my List of References recommending GP's keep TSH lower in range : feel free to add any others you have in replies.

[tattybogle]

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 [e-mail]

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)."

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

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."

[SarahJane1471]

Great post for saving 👏👏👏👏👏

[SeasideSusie Remembering]

lynmynott Could this be a pinned post please?

[tattybogle in reply to SeasideSusie]

just adding this here so it remains visible near top of post:

WHEN TO TAKE LEVO BEFORE BLOOD TESTS.

In case you , (or your GP) don't understand why we recommend to delay taking the morning dose of Levo until after a blood test at 9 am :

~ This paper confirms it is 'best practice' for GP's to test thyroid blood tests (TSH and fT4) at a consistent time of day and BEFORE taking that days Levothyroxine dose : hindawi.com/journals/cmmm/2...

Volume 2013 | Article ID 831275 | doi.org/10.1155/2013/831275

General Error Analysis in the Relationship between Free Thyroxine and Thyrotropin and Its Clinical Relevance Simon L. Goede and Melvin Khee-Shing Leow

(* note ~ Thyrotropin= TSH , and L-T4 = Levothyroxine )

"2.1. Diurnal Variations in [TSH]

Biological variations are expected to occur in the [FT4] and [TSH]. A very important condition for TFT measurements is the time of day the blood is sampled as many hormone systems in the body exhibit natural circadian biorhythms dependent on time including the HPT axis. The diurnal rhythm of [TSH] plays an important role and exhibits a significant difference between morning and evening readings [8]. The reported variations in [TSH] levels are ranging from an average [TSH] of 1 mU/L at about 15.00 h in the afternoon to an average of [TSH] = 2 mU/L at about midnight. This reveals the importance of a repeatable defined measurement regime at a fixed time of day. Any measurement accuracy of [TSH] to the extent we have available loses significance if we ignore these effects.

The amount of variability is dependent on the individual in question, but the smallest interindividual variations in [TSH] are observed around 15.00 h in the afternoon [8].

In another study [9], it was evident that several persons being probed for FT4 after taking their daily dose of levothyroxine (L-T4) had different readings because of interindividual differences in pharmacokinetics and metabolism. Therefore it is important to probe a person already using L-T4 on a fixed time of the day before the intake of the daily L-T4 dose. For practical reasons, this can be done shortly upon awakening (i.e., prior to the ingestion of daily dose of L-T4) in the early morning between 07.00 h and 10.00 h. The same time interval for TFT assessment also applies to people being investigated for the first time."

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ncbi.nlm.nih.gov/pmc/articl... Increased fT4 concentrations in patients using levothyroxine without complete suppression of TSH (Heleen I Jansen, Marijn M Bult, Peter H Bisschop, Anita Boelen, Annemieke C Heijboer,Jacquelien J Hillebrand 2023)

"Since 72–81% of the studied patients with discordant fT4 + TSH results used L-T4, literature was researched to explain this phenomenon with a specific focus on time of blood withdrawal and time of L-T4 intake. Multiple studies have investigated serum fT4 concentrations directly after L-T4 ingestion, all including hypothyroid patients treated with a stable dose of L-T4. These studies all reported an equivalent course of fT4 after morning L-T4 intake (3, 4, 5, 6, 7, 8, 9, 10). Figure 2 depicts a summary of this literature search; it shows that fT4 concentrations rise after 1 h and peak between 2 and 4 h after L-T4 intake (+15–25%) followed by a gradual decline and return to baseline within 24 h in accordance with the known time to maximal concentrations of L-T4 (T-max = 2–3 h) ..... Timing of blood withdrawal following L-T4 intake can lead to high fT4 concentrations without (complete) TSH suppression. Hypothyroid patients are mainly treated with L-T4 and the effect of treatment is monitored by measuring serum TSH, sometimes accompanied by fT4. Hypothyroid patients are advised to take a single daily dose of L-T4 orally in a fasting state. L-T4 administration in the morning or at bedtime is considered equally effective as long as L-T4 is taken on an empty stomach to ensure optimal uptake (14, 15). In contrast to fT4, no direct alterations of TSH and T3 have been reported directly after L-T4 ingestion (4, 5, 6, 7, 8). An fT4 course as Fig. 2 presents was found in patients taking L-T4 in the morning before breakfast, and one would also expect an increase in fT4 levels during the night when L-T4 is taken at bedtime (16). However, literature on extensive follow-up of fT4 and TSH levels following L-T4 intake in the morning compared to bedtime is lacking. Ain et al. (7) as well as Hoermann et al. (17) specifically emphasized that fT4 concentrations in L-T4 users were influenced by the time of day, meaning the time interval between L-T4 intake and blood sampling should be considered in the interpretation of fT4 values. In line with this advice, the European Thyroid Association guideline on treating central hypothyroidism advises blood withdrawal for monitoring treatment to be performed before L-T4 intake or at least 4 h after L-T4 intake (18), but other international guidelines do not yet ..... Physicians and laboratory specialists should be aware of the importance of timing of blood withdrawal and the timing of L-T4 intake to avoid questioning the assay’s performance or, worse, unnecessarily adapting L-T4 dose in patients. ".

