...

pharmacytimes.com/publicati...

When were vitamin D, folate, ferritin and B12 last tested

What vitamin supplements are you currently taking

Low B12 often causes hot sweats, especially at night

When were thyroid levels last tested?

[Fenioux in reply to SlowDragon]

Hello

I stopped taking lansoprazole last July, managing without at the mo.

Blood results July 2020

Ferritin 58 (20-204)

Folate 18 (3.1-20.5)

B12 647 (187-883)

Blood results Nov 2020

Tsh 1.01 (0.34-4.94)

T4 13.7 (9.91-19.05)

T3 3.6 (2.63-5.7)

Vit D 88.4 (80-150)

My current medication daily

Aspirin 75mg

Levo 50/75mg alt/days

VitD 1000 mcg

B12 10 mcg

Folate 400 mcg

Ferritin 17 mg

The above 3 in one tablet, Feroglobin

Vit C 500 mg

Zinc 15 mg

How do you rate the above supplements?

I was wondering about taking selenium or magnesium but I seem to be taking rather a lot of supplements and wondered if they could be streamlined.

I also looked at Wellwoman 70+ which seems to cover most of the above in 1 tablet.

Advice is needed please.

I have bloods next week for

D, B12, Fol, Fer, and chol and thyroid bloods again in May.

Regards and thank you for any help.

[SlowDragon Administrator in reply to Fenioux]

Blood results Nov 2020

Tsh 1.01 (0.34-4.94)

T4 13.7 (9.91-19.05)

T3 3.6 (2.63-5.7)

These results suggest you are under medicated

Ft4 is only 41% through range

Ft3 is only 32% through range

Helpful calculator for working out percentage through range

chorobytarczycy.eu/kalkulator

So you are under medicated and poor conversion of Ft4 to ft3

Request 25mcg dose increase in levothyroxine

Hardly surprising....guidelines on dose levothyroxine by weight is 1.6mcg per kilo of your weight

Unless extremely petite, most patients will need to be on at least 100mcg levothyroxine per day

Which brand of levothyroxine are you currently taking

Are you on absolutely strictly gluten free diet

[Fenioux in reply to SlowDragon]

Hi again

Endocrinoligist reduced dosage from 100 as tsh was 0.4 on previous test and said it was too low!

I am not gluten free.

I'm on eltroxin.

[SlowDragon Administrator in reply to Fenioux]

TSH is completely irrelevant on levothyroxine

Many people have low TSH when adequately treated

Your Ft4 and Ft3 show you are under medicated

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]

heart.bmj.com/content/84/4/455

Over replacement with thyroxine?

There is some concern that administering thyroxine in a dose which suppresses serum TSH may provoke significant cardiovascular problems, including abnormal ventricular diastolic relaxation, a reduced exercise capacity, an increase in mean basal heart rate, and atrial premature contractions.12 Apart from an increase in left ventricular mass index within the normal range, these observations have not been verified.13 Moreover, there is no evidence, despite the findings of the Framingham study, that a suppressed serum TSH concentration in a patient taking thyroxine in whom serum T3 is unequivocally normal is a risk factor for atrial fibrillation.

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

Interestingly, patients with a serum TSH below the reference range, but not suppressed (0.04–0.4 mU/liter), had no increased risk of cardiovascular disease, dysrhythmias, or fractures. It is unfortunate that we did not have access to serum free T4 concentrations in these patients to ascertain whether they were above or within the laboratory reference range. However, our data indicate that it may be safe for patients to be on a dose of T4 that results in a low serum TSH concentration, as long as it is not suppressed at less than 0.03 mU/liter. Many patients report that they prefer such T4 doses (9, 10). Figure 2 indicates that the best outcomes appear to be associated with having a TSH within the lower end of the reference range.

thyroidpatients.ca/campaign...

thyroidpatients.ca/2018/07/...

paulrobinsonthyroid.com/col...

No link between TSH and bone health

healthunlocked.com/thyroidu...

[SlowDragon Administrator in reply to Fenioux]

Suggest you increase dose to 75mcg daily

Retest in 6-8 weeks

You may need to increase again to 75/100mcg alternate days

Or might need 75mcg 2 x week and 100mcg 5 x week

Or similar fine tuning of dose

How much do you weigh in kilo

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.

BMJ also clear on dose required

bmj.com/content/368/bmj.m41

bestpractice.bmj.com/topics...

[SlowDragon Administrator]

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

Low vitamin levels affect Thyroid hormone working

Poor gut function with Hashimoto’s 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.

[Fenioux in reply to SlowDragon]

Will try to persuade endo consultant to increase dosage but he was adamant that 75mg daily was too much, hence 50/75mg. I weigh 49 kilos.

I have requested, by email, the info you suggested re Dr Toft and dosages. When received I can send it to Endo as only having telephone consultations at present.

Thank you.

Any thoughts on supplements I should take as the Endo wont help there.

[SlowDragon Administrator in reply to Fenioux]

49 kilo x 1.6 = 78.4 per day

78.4 x 7 = 548.8mcg per week

Nearest to that is

75mcg per day plus extra 25mcg per week

So you might take 75mcg x 5 days a week

87.5mcg 2 days x week

I would strongly argue to trial this dose for minimum of 6-9 months

[Fenioux in reply to SlowDragon]

Will try and convince !

[SlowDragon Administrator in reply to Fenioux]

I would inform endocrinologist you wish to dose levothyroxine as per NICE guidelines

Also same guidelines in BMJ

And GP update link

Send him the links if necessary

They are there to advise....not to dictate

It’s shared care