These references all recommend GP's keep TSH between 0.4/ 0.5 and 2/2.5 in patients on levo.
Some were taken directly from GP update sources ,one was written specifically for GP's by Specialist registrars in cardiology and endocrinology , and one is from the 2023 consensus statement from leading endocrinologists, intended for guidance of NHS endocrinologists.
So there should be NO argument from a GP about their validity.
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This one ..... from page 13 in the 2019 RMOC Liothyronine (T3) guidance.
**NOTE, as of Aug 2023 , this 2019 RMOC guideline is no longer in use as an NHS T3 guideline ....... see UPDATE at end of post fro current one **
sps.nhs.uk/wp-content/uploa... (link no longer works)
" NHS consultant endocrinologists may start a trial of combination levothyroxine and liothyronine in circumstances where all other treatment options have been exhausted.
1. Where symptoms of hypothyroidism persist despite optimal dosage with levothyroxine.
(TSH 0.4-1.5mU/L)
2. Where alternative causes of symptoms have been excluded, see box 1 below"
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This one ..... from PULSE magazine for GP's... The article is available from ThyroidUK
If you want a copy of the article then email tukadmin@thyroidUK.org
and ask for a copy of the Dr Toft article in Pulse magazine. The quote is in answer to question 6.
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)."
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This Graph showing TSH in healthy population .....show's most people are around 1 ish,
3/4 is extremely rare in healthy people...
and a post on here discussing it: healthunlocked.com/thyroidu...
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This one ........ found in GPonline.com 15th April 2010.
gponline.com/endocrinology-...
"Replacement therapy with levothyroxine should be initiated in all patients to achieve a TSH level of 0.5-2.0pmol/L." Written for GP's by "Dr Iqbal is a specialist registrar in endocrinology and Dr Krishnan is a specialist registrar in cardiology, Liverpool".
* NOTE this one also clearly states that raised cholesterol is caused by hypothyroidism *
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and This one ....from gpnotebook 2021.
gpnotebook.com/en-gb/simple...
"Target TSH level when treating hypothyroidism
Last edited 05/2019 and last reviewed 06/2021"
"The goal of treatment is to make the patient feel better and this tends to correspond with a TSH in the lower half of the reference range (0.4–2.5 mU/l).
If a patient feels perfectly well with TSH between 2.5 and 5 mU/l there is no need to adjust the dosage
LOW levels (0.1 to 0.4 mU/l) MAY BE tolerated in young individuals who require a higher dose of levothyroxine to fully control symptoms " .
"Primary hypothyroidism in a non-pregnant adult
Thyroid function test should be done at least after 6-8 weeks of therapy.
fine tuning of the dose could be necessary in some patients
aim of levothyroxine treatment is to make the patient feel better, and the dose should be adjusted to maintain the level of thyroid stimulating hormone within the lower half of the reference range, around 0.4 to 2.5 mU/l. If the patient feels perfectly well with a level in the upper half of the reference range, then adjustment is unnecessary (1)
in a small prospective study of initiating levothyroxine treatment for newly diagnosed primary hypothyroidism, there was no difference in lipid profile, body composition, or bone mineral density in patients maintained on low TSH (0.4-2.0 mIU/L) as compared with those maintained on higher TSH (2-4 mIU/L) for 12 months (2)
TSH level below the reference range may be acceptable in younger patients who require a higher dose of levothyroxine to fully control symptoms but over treatment should be avoided (3)
a serum TSH level of less than 0.1 mU/l (fully suppressed) should always be avoided.
LOW LEVELS (0.1 to 0.4 mU/l) MAY BE TOLERATED in young individuals WHO REQUIRE A HIGHER DOSE of levothyroxine to fully control symptoms (1)
low TSH levels in older people (>60 years) should prompt a small dose reduction of 25 µg daily, or on alternate days
maintaining TSH concentrations below 0.1 mU/l is poor practice due to the increased risk of osteoporosis and atrial fibrillation (1,3,4). The exception to this is after thyroidectomy for thyroid cancer, when TSH values may need to be suppressed to and maintained at a concentration <0.1 mU/l (1,3,4) "
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and another one ..... ncbi.nlm.nih.gov/pmc/articl...