,

[tattybogle in reply to tattybogle]

THE NHS SAY THE TSH TEST DOES NOT NEED TO BE A FASING TEST ...

THIS SHOWS WHY IT SHOULD BE:

A recent paper showing that eating breakfast DOES lower TSH quite significantly:

bmcendocrdisord.biomedcentr...

Effects of calorie intake and sampling time on thyroid stimulating hormone concentration

Aimei Dong, Youyuan Huang, Yucheng Huang & Bing Jia (Published: 01 April 2022 in BMC Endocrine Disorders)

"Discussion

The findings of this study showed that the TSH level was reduced significantly by about 30% after calorie intake in the morning, The components of calories had no significant influence on TSH variation rate when the calories intake was similar. The TSH level was reduced slightly by 5.2% in the subjects after maintaining the fasting state. The rate of TSH reduction was significantly pronounced after calorie intake compare to the fasting state, suggesting that the influence of food on TSH was more evident than the diurnal rhythm of TSH.

The findings of this study showed that the variation of TSH level after calorie intake in the morning might influence the diagnosis of subclinical thyroid dysfunction. Subjects with subclinical hypothyroidism might be underestimated due to the non-fasting state.

Conclusion

In summary, the TSH level was reduced significantly after food intake, compared with that at fasting state in the morning. If the reference range of TSH used in the laboratory was from fasting blood samples, it would be better to evaluate the TSH level in fasting blood obtained in the morning compared with random or postprandial samples."

[tattybogle in reply to tattybogle]

and another more recent paper which confirms that eating lowers TSH levels ...see   helvella 's post here ( healthunlocked.com/thyroidu... )

direct link to paper : cureus.com/articles/222188-... -effect-of-pre--and-postprandial-plasma-glucose-levels-on-thyroid-hormones-a-cross-sectional-study#!/

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

and one that shows why TSH should be an early morning test : pmc.ncbi.nlm.nih.gov/articl...

Does Time of Sampling or Food Intake Alter Thyroid Function Test?

Shriraam Mahadevan 1,2,✉, Dhalapathy Sadacharan 2,3, Subramanian Kannan 4, Anita Suryanarayanan 5

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and one showing the natural daily variation in TSH /fT4 / fT3 : thyroidpatients.ca/2020/07/... circadian-rhythms-tsh-f4-f3/

[blogfrog]

Thank you. I am going to send this info to my GP and NHS endo

[SeasideSusie Remembering]

Now pinned!

[WildDeer]

Thanks Tattybogle-I’ll add these to my armoury.

[TaraJR]

Brilliant!

[Auders]

Thank you, some very interesting snippets to print off for the next time I go into battle with the medics!

[LindaC]

Oh, thank you Great Find xox

[Topie]

Thank you so much great 👍

[pennyannie]

Kriticat

[Charlie-Farley]

YAY! just Brilliant tatty

This is unequivocally one of the big misunderstandings that’s leads to so Many people being mismanaged.

turquoisea7

[tattybogle in reply to Charlie-Farley]

this one's my favourite

"The goal of treatment is to make the patient feel better..... " Doh!

[Charlie-Farley in reply to tattybogle]

Never! 😂. The fact it has to written is a sad indictment of where these drs’ heads are firmly lodged in many cases…

😱🤣🙄

[Charlie-Farley]

By the way I’m referring to your collation all over the place. Misunderstanding around TSH has to be the main driver for mismanagement. This collection of references are extremely important.

