Visit with endocrinologist this week... first after starting NDT

[goodoldan]

My endocrinologist has been in the process of changing to a new practice, so I haven't been in touch with him for a couple of months. I had full labs drawn a couple of weeks ago, and I'll be seeing him this week for the first time at his new practice.

Before he moved, I was on 50 mcg of levothyroxine (only) and he had just given me the OK to start on 15 mg/day of NP Thyroid (at my suggestion... I am very sensitive to liothyronine), and to decrease the levothyroxine by the approximate amount of T4 in the NDT (9 mcg)... so I decreased the levothyroxine to 37.5. After a few weeks, I increased (on my own) the NDT to 30 mg/day and again (per the agreement with the endo doc) lowered the levothyroxine dose by the approximate increase of T4 in the NDT (another 9 mcg), to 25 mcg (rounding the T4 dose to the closest reasonable levo pill/split size). So, at this moment, I have a roughly net 10:1 T4/T3 ratio in my dosage (44 mcg T4 and 4.5 T3)

When I see him this week, I feel pretty confident in again asking to increase the NDT, this time to at least 45 mg/day and maybe even 60 mg/day. I think we should also probably increase the levothyroxine dose such that (in combination with the T4 in the NDT), we are maintaining a roughly 10:1 ratio of the combined T4 and T3 doses, at least as a starting point until we get more labs. That would be about 50 mcg levothyronine in the case of a 60 mg dose of NDT, and about 37.5 mcg levothyronine in the case of a 45 mg dose of NDT (again rounding the T4 dose to the closest reasonable levo pill/split size).

Just for additional info, here are the highlights of the most recent labs (after a few weeks on the 30 mg NDT and 25 mcg levo)...

TSH: 1.82 mIU/L (Ref 0.4 - 4.5)

FT4: 1.20 ng/dL (Ref 0.8 - 1.8)

TT4: 6.30 mcg/dL (Ref 4.9 - 10.5)

FT3: 3.30 pg/mL (Ref 2.3 - 4.2)

TT3: 103 ng/dL (Ref 76 -181)

RT3: 18 ng/dL (Ref 9.2 - 24.1) * NOTE: Down from 24-27 before starting NDT

Iodine: 75 mcg/L (Ref 52 -109)

Zinc: 86 mcg/dL (Ref 60-130)

Selenium: 145 mcg/L (Ref 63-160)

Antibodies = Negative

Cortisol @ 7 AM: 13.1 mcg/dL (Ref 4-22)

Various other vitamins / minerals / iron are all in range.

I am currently splitting the NDT into two doses at 7AM and 12PM (and considering a third split at 5PM). Levothyroxine is currenty taken once each day at bedtime (10:00 PM). Would it be better to take the Levothyroxine at 7:00 AM along with the first dose of NDT each day? (It would certainly make things easier on the days I have a 7AM lab draw... just delay the 7AM doses a few minutes until the draw is complete).

So... does that all sound reasonable at this point? Should I be asking the doc for something else?

Thanks!

[pennyannie]

Hello Goodoldan :

Personally I don't understand why you are starting off taking two different forms of thyroid hormone replacement -

NDT was successfully used for over 100 years to treat hypothyroidism and it worked well then, just as it does today, with the ratio of around a 1/4 - T3/T4 :

With NDT you dose to the relief of symptoms and treat on clinical symptoms.

The blood tests, ranges and guidelines were all introduced to be used alongside Big Pharma's launch of T3 and T4 thyroid hormones as their treatment option to NDT in the middle of the last century.

I think it would be wise to build up your dose of NDT slowly in 1/4 grain increments every 7-10 days and drop the T4 completely.

If you get to 2 grains stay on that dose for 6-8 weeks letting it bed in and then run a blood test just to see if your T3 and T4 have moved much from your bench mark readings from before taking NDT.

If your T3 hasn't moved much and you are still with symptoms maybe NDT isn't the right medication for you .

If your T3 has moved and you feel improved, but not fully, start again building up in 1/4 grain increments.

One week you'll find you've gone too far and feel a little unwell, and not as good as the previous week, so drop back down to the previous weeks dose - stay on that does for 6-8 weeks, take a blood test if you wish, as that is your best dose on NDT at that point in time.

No thyroid hormone replacement works well until your ferritin, folate, B12 and vitamin D are up and maintained at optimal levels.

I self medicate NDT and I found at my first blood test comparison from being on T4 only that my T3 and T4 had swopped % through ranges as my T3 was now 110% and my T4 was 25% :

I was with no " hyper " type symptoms and if anything still with hypo symptoms and took the blood test after around 8 hours from blood draw.

My pulse and blood pressure remained constant throughout the experiment and my temperature rose from 35.4 to 36.6 where it still hovers some 4 years later.

There are people who add a little T3 or a little T4 to their NDT to fine tune their " NDT " but believe their base medication to be NDT first and foremost.

With NDT your blood test will look different :

Your TSH will likely go low/suppressed :

Your T4 may drop lower in the range but your T3 should be higher in the range :

With NDT it's all about tracking the T3 :

[goodoldan in reply to pennyannie]

Thank you for your response! The reason I'm currently trying to take both levothyroxine and NDT is the result of an evolutionary process, not as a first step. Since being diagnosed as hypothyroid, my endocrinologist (and before that my family doctor) have tried the standard T4-only treatment to one degree or another. With 25-50 mcg of levothyroxine, my TSH reduced to normal levels (it was like 10+), and both my cholesterol numbers (notably) and my kidney function (creatinine clearance) numbers improved significantly. Full labs have been being drawn about every six weeks though this process. Vitamins, iron/ferritin, zinc, selenium and all the rest are good, and antibodies are negative. In fact, the only labs that seemed to be significantly "off" were a stubbornly high RT3 (like 25-27 with the range <15). FT3 and FT4 are more or less in the middle of their respective ranges.

Both my family doctor and the endocrinologist have separately tried to introduce additional T3 (in the form of liothyronine) to address the RT3). When my family doc started me on 5 mcg of liothyronine in addition to levo (like 5 years ago) I ended up after the first dose in the emergency department at the hospital with a sustained heart rate of 160. Clearly I am very sensitive to that drug. Recently, my endo doc also tried a very small dose of liothyronine... 1/4 of the smallest 5 mcg pill, just 1.25 mcg... and I still reacted badly to it. The introduction of NDT was primarily to see if I could tolerate the "natural" form of T3 it contains before abandoning the levothyroxine.

So far, the trial of introducing NDT (while still maintaining the small 25 mcg dose of levo) is inconclusive. At just 30mg (1/2 grain) daily (divided into two doses), the previously stubborn RT3 fell from like 25 to a (barely) in range 18, although FT3 did not increase significantly. I do feel the effects of the NDT as anxiety and physical tension, although at the current dose it does not seem to increase my heart rate. As an aside, I have a history of heart arrhythmia and have an implanted AICD (defibrillator), so the cardiac effects are of concern.

I see the endo doc again tomorrow to discuss all this. I am not at all committed to the approach of using both levo and NDT, although some people seem to use this very successfully. I would actually prefer to be on NDT only, provided we can overcome my (apparent) oversensitivity to T3. I do seem to tolerate the levo/T4, but the endo doc's reluctance to raise that further per the "standard of care" is concern over the high RT3 (fearing a higher levo dose would support or further increase the already high RT3) and my (apparently) low T4>T3 conversion. A SIBO (small intestine bacterial overgrowth) test last week was negative.

Thanks again! All comments and suggestions are welcomed.