"Given the complexity of pathways that govern TH action at tissue and cellular levels, it is not surprising that some patients receiving exogenous thyroid hormone replacement therapy report on-going symptoms despite optimal thyroid function tests
(e.g. normal T4 and T3 with TSH <2 mU/L in primary hypothyroidism)"
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and one more .... frontiersin.org/articles/10...
A Renewed Focus on the Association Between Thyroid Hormones and Lipid Metabolism
Leonidas H. Duntas1* and Gabriela Brenta2
"Treatment With L-T4: Why, Who, and How~
....therefore, TSH values can be considered a good predictor of cardiovascular disease, notably when its levels are above 10 mIU/L (75). In particular, a TSH above 2.5 mIU/L in women of childbearing age may induce oxidative damage to membrane lipids and unfavorably alter the lipid profile, suggesting that TSH levels in this population should preferably be maintained below 2.5 mIU/L (76) ".
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A Helpful Quote from another members GP ,on what to expect when starting treatment for hypothyroidism.
"The way my new GP described it was ..."You know how your body is continually breaking down and rebuilding itself? Well, the thyroid controls the rebuilding, so if it isn't working you carry on breaking down but don't rebuild properly. Your body now has a lot of catching up to do, which will take a minimum of 12 months, probably a lot longer...." or words to that effect. He also said it would be a saw tooth recovery (get better, go backwards a bit, get better, go backwards a bit) and he's been right so far."
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helpful information for your family/ friends to understand about living with thyroid-disease-
verywellhealth.com/when-you... when-your-family-member-or-friend-has-thyroid-disease-
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( a useful guideline allowing GP's to prescribe the same brand of levo if needed )
MHRA Drug Safety Update From:
Medicines and Healthcare products Regulatory Agency
Published 19 May 2021
gov.uk/drug-safety-update/l...
"Levothyroxine: new prescribing advice for patients who experience symptoms on switching between different levothyroxine products
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...."
~~~~~~~~~~~~~~~~~~~~ UPDATE~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
** UPDATE ~ 2023 Liothyronine consensus statement ** now used as basis for NHS guidelines.
(NHS England liothyronine-advice-for-prescribers england.nhs.uk/long-read/li... says: "This advice UPDATES and REPLACES that developed in 2019 by the South Regional Medicines Optimisation Committee RMOC" )
Use of liothyronine (T3) in hypothyroidism: Joint British Thyroid Association/Society for endocrinology consensus statement. Revised: 18 May 2023
british-thyroid-association...
Rupa Ahluwalia | Stephanie E. Baldeweg | Kristien Boelaert |Krishna Chatterjee |
Colin Dayan | Onyebuchi Okosieme |Julia Priestley | Peter Taylor | Bijay Vaidya |
Nicola Zammitt |Simon H. Pearce
The consensus statement says:
" In those with established overt hypothyroidism, levothyroxine doses should be
optimised aiming for a TSH in the 0.3–2.0 mU/L range for 3 to 6 months before a
therapeutic response can be assessed. In some patients, it may be acceptable to have
serum TSH below reference range (e.g. 0.1–0.3 mU/L) but not full y suppressed in
the long term."
Regarding treatment with Levothyroxine it also says:
"If symptoms of hypothyroidism persist despite normalisation of TSH, the dose of levothyroxine can be titrated further to place the TSH in the lower part of the reference range or even slightly below (i.e., TSH: 0.1–2.0 mU/L), but avoiding TSH < 0.1 mU/L."
Great Find xox
Dr Toft Pulse Article: Inconsistencies?
Could this be Hashimoto's
