On levo for a year and T3 is still the same!

[Ladysmith53]

I'm currently on 100mcg/75mcg alternating days. These are blood test results from this week:

TSH 1.7 (0.4 - 5.5)

T4 18.3 (11.0 - 26.0)

T3 3.8 (3.0 - 6.0)

8 weeks ago my results were:

TSH 2.2 (0.4 - 5.5)

T4 16.5 ( 11.0 - 26.0)

T3 3.9 ( 3.0 - 6.0 )

I was taking propranolol and weaned off the beginning of the year with advice from slowdragon, ( it was taken for headaches/migraines) as propranolol can affect T3 conversion. I have had very bad migraines every 2 weeks on the dot that last 3 to 4 days since January. I am 4 years post menopause and have been on tablet form HRT. Two weeks ago I changed to a patch (with a lower dose) could the T3 level be anything to do with oestrogen dominance. Any advice would be very much appreciated as the migraines are really getting me down. Thank you 😊

[SlowDragon Administrator]

Your results show you are under medicated

Request dose increase to 100mcg daily

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

HRT will affect dose levothyroxine required

Do you always get same brand levothyroxine at each prescription

Headache and migraine are hypothyroid symptoms

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

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...

Guidelines are just that ....guidelines.

Some people need more …..some less

healthunlocked.com/thyroidu...

[SlowDragon Administrator]

Ft4 is only 49% through range Ft3 only 27% through range

Helpful calculator for working out percentage through range

chorobytarczycy.eu/kalkulator

When adequately treated, TSH will often be well below one.

Most important results are ALWAYS Ft3 followed by Ft4.

When adequately treated Ft4 is usually in top third of range and Ft3 at least 60% through range (regardless of how low TSH is)

Extremely important to have optimal vitamin levels too as this helps reduce symptoms and improve how levothyroxine works

[Ladysmith53 in reply to SlowDragon]

Thank you slowdragon, I had all vits tested 8 weeks ago

Vit D 147.2

B12 591 (190 - 910)

Ferritin 157 (10.0 - 291.0)

Folate 12.3 (3.9 - 26.8)

I do not always get the same brand from chemist. But if I get an increase to 100mcg i will request i get the same brand so its constant.

My doctor is always very reluctant to give me an increase. Any advice on what to say as I always feel like she thinks I'm telling her what to do 🤷‍♀️

[SlowDragon Administrator in reply to Ladysmith53]

How much do you weigh in kilo….can help persuade them to increase if your under dosed for weight

Ask for dose increase too 100mcg as “trial” increase.

Also take these results in (mark up next to Ft4 that it’s only 49% through range and next to Ft3 that it’s only 27% through range)

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]

If you can’t get increase from GP …request referral to endocrinologist of your choice…or go private

Email Thyroid UK for list of recommend thyroid specialist endocrinologists

...NHS and Private

[e-mail]

[Ladysmith53 in reply to SlowDragon]

Thank you slowdragon, you always give such good advice!I weigh 57 kg at present

I will suggest the 'trial' of 100mcg to doctor and give her the percentage of ranges. At least I am equipped with an answer! 🙏 thank you

[SlowDragon Administrator in reply to Ladysmith53]

So guidelines on dose by weight is 91.2mcg per day 91 x 14 days = 1277

Currently taking 75mcg x 7 days and 100 x 7 days = 1225mcg per 14 days

So guidelines suggest an extra 50mcg …but on HRT likely to need higher dose

Hashimoto’s often results in poor absorption too

Your results suggest you are under medicated

And different brands at each prescription may not be helping

Are you on strictly gluten free diet?

[Ladysmith53 in reply to SlowDragon]

Yes strictly gluten and dairy free

[SlowDragon Administrator in reply to Ladysmith53]

So likely another reason to need dose increase in levothyroxine as gut is affected

If lactose free Are you currently taking lactose free levothyroxine ? Teva or Aristo ?

Lactose intolerance often results in needing higher dose than guidelines

[Ladysmith53 in reply to SlowDragon]

I'm taking teva 75 and aristo 100, thank you slowdragon