Endocrinologist Keeps Lowering my Tirosint Dose

[KarmaMaya]

Hi Everyone,

Since my partial thyroidectomy in December, I moved from an integrative practitioner to a new endocrinologist (who can better monitor my thyroid nodules) but who has also been adjusting my medication solely on TSH numbers.

I went from a compounded T4/T3 (80mcg T4/12 mcg T3) prescription before my surgery. I was prescribed this by an integrative practitioner due to Hashimotos. I felt good on this dose combination. But after my surgery my endocrinologist switched me to straight up 100 mcg Tirosint (and I asked for 5 mcg of T3).

December 24 - Started with Tirosint 100 mcg plus liothyronine 5 mcg (did feel a little jittery). In January I dropped the extra liothyronine. No more heart palipatations or jitteriness.

February 24 - saw integrative practitioner (she wasn't worried about these numbers):

TSH was 0.015 (range .4-4.5)

Free T4 1.41 (range .8-1.8)

Free T3 3.01 (range 2.2-4.0)

TPO 130 (range <60)

Vit D 34 (range 30-100 ng/ml)

But endocrinologist saw the TSH and was very concerned - he lowered Tirosint to 88 mcg/day. I spent four months on this dose and had tests again. The results were:

July 9, 2022

TSH 0.029 (range .4-4.5)

Free T4 1.34 (range .8-1.8)

Endocrinologist was still concerned and lowered Tirosint from 88mcg/day to 75mcg/day. He's not interested in Free T3 numbers, but I requested we test that this time around.

October 19, 2022 - My current numbers are:

TSH 0.15 (range .4 - 4.5)

Free T4 1.11 ng/dl (range .8 - 1.8)

Free T3 2.4 pg/ml (range 2.2 - 4.0)

He wants to lower my Tirosint some more. I see that the TSH is still low, but my Free T4 and T3 are also low. He doesn't look at any of the other numbers besides TSH. It is strange to me that I would be taking less thyroid replacement AFTER having half of my thyroid removed than before I had it removed (even considering compounded tablets absorb differently). Does this make sense? What danger would I be in if I stayed at these numbers? If I lower my Tirosint won't my Free T4 and free T3 drop some more?

I feel okay on this dose (still alittle depressed), and I've gained weight the past couple months. I know that being undermedicated can contribute to depression, but I just read a study saying overmedication can contribute to depression in post-menopausal women. Yikes!

I appreciate your thoughts. Thanks in advance.

[SlowDragon Ambassador]

FT4: 1.11 pmol/l (Range 0.8 - 1.8)

Ft4 only 31.00% through range

FT3: 2.4 pmol/l (Range 2.2 - 4)

Ft3 even worse at only 11.11% through range

October results show under medicated and poor conversion of Ft4 to Ft3…..common with low vitamins

You need increase in dose levothyroxine back up to 100mcg

Essential to test vitamin D, folate, ferritin and B12

Being under medicated for thyroid, results in low vitamin levels

[KarmaMaya in reply to SlowDragon]

Thanks. I’m in a quandry because my endo thinks I am over medicated. I did feel better at 100mcg/day. Still I have read heart issues and bone problems can occur with TSH lower than .2. I will talk to him. See why he doesn’t look at the free T3 and see that it is low in normal range. If we go down in Tirosint it will put me out of the range and I will clearly be under medicated. Do you know what the research says about TSH this low?

[SlowDragon Ambassador in reply to KarmaMaya]

T4 therapy

ncbi.nlm.nih.gov/labs/pmc/a...

In a study evaluating tissue function tests before total thyroidectomy and at 1 year postoperatively when using LT4, it was found that peripheral tissue function tests indicated mild hyperthyroidism at TSH <0.03 mU/L and mild hypothyroidism at TSH 0.3 to 5.0 mU/L; the tissues were closest to euthyroidism at TSH 0.03 to 0.3 mU/L [48]. A normal serum TSH level consequently does not necessarily indicate a euthyroid state at the tissue level.

see reply by Diogenes in this post

healthunlocked.com/thyroidu...

the best paper on this that I have seen indicates that a TSH of 0.03-0.5 is best on therapy. Above that is insufficient and below MAY or MAY NOT indicate slight overdosing

academic.oup.com/jcem/artic...

