Results help please

[Chris1802p]

Hi all

I have several previous posts about my thyroid- I feel I’ve had thyroid symptoms for years then had to have a hemi-thyroidectomy in Feb 20 due to multi-nodular goitre. I started Levo shortly afterwards when my symptoms started increasing and my TSH increased to over 6.

I saw an endo privately in Oct as I still wasn’t feeling great and I had tried to optimise all my Vits as much as I could. At that time I was on 75mcg Levo and my results were Oct 20: TSH 1.98 (0.27-4.2) Ft4: 16.6 (12-22). My Vit D was 70.

The endo increased Levo to 100mcg and asked me to retest end of Jan, he said the aim is to get your TSH under 1 which I thought was surprisingly sensible! He said if that doesn’t work we could try adding T3.

So, I’ve now been on 100mcg Mercury Pharma Levo for 10 weeks, I’ve been taking good quality B12, B complex and Vit D (I stopped the B well before testing). But I haven’t been feeling that great again. I’ve just got my latest results back, and my TSH hasn’t moved, and my FT3 and FT4 are both falling again! I’m really confused. When I first started Levo I seemed to respond really well.

The latest result is in the photo. And below is the result from before I was on Levo at all, just for reference:

Jun 20: TSH 6.1 (0.27-4.2) FT3 4.5 (3.1-6.8) FT4: 13.2 (12-22)

Thyroglobulin abs 11.3 (<115) TPO abs <9 (<34)

Sorry it’s so long. Wonder if anyone can make sense of it. And before anyone asks, I’m not gluten free, no. 😢

[SlowDragon Administrator]

Well your results show you need next 25mcg dose increase in levothyroxine

Roughly how much do you weigh in kilo?

guidelines on dose levothyroxine by weight

Even if we frequently 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 eventually 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...

You need to test vitamin D twice year

Folate, ferritin and B12 at least annually

[Chris1802p in reply to SlowDragon]

Thanks- I weigh 85kg. I agree with you about increasing the dose but I bet the Endo won’t!

[SlowDragon Administrator in reply to Chris1802p]

So 85 x 1.6 = 136mcg is likely dose you will need....possibly more.

Ft4 is only 22% through range

Ft3 at 27% through range

Helpful calculator for working out percentage through range

chorobytarczycy.eu/kalkulator

TSH should be under 2 as an absolute maximum when on levothyroxine

gponline.com/endocrinology-...

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

New NHS England Liothyronine guidelines July 2019 clearly state on page 13 that TSH should be between 0.4-1.5 when OPTIMALLY treated with just Levothyroxine

Note that it says test should be in morning BEFORE taking levothyroxine

Also to test vitamin D, folate, B12 and ferritin

sps.nhs.uk/wp-content/uploa...

Aim is to bring a TSH under 2.5

UK guidance suggests aiming for a TSH of 0.5–2.5

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]

Dose levothyroxine is only increased up in 25mcg steps

Important to regularly retest vitamin levels

[Chris1802p in reply to SlowDragon]

Thankyou

[aspenca in reply to Chris1802p]

Your FT3 went down 4.5 to 4.09 and your FT4 went up from 13.2 - 14.2. Since you don't have your RT3 it 'appears' that your not converting from FT3 to FT4. You need two things to be optimal to convert 1) Cortisol (have you have a 24 hour saliva cortisol test done? 2) Iron (TIBC/%Saturation/iron/Ferritin) have to have "all" 4 labs/blood draws. Any inflammation in the body whether it comes from gluten or any GMO's (toxins) will not help the Thyroid/hormones do their job but you probably already know this.