Analysis please on my sister’s results from Ireland - Hashimoto’s and cognitive issues - mainly short term memory

[Butterflycake1]

Bloods taken 22/11/22 (will be retested on 28/2/23)

NDA started on 1/12/22 1 grain 60mg (was previously taking 75mcg of Levo).

She is now taking supplements of Vit D3, K2, Selenium, Zinc, Omega 3. She is now “gluten free” and taking no artificial sugars. Diet changed to include more leafy veg. fruits, avocados, nuts, organic oats; no tinned fish. (She ate lots of tinned tuna in Sydney - mostly every day, and dairy milk chocolate).

Anti Thyroid Peroxidase 162 kIU/L flagged HIGH range (0-34)

Thyroglobulin 69.7 ng/ml range (3.5-77)

Anti-Thyroglobulin 15 IU/ml range (0-115)

TSH 4.59 mIU/L flagged HIGH range (0.27-4.20)

Free T4 17.4 pmol/L range (11.9-21.6)

Free T3 3.6 pmol/L range (3.1-6.8)

Vit B12 473 ng/L range (197-771)

Folate 4.3 ug/L (no range given)

Ferritin 134 ug/L range (13-150)

25 (OH) Vitamin D 83 nmol/L range (30-125)

Total cholesterol 9.2 nmol/L

Triglycerides 1.6 nmol/L

HDL cholesterol 1.95 nmol/L

Non-HDL cholesterol 7.3 nmol/L

LDL Cholesterol (calculated) 6.5 nmol/L

Comment: significantly elevated LDL cholesterol patient at high risk of CVD.

If there were no ranges written in above, they were not given. Thank you to everyone in the Thyroid community! My sister is at the beginning of this process but am confident she is moving in the right direction. I’d be very interested in any comments.

[SlowDragon Administrator]

These results showed she was under medicated on 75mcg levothyroxine

[Butterflycake1 in reply to SlowDragon]

Yes, and she was on this dose for about 4 years. The only reason I started to research hypo-thyroidism is because I noticed a slow down in her cognitive function and questioned whether she was converting adequately from T4 to T3. Thanks.

[SlowDragon Administrator in reply to Butterflycake1]

until on adequate dose levothyroxine and all four vitamins at optimal levels you can’t tell how good conversion is

And strictly gluten free diet/dairy free diet frequently necessary

Approx how much does she weigh in kilo

75mcg is only one step up from starter dose

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.

[Butterflycake1 in reply to SlowDragon]

She weighs 10 stone; approx 63.5 kilos. 5ft 7”

[SlowDragon Administrator in reply to Butterflycake1]

so guidelines suggest at least 100mcg levothyroxine per day

Always on empty stomach and then nothing apart from water for at least an hour after

No other medications or supplements within 2 hours

No iron, magnesium, calcium, vitamin D tablets within 4 hours

[BlueKeith in reply to Butterflycake1]

I'm on 75mcg of levothyroxine. Been on it for over a year and suffer terrible brain fog. Everyone around me noticing it. Some more sympathetic than others. I'm going to ask to be retested next week. Hope she manages to find solution. Good luck with doctor increasing dose

[Jaydee1507 Administrator]

These bloods were taken too soon after switching to NDT. It was only 3 weeks and needs to be 6-8 weeks after a brand/type/dose change.

High cholesterol is common in under replaced hypothyroidism, not to worry about it. Should resolve when better treated.

Her folate is too low. Would recommend