Test Results are they elevated ?

[Carnations21]

Thyroid test results Can you help...

I'm 62 and Hushimoto

I felt hypo but came back normal range ??

Serum free T4 level 11.2 pmol/L [9.0 - 19.1]

[SlowDragon Administrator]

Just testing Ft4 is inadequate

Was test done early morning and last dose levothyroxine 24 hours before test

How much levothyroxine are you currently taking

Free T4 (fT4) 11.2 pmol/L (9 - 19.) 

Ft4 is only 22.0% through range

Most people when adequately treated will have Ft4 at least 70% through range

Request 25mcg dose increase in levothyroxine

Which brand of levothyroxine are you currently taking

Do you always get same brand levothyroxine at each prescription

Bloods should be retested 6-8 weeks after each dose change or brand change in levothyroxine

If been under medicated a long time …..you might initially only want to increase dose by 12.5mcg before increasing again after 6-8 weeks

What vitamin supplements are you currently taking

When were vitamin D, folate, ferritin and B12 levels last tested

[Carnations21 in reply to SlowDragon]

Actually I reduced by 25mg 4 days before I was drawn because I felt very hyper with flushing and sweats and a tremor, maybe this was caused by something else, I'm feeling better for reducing at mo, though it's to early too say. The other thing is I take my meds at 10pm every night. My bloods were taken at 2pm afternoon, I had a cuppa tea beforehand. Do you think this would alter the results by much ?

[SlowDragon Administrator in reply to Carnations21]

Being very hypothyroid actually often feels like being hyperthyroid….because your body is running on adrenaline instead of thyroid hormones

Eventually adrenals can’t keep that level of adrenaline and cortisol up and can crash really low

TSH is at its lowest early afternoon

Your likely extremely under medicated

ALWAYS test thyroid levels early morning for highest TSH

As you normally take levothyroxine at bedtime/in night ...adjust timings as follows prior to blood test

If testing Monday morning, delay Saturday evening dose levothyroxine until Sunday morning. Delay Sunday evening dose levothyroxine until after blood test on Monday morning. Take Monday evening dose levothyroxine as per normal

If you had left 24 hours between last dose levothyroxine and test Ft4 would have been even lower….almost certainly below range

[Carnations21 in reply to SlowDragon]

Thank you for your very helpful comments. I will indeed take this advice on board. My leaving query is, why doesn't the doctor know all this! I'm stumped ??

[SlowDragon Administrator in reply to Carnations21]

A GP in training covers the whole endocrine system over a couple of days….thyroid disease about half a day

That would be acceptable if this was a rare disease….it isn’t….there’s around 2 million people in U.K. on replacement thyroid hormones

A key point being 90% are female ….and usually middle aged or older …it’s not a glamorous specialist area

Government and NHS are trying to get medics to follow guidelines …..but they can’t force to actually read and follow them

The main point to understand is that levothyroxine doesn’t “top up” a failing thyroid. Once you start on levothyroxine, because of the feedback mechanism, your own thyroid shuts down. So it’s important to be taking high enough dose

Many many people have to start on low dose levothyroxine (usually 50mcg unless over 60 yrs old) and increase dose slowly upwards in 25mcg steps over 6-12 months until on full replacement dose.

That’s a high enough dose to bring Ft3 and Ft4 to at least 60% through range or higher …..usually TSH will be around or under one. Never over 2

If left on inadequate dose levothyroxine, this results in low stomach acid, poor nutrient absorption and low vitamin levels as direct result

Low vitamin levels cause symptoms in their own right

Low iron - breathlessness, restless legs and exhaustion

Low vitamin D - joint pain, poor sleep and malaise

Low B12 - sweats, dizziness, pins and needles

Low vitamin levels tend to lower TSH and result in poor conversion of Ft4 to Ft3. Low Ft3 tends to lower vitamin levels further

Vicious circle downwards

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...

pathlabs.rlbuht.nhs.uk/tft_...

Guiding Treatment with Thyroxine: 

In the majority of patients 50-100 μg thyroxine can be used as the starting dose. Alterations in dose are achieved by using 25-50 μg increments and adequacy of the new dose can be confirmed by repeat measurement of TSH after 2-3 months. 

