Advice on blood tests please

[Wired123]

Hello

My 65 year old mother is very unwell and been on Levo-only for over 20 years and has Hashi's.

Typical symptoms: low energy, fatigue, struggles to wake in AM, hair thinning, feeling cold, weight gain.

After writing multiple letters to her GP and asking for Endo referral and then writing more letters to her Endo, he has agreed to a trial of Liothyronin. This came with a huge caveat from him that he does not recommend Lio and that there's a lot of risks! She hasn't yet commenced Lio as she's been frightened off by the Endo, but I still persevere and use my own example as someone who has benefited.

Based on her current blood test results on 100mcg Levo only, he has recommended she reduce Levo to 75mcg and add in 5mcg of Lio. I think that it's bonkers advice as her T4 is at the bottom of the range already!

What would you recommend, should she first try to raise her T4 levels with more Levo or keep Levo at 100mcg and start Lio and see how she feels?

Curious if anyone has any idea why her T4 could have dropped so much in 6 months with no change in diet, drugs or lifestyle?

[SlowDragon Administrator]

Her low Ft4 suggests she’s under medicated

Why not first try 25mcg increase in levothyroxine

Was last test done early morning, ideally before 9am and last dose levothyroxine 24 hours before test

FT4: 11.9 pmol/l (Range 9 - 23)

Ft4 only 20.71%

FT3: 4.3 pmol/l (Range 2.4 - 6)

Ft3 is 52.78%

Most people when adequately treated on just levothyroxine have Ft4 at least 60-70% through range

Essential to test vitamin D, folate, ferritin and B12

Suggest you get her a 25mcg dose increase in levothyroxine and get FULL Thyroid and vitamin testing done 6-8 weeks later

What vitamin supplements is she currently taking

[SeasideSusie Remembering]

Wired123

Just my opinion based on my own experience, I am not medically trained:

Neither of those tests show poor conversion and I would have thought the first thing to do would have been to raise FT4 into the upper part of it's range. I honestly don't think that adding T3 at this point is the way to go.

Her current FT4 is very low in range at 20.71%. When was her last dose of Levo before the test, it should be 24 hours before the blood draw.

The aim of a treated hypo patient on Levo only, generally, is for TSH to be 1 or lower with FT4 and FT3 in the upper part of their ranges if that is where you feel well.

Dr Anthony Toft, leading endocrinologist, answered questions in the doctors’ magazine, Pulse, in an article entitled, “Key questions on thyroid disease” in which he stated:

“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.”

What are her key nutrient levels like - Vit D, B12, Folate and Ferritin?

[JAmanda]

Agree I’d get a 25 Levo increase first before trialling the lio. Plenty of room for improvement on t4 (and T3).

[Wired123]

Thanks all. The Endo has been pretty useless.

Last dose of Levo was c24 hours prior and tests done at 9am.

Agree no conversion issue given her FT3 has stayed the same despite drop in FT4.

Only thing is the TSH is quite low despite low FT3 and FT4. This Endo seems to think TSH is the be all and end all sadly. I imagine this is where we need to push back and remind him TSH fluctuates independently due to Hashi’s?

[MariLiz]

Like your mother, I have always been on that same dose of Levothyroxine. When I began to get those symptoms of extreme fatigue and hair loss plus pins and needles I saw my GP. My blood test included a check for B12, and it was found to be very low. Once that was treated I began to feel a lot better, even though my Levothyroxine dose has remained the same. Pins and needles is a typical symptom of low B12, as are hair loss, extreme fatigue, poor balance, muscle weakness, and susceptibility to infection. I would certainly suggest asking for a full blood check for B12, ferritin, folate, and VitD. If these are low we struggle to use the

thyroxine medication.