How do you take your Levothyroxine?

[4sibbs]

I have been on 50mg Levothyroxine for over 15 years and have always taken in the morning with a little milk only because I have a cup of tea first thing. I’ve just had a blood test & my TSH has slightly raised from 4.2 to 4.6 my GP is saying I should take with water not milk and wait 30 minutes before I have anything to eat or drink as it needs time to absorb into the system. I knew you should take on an empty stomach but have never been told to wait 30 minutes before having a drink & not to take with anything other than water, just wondering if I’ve been doing it wrong all these years how come the results have always come back normal any thoughts?

[greygoose]

A TSH of over four is not normal. A 'normal' TSH - euthyroid - is around 1, never over 2, and you are hypo when it gets to 3.

The best way to take levo is on an empty stomach, with nothing but water, leaving at least 1 hour before eating or drinking anything else. Take it at least two hours away from any other medication, but it should be four hours for vit D, calcium, iron, magnesium, oestrogen and PPIs.

That said, if you are taking 50 mcg, you are more than likely under-medicated anyway. That's just a starter dose, and should have been increased to 75 six weeks later, etc. Perhaps if you take your levo correctly, and your TSH is still over 2, then your doctor will give you an increase in dose.

[shaws Administrator]

I take my dose of thyroid hormones when I get up a.m. with one glass of water and wait an hour before I eat.

I feel fine and have no symptoms.

[tattybogle]

basically , some things (calcium / caffeine /iron) if they are in your gut at the same as the levo tablet, will reduce the amount of levo you can absorb into your blood from that tablet.

So, say you took a 100mcg tablet under perfect conditions (empty stomach) you would absorb about 80mcg . ( you never get all of it, even under perfect conditions ) but if you had an amount of calcium or caffeine or iron in there too ,you might only absorb 50mcg . ( how much will probably be very individual, and we don't know the exact amounts. just that these things do reduce the amount absorbed)

(lots of other substances probably have a similar effect , it's just that studies have been done proving it for calcium / iron / caffeine, so these things are what is usually mentioned.)

If you have always done the same thing then , in effect you dose will have always been a bit less than what you think you take .. however it doesn't stop the amount that you do absorb from working once it's in your blood stream.

Up to a point , it doesn't really matter that much, as long as what you do is consistent all the time (meaning the amount you absorb is the same each day) .

ie. all your blood tests will then have shown the effect of 'how ever much you did absorb' every day , whether it's 80mcg or 50mcg , and in theory your dose should have been adjusted based on those results , So for example, if the 50mcg you absorbed wasn't enough to get your TSH low enough , and your fT4 high enough , then the 100mcg prescription would have been increased accordingly .. so you might then have be prescribed 125mcg and then you would have absorbed more like 80 mcg again, even though you still had a bit of milk with it.

But if you were inconsistent , and some days had a large milky double strength coffee with your levo and other days you just had weak tea with just a tiny dribble of milk .. then that would cause problems with adjusting the dose correctly.... because some days you'd be getting eg. 75mcg and some day you might only get eg. 30mcg.

I have always taken my Levo with a cup of rooibos (like tea but without the caffeine) with a splash of milk first thing in the morning , then wait an hour before eating breakfast.......i was in my 30's when diagnosed and decided there was no way i was not having a cup of tea when i woke up for the rest of my life ...so even if i do absorb less because of the milk , my dose has always taken this into account.

Having said all that ...... if your TSH has been as high as 4 for all this time than that strongly suggests that you have not been on a large enough dose of levo anyway .(unless you felt perfectly ok like that)

TSH of 4 is still too high for most people to feel well... the most common level for TSH in the healthy population is closer to 1..... anything over 3 / 3.5 ish is a bit unusual, and in some countries you would be diagnosed hypo if TSH is over 3.

The TSH '95% population reference range' goes from something like 0.4 -4 .5 ish , but for 'optimal' treatment with levo , the best advice from experienced Endo 's and cardiologists is to keep it below about 2 / 2.5 .

See this graph of TSH levels in the 'healthy' population with out thyroid disease. healthunlocked.com/thyroidu...

And see my reply to this post ( 4th reply down) for a list of references advising GP's to keep TSH below 2/2.5ish in patient's on levo. healthunlocked.com/thyroidu...

[SeasideSusie Remembering]

4sibbs

Always advised here is to take Levo exactly as Greygoose has mentioned in her reply above.

I take my Levo in the early hours of the morning when I regularly need the bathroom. I put it out on my bedside cabinet with a glass of water and take it around 3-5am. This keeps it away from other medication I need and all food, coffee, supplements, etc.

Is your TSH at 4.6 now over range? Was only TSH tested? This is not an indication of thyroid status as it's not a thyroid hormone, it's a pituitary hormone. We need FT4 and FT3 tested to know our thyroid status. I expect with a TSH of 4.6 then your FT4 will be quite low in range and maybe you are symptomatic and not feeling as well as you could be?

[BonnieG123]

I take it same time every day (6:00 AM), with a full glass of water and wait an hour before eating.

[Jazzw]

I think consistency is key. I think it’s highly unlikely that drop of milk in a cup of tea is seriously going to interfere with absorption.