The majority of patients will be clinically euthyroid with a ‘normal’ TSH and having thyroxine replacement in the range 75-150 μg/day (1.6ug/Kg on average).

The recommended approach is to titrate thyroxine therapy against the TSH concentration whilst assessing clinical well-being. The target is a serum TSH within the reference range. 

……The primary target of thyroxine replacement therapy is to make the patient feel well and to achieve a serum TSH that is within the reference range. The corresponding FT4 will be within or slightly above its reference range.

The minimum period to achieve stable concentrations after a change in dose of thyroxine is two months and thyroid function tests should not normally be requested before this period has elapsed.

suggest you get back on 50mcg every day…..or even back on 75mcg every day

Wait 6-8 weeks on constant unchanging dose and brand of levothyroxine and then test TSH, Ft4 and Ft3

Meanwhile test vitamin D, folate, ferritin and B12 levels now

Come back with new post once you get results

Email Thyroid U.K. for list of recommended thyroid specialist endocrinologist and doctors 

[e-mail]

Vast majority of endocrinologists are diabetes specialists and useless for thyroid

[Carnations21 in reply to SlowDragon]

Thank you Very helpful advice,

[SeasideSusie Remembering]

Carnations21

Serum free T4 level 11.2 pmol/L [9.0 - 19.1]

Yes, your FT4 has come back within range, but just because it's within the range doesn't mean that's the optimal level for you. Your result is very low in the range, it's just 21.78% through the range

Calculation here: thyroid.dopiaza.org/

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

Were TSH and FT3 also tested?

What thyroid meds do you take?

Did you do the test as we always advise:

* Book the first appointment of the morning, or with private tests at home no later than 9am. This is because TSH is highest early morning and lowers throughout the day.

In fact, 9am is the perfect time, see first graph here, it shows TSH is highest around midnight - 4am (when we can't get a blood draw), then lowers, next high is at 9am then lowers before it starts it's climb again about 9pm:

healthunlocked.com/thyroidu...

If we are looking for a diagnosis of hypothyroidism, or looking for an increase in dose or to avoid a reduction then we need TSH to be as high as possible.

* Nothing to eat or drink except water before the test - have your evening meal/supper as normal the night before but delay breakfast on the day of the test and drink water only until after the blood draw. Certain foods may lower TSH, caffeine containing drinks affect TSH.

* If taking thyroid hormone replacement, last dose of Levo should be 24 hours before blood draw. If taking NDT or T3 then last dose should be 8-12 hours before blood draw, split dose and adjust timing the day before if necessary. This avoids measuring hormone levels at their peak after ingestion of hormone replacement. Take your thyroid meds after the blood draw. Taking your dose too close to the blood draw will give false high results, leaving any longer gap will give false low results.

* If you take Biotin or a B Complex containing Biotin (B7), leave this off for 7 days before any blood test. This is because if Biotin is used in the testing procedure it can give false results (most labs use biotin).

These are patient to patient tips which we don't discuss with phlebotomists or doctors.

Your FT4 result suggests that you are undermedicated and would benefit from an increase in your dose of Levo, 25mcg now and retest in 6-8 weeks.

As you have Hashimoto's this can deplete key nutrients. Have you had them tested:

Vit D

B12

Folate

Ferritin

They all need to be optimal for thyroid hormone to work. If you haven't had them tested then it would be a good idea to do so, either through your GP if he's willing to do them or do them privately with one of our recommended labs.

[SlowDragon Administrator]

previous post

healthunlocked.com/thyroidu...

Are you still only on 50mcg levothyroxine?

Highly likely to have low vitamin levels on such low dose

[SlowDragon Administrator]

suggest you request/insist GP test vitamin D, folate, ferritin and B12 levels NOW

Ideally also cortisol test too

sweats is frequently low B12

Tremor is likely excess adrenalin

List of private testing options and money off codes

thyroiduk.org/getting-a-dia...

Medichecks has 25% off test at moment

Medichecks Thyroid plus antibodies and vitamins

medichecks.com/products/adv...

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