Interestingly, patients with a serum TSH below the reference range, but not suppressed (0.04–0.4 mU/liter), had no increased risk of cardiovascular disease, dysrhythmias, or fractures. It is unfortunate that we did not have access to serum free T4 concentrations in these patients to ascertain whether they were above or within the laboratory reference range. However, our data indicate that it may be safe for patients to be on a dose of T4 that results in a low serum TSH concentration, as long as it is not suppressed at less than 0.03 mU/liter. Many patients report that they prefer such T4 doses (9, 10). Figure 2 indicates that the best outcomes appear to be associated with having a TSH within the lower end of the reference range.

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)."

[KarmaMaya in reply to SlowDragon]

Wow! You are amazing. I've seen on this website how much you have helped people. Thank you. I am impressed with your knowledge and your willingness to help so many of us! I have written an email to my doctor citing these studies and stating I don't want to lower my dose any more. Here's my email:

Hi Dr. H,

I've done some research and I actually think I may be slightly undermedicated at the 75mcg Tirosint dose. I don't want to reduce my Levothyroxine dose any more. Please look at my free T3 and free T4 which are both in the lower end of normal.

TSH 0.15 (range .4 - 4.5)

Free T4 1.11 ng/dl (range .8 - 1.8)

Free T3 2.4 pg/ml (range 2.2 - 4.0)

If we reduce my meds any more they will be out of range. There is some evidence that mildly suppressed TSH levels post surgery are not indicative of overmedication:

ncbi.nlm.nih.gov/pmc/articl... "Biochemical Markers Reflecting Thyroid Function in Athyreotic Patients on Levothyroxine Monotherapy"

“the serum biochemical markers of thyroid function in patients on LT4 [1 year] following total thyroidectomy demonstrated…the patients with mildly suppressed TSH levels [TSH 0.03 to 0.3 mU/L] were closest to euthyroid, whereas those with normal TSH levels were mildly hypothyroid, and those with strongly suppressed TSH levels were mildly hyperthyroid.”

academic.oup.com/jcem/artic... "Serum Thyroid-Stimulating Hormone Concentration and Morbidity from Cardiovascular Disease and Fractures in Patients on Long-Term Thyroxine Therapy"

“patients with a serum TSH below the reference range, but not suppressed (0.04–0.4 mU/liter), had no increased risk of cardiovascular disease, dysrhythmias, or fractures. “

** I will let you know what he says (assuming he actually reads the email - usually his staff screens his emails.) Thank you!

[SlowDragon Ambassador in reply to KarmaMaya]

I would have included percentage results

Ft4 only 31.00% through range 

Ft3 only 11.11% through range

[KarmaMaya in reply to SlowDragon]

Yes, I thought about it (and I appreciate your calculating those numbers), but he's got a big ego, and I didn't want to push him too far by doing the math for him. If he looks at the numbers he can see how low they are. Assuming he thinks that T3 and T4 are valid measures he will see my point. Thank you again.

[SlowDragon Ambassador in reply to KarmaMaya]

Osteoporosis can be linked to high Ft3 …..and just as importantly LOW Ft3

Not TSH

thyroidpatients.ca/2018/07/...

[Batty1 in reply to KarmaMaya]

because no Endo likes to test for FT3 and honestly the bone issues with low TSH drives me batty Im without a thyroid and on both T3 and T4 and my Dexa scan didn’t show my bones being any worse then what they were 10 years earlier and as for heart issues thats been a mixed bag of opinions unless you have a known heart issue why worry about it right now… Doctors like to make patients paranoid when it comes to thyroid disease.