[tattybogle in reply to Charlie-Farley]

glad it's been useful ... i haven't been on much lately .. busy persuading rain to stay on the outside of the basement, as opposed to the inside. Just went to see if it's stayed dry today...nope.... Damn it .... and i've run out of obvious places to seal up now .. oh well... it's 90% drier than it was a month ago, but i rather had my heart set on 'dry' rather than 'less wet' as a reward for all my hard work.

Was sorry to hear your Celtic retirement didn't pan out as planned.... ah well ... onwards

[Charlie-Farley in reply to tattybogle]

hi tatty

Thank you for condolences- it was incredibly difficult getting back into the business headspace. Down thousands in lost trade (living frugally) - the ‘buyer’ couldn’t afford to buy as we found out (too late). Now moved on and buying a place half the price 😱

Live and learn. Won’t close until money in bank next time.

We still want to move to Wales and properly integrate. The place we were moving to was lovely and quiet 😞.

[helvella Administrator in reply to Charlie-Farley]

FYI - I have put Tattybogle's info. into a downloadable document.

helvella.blogspot.com/p/tat...

[Charlie-Farley in reply to helvella]

Thank you Helvella 🤗

I love your blog spot! Bookmarked And fascinating, the account of the Spanish lady!

I’m making slow progress on reading seriously and with purpose, but it is progress- I’m drawing on observations and reading. I’ve noticed- just from the stream of people who are coming through our place and declaring hypo when I tell them about my hypo that the people small in stature and light weight seem to do far better than bigger framed folks.

I’m overweight at 15 stone and 5’8” (comfort eating- want to sell up) but relatively speaking I’m doing exceptionally well. In many respects I’m doing better than other women of the same age - but I feel the speed at which I pushed to full therapeutic dose may have mitigated the effects of under medication in the early stages of treatment - though effects were severe at the time.

I’m also wondering if the lack of a diagnosis, or length of time knowingly left untreated because of the subclinical categorisation is the period when the seeds of co-morbidities are laid down. A retrospective on my records strongly suggests at least 10 years symptomatic (if I had but known). I was diagnosed by a guest, only confirmed by a GP and I think the results of my blood test were unexpected- but for our guest I have no doubt I would still be undiagnosed. I was so tied up caring for both parents whilst trying to help hubby in the business I missed all the signs. Hell I missed my hair going grey and my menopause- there was a lot going on! 😬😱😂

I actually had problems looking in the mirror when I reconnected (sorry that sounds a bit new-age) I literally did not recognise myself- took about a year for that to settle down.

However all that said doing well but I have to pace myself (list my overdrive ). I get my 150ug and if I burn the candle, after a few days, I putter out and then need to rest for a few days. I’m seeing a pattern- I wish to test the theory but cannot risk doing anything deliberately until we are out of here. I can’t afford to putter out mid way through cooking breakfasts. Frustratingly I have to pace. Still Eden Project announcement should help us now - fresh fields 😊👍

[helvella Administrator in reply to Charlie-Farley]

I am absolutely convinced that time spent in that mysteriously ill-defined subclinical zone and/or overt but not diagnosed and/or under-treated/mistreated ends up meaning less complete resolution.

Not sure we'll ever have any way of actually measuring this meaningfully.

[Charlie-Farley in reply to helvella]

I have read there was a study done a retrospective looking at symptoms of people with hypothyroidism, but I’m wondering if the symptoms were defined as the ones they (researchers) recognised or whether they did an all-encompassing retrospective study to see what was thrown up. One thing I’m finding is that they appear to be building on each other’s assumptions and it’s interesting. I’ve read Chaker et al 2017 from the Lancet (Bianco 2nd author) and the statement of, however, a substantial proportion of patients treated with levothyroxine have persistent complaints, despite reaching the biochemical therapy targets. I have to read on to see in other references how they were set. But I think there is a problem with a lack of study, with regard to the subjects thus setting of arbitrary thresholds and treating the lab work, rather than the patient seems to be endemic.

[Charlie-Farley]

tatty

Off at a tangent have you heard of SIKA admix? A waterproofing agent that can be mixed with cement? If you decide to do some serious tanking.

[purplespottycat]

excellent - just the info I need for my endo appointment on 11/10! Thank you tattybogle

[Juliet_22]

Absolutely brilliant, saved and thank you so much for putting it together!

[helvella Administrator in reply to Juliet_22]

To (hopefully) make it easier to find I copied it onto my blog when tattybogle first posted it.

helvella.blogspot.com/p/tat...

[pennyannie]

Elaine22