The real issue here is that you have a GP who knows zilch about how to treat hypothyroidism.

50mcg for 15 years… Honestly, how are you feeling? Do you feel well??

[SlowDragon Administrator]

50mcg levothyroxine is only a STARTER dose

Levothyroxine doesn’t top up failing thyroid levels, it replaces it…..

Bloods should be retested 6-8 weeks after starting on levothyroxine and if TSH is over one, or definitely if TSH is over 2 , and you have symptoms dose should be increased

Dose should be increased slowly upwards in 25mcg steps. Retesting 6-8 weeks after each dose change or brand change

ALWAYS Test thyroid levels early morning, ideally before 9am and last dose levothyroxine 24 hours before test

Essential To also test vitamin D, folate, ferritin and B12 at least once a year

What vitamin supplements are you currently taking

When were vitamin levels last tested

Having been left on only a starter dose for years, it’s likely you have low vitamin levels as direct result

Low vitamins tend to lower TSH, because we need good vitamin levels for good conversion of levothyroxine (Ft4) to active hormone (Ft3)

Which brand of levothyroxine are you currently taking

GP should increase dose levothyroxine to 75mcg

However …Many people find Levothyroxine brands are not interchangeable.

Many patients do NOT get on well with Teva brand of Levothyroxine.

Teva contains mannitol as a filler, which seems to be possible cause of problems.

Teva is the only brand that makes 75mcg tablet. So if avoiding Teva for 75mcg dose ask for 25mcg to add to 50mcg or just extra 50mcg tablets to cut in half

But for some people (usually if lactose intolerant, Teva is by far the best option)

Teva, Glenmark or Aristo (100mcg only) are the only lactose free tablets

Most easily available (and often most easily tolerated) are Mercury Pharma or Accord

Mercury Pharma make 25mcg, 50mcg and 100mcg tablets

Accord only make 50mcg and 100mcg tablets

Accord is also boxed as Almus via Boots, and Northstar 50mcg and 100mcg via Lloyds ....but Accord doesn’t make 25mcg tablets

beware 25mcg Northstar is Teva

List of different brands available in U.K.

thyroiduk.org/if-you-are-hy...

Having been left so long on starter dose you may need to increase slowly initially…..50mcg and 75mcg on alternate days (or cut 25mcg tablet in half to get 12.5mcg to add to 50mcg every day) for few weeks …….before increasing to 75mcg everyday

Likely to need further increase in levothyroxine after next blood test

[SlowDragon Administrator]

Your last post 4 years ago

healthunlocked.com/thyroidu...

I have been on 50mg Thyroxine for about 20 years always

Serum TSH level - Above Range 9.0 mu/l (0.27 - 4.2) outside reference range

Serum Free T4 level - 15.0 pmol/L ( 12.0 - 22.0)

……showed you were extremely under medicated

I advised you then that you were in desperate need of 25mcg dose increase in levothyroxine

Why was levothyroxine not increased 4 years ago

[SlowDragon Administrator]

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.

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...

Graph showing median TSH in healthy population is 1-1.5

web.archive.org/web/2004060...

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...

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/files/docs/...

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

healthunlocked.com/thyroidu...

jamanetwork.com/journals/ja...

[4sibbs]

Wow thank you all so much my GP surgery just tell me I am within normal range every time I have a blood test, they never volunteer the results I usually ask but I’m only ever given a TSH result, my recent result was 4.6 from the previous one of 4.2. I don’t ever recall having a face to face appointment with a GP to discuss my thyroid function except for when I was first diagnosed and then I was told I was borderline & it was a locum doctor, I think I started on 25mg but it was a long time ago.

I feel ok & don’t seem to have any major symptoms but following all your informative comments I’m going to check out the links on the posts and definitely look into this more as it is clear my surgery are useless and don’t even seem to know the basics of thyroid problems. Once again thank you all

[nellie237 in reply to 4sibbs]

Hello 4sibbs,

Aside from all the great info above.............If your GP thinks it is going to make a difference, he should re-test in 6-8 weeks. Don't let him dismiss you for another year with that result.

[4sibbs]

Thank you They did say to retest in 6-8 weeks

[SlowDragon Administrator in reply to 4sibbs]

Suspect they are not even aware you are on levothyroxine

Print out guidelines and take to appointment….or have ready to quote if it’s a telephone consultation

Request 25mcg dose increase in levothyroxine and bloods retested in 6-8 weeks

Also request vitamin D, folate, ferritin and B12 levels are tested now

Come back with new post once you have got vitamin results and update on what GP is doing

[4sibbs in reply to SlowDragon]

They did test B12 and Ferritin, iron level was a bit high apparently they asked if I took supplements which I don’t.

[SlowDragon Administrator in reply to 4sibbs]

Approx how old are you …..pre or post menopause?

High ferritin can be due to inflammation.

What was B12 result

You need folate and vitamin D tested too

[4sibbs]

I’m 71 guessing B12 was ok because they only queried the iron & thyroid I’ve had Vertigo for a few weeks hence the other blood tests going to have the epley manoeuvre next week