Advice on bloods please

[Wired123]

Hi all, my 65 year old mother’s results attached.

I begged her GP to up her T4 in Jan and you will see her T4 went up slightly and TSH has continued dropping to what some would say looks like over treatment.

She’s still got every symptom in the book (tiredness, fatigue, feels cold, weight gain, brain fog, hair loss, skin issues, etc, etc).

It’s strange that her T4 levels haven’t moved much since upping the dose and certainly there’s room to increase her Levo to move her T4 levels higher up the reference range. I imagine her NHS Endo will look at her TSH and say no way/recommend a dose decrease.

I’ve written a letter for the Endo explaining TSH can fluctuate at random with autoimmune/Hashimoto’s (although I’m sure he will ignore that).

Any other advice gratefully received.

Thanks in advance

[SlowDragon Administrator]

What vitamin supplements does she take

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

As she has Hashimoto’s is she already on strictly gluten free diet

If not has she had coeliac blood test done yet

If not get that tested before trying strictly gluten free

[Wired123 in reply to SlowDragon]

Let’s just focus on the impact of the change in dosing to start with. It’s not quite having the impact expected. Vits, etc should be secondary.

[Anthea55 in reply to Wired123]

Hello Wired123, I disagree with your priorities. Get nutrition sorted out first - this is from my own experience.

Years ago I saw a nutritional doctor. One of the things he said was that if you get your nutrition as good as you can, then any medical problem will present more clearly.

Most doctors have very little training in nutrition and wouldn't recognise a deficiency if there was one. For a fuller check your mother might do well to see a nutritionist.

Also, don't forget that if your mother takes anything containing biotin it can skew the blood test results.

[DippyDame in reply to Wired123]

I understand your concern but don't dismiss SlowDragon's excellent advice and the impact of these nutrients ...they are not "secondary"!They need to be optimal to support thyroid function and conversion.

Her FT4 level has most likely remained the same because the hormone T4 has been converted to T3 evidenced by a rise in FT3.

The injection of Vit B12 has most likely improved her conversion rate underlining the importance of optimal nutrients.

Her hormone levels have increased and as a consequence her TSH has dropped

She was clearly undermedicated in Jan hence the raised TSH back then.

Unfortunately medics are trained to dose by TSH at the expense of clinical evaluation/signs and symptoms and this is causing misery for patients who remain wrongly dosed....examples throughout this forum.

At this point it looks as if she may have room for a 25mcg increase, her symptoms suggest remaining undermedication. BUT, a further test 6/8 weeks after the last increase will confirm if this is the case. Her last increase (1/09) has not had time to settle into her system yet. Dose adjustments must be slow!

I suggest you test nutrients as SlowDragon has advised....they must be optimal.

The following might help you argue against dosing by TSH, should the need arise.

paulrobinsonthyroid.com/we-...

bmcendocrdisord.biomedcentr...

thyroidpatients.ca/2021/07/...

thyroidpatients.ca/2019/09/...

[Wired123 in reply to DippyDame]

She’s only had one dose change and that was Jan.

[DippyDame in reply to Wired123]

All the more reason to add more levo then!Did she feel any improvement in symptoms after increase to 100mcg?

Were all tests done as advised here?

Her FT3 remains in range so she is not overmedicated despite what TSH may indicate...see the links I added above.

You say the dosing is not having the impact you expected, out of interest what difference did you expect an extra 25mcg to make?

With the 8/01 results it looked clear that more than a 25mcg increase may be necessary.

By 20/3 both Frees increased, but by 17/7 they had dropped back It is possible that this is a sign that the body "appreciated" the first increase but it proved to be too little and the later drop is a sign that more levo is needed.

I've had this experience when first dosing T3-only.

Nevertheless both Frees have increased from 8/01 which is a very slight improvement but percentages are still low. They should both be approaching 75% which is higher than your mother's current levels....change in ranges won't alter the %age calculations.

I suggest your mother builds a case from the info offered here by members and asks for a trial of a further increase of 25mcg followed by testing after 6/8 weeks and a reassessment. That way the GP still feels in control!

[Lalatoot]

you will see her T4 went up slightly her T4 levels haven’t moved much since upping the dose

I would disagree with your thoughts. From her increase in January her FT4 went up a lot. It increased from 26% in Jan to 51% in March. That is not a slight increase!

However it has now begun to drop again and is currently 37%. It is the drop that should be your focus not the "slight increase".

So why has it dropped?

SlowDragon has suggested that vitamin levels may have dropped causing the body to run inefficiently. She also mentioned gluten free. Even though we are not coeliac we can be gluten intolerant. This in turn affects the gut which causes malabsorption of the levo. If something has altered gut function this can result in reduced FT4 levels due to malabsorption of the levo.

And as you say it could be also that she is needing another increase.

The impact of the change of dosing was a significant increase in FT4 which has now dropped away. You need to consider why it has dropped away and look at vitamin levels (how does the drop tie in with the timing of B12 injections?), gut issues and even the change of seasons - some need a higher dose in the winter.

[Wired123 in reply to Lalatoot]

I think the ref range change confuses things slightly. She’s gone up and stayed constant at around 14.

I’m assuming the blood levels of T4 have not changed after hitting the 14 mark, just the ref range has changed.

The TSH has kept dropping.

Now does the doctor increase the T4 dose to move her up the range into the high teens or does he say her low TSH warrants a lower dose of T4?

[SlowDragon Administrator]

Does she always take Levothyroxine on empty stomach and then nothing apart from water for at least an hour after

Taking Levothyroxine waking or bedtime?

Assuming all tests are done as early as possible in morning before eating or drinking anything apart from water and last dose Levothyroxine 24 hours before test

How much does she weigh in kilo

Guidelines on dose Levothyroxine by weight is 1.6mcg per kilo per day

Does she have PA or just low B12

Low B12 suggests low stomach acid

Common after 50 years old and EXTREMELY common when hypothyroid/hashimoto’s

Low stomach acid results in poor absorption (low Ft4) and low nutrient absorption leads to low vitamin levels and poor conversion of Ft4 to FT3

Getting gut issues addressed is always key

[Wired123 in reply to SlowDragon]

What would your advice be for assessing and treating gut function?

[SlowDragon Administrator in reply to Wired123]

How much Levothyroxine is she currently taking

Does she always get same brand Levothyroxine

With TSH so low highly unlikely to get dose increase

Many endocrinologists would want to reduce dose

Is she gluten free

[tattybogle]

you don't say , but what changes (if any) has she felt since being on 100mcg ?

[SlowDragon Administrator]

Looking at this post from 2 months ago

healthunlocked.com/thyroidu...

Ferritin obviously continues to be a problem

Has she been prescribed liquid Levothyroxine yet?

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

If a patient reports persistent symptoms when switching between different levothyroxine tablet formulations, consider consistently prescribing a specific product known to be well tolerated by the patient. If symptoms or poor control of thyroid function persist (despite adhering to a specific product), consider prescribing levothyroxine in an oral solution formulation.

[SlowDragon Administrator]

The week after B12 injection conversion was better

Does she take a daily B complex- this can help maintain B12 between injections

How frequent is B12 injection

If only every 3 months might need to be more frequently

[Wired123]

So by way of update the Endo is trialling T3 for 2 months even though he doesn’t recommend T3 as it has side effects but fails to recognise the benefits from T3. Idiot really!

Let’s see if T3 solves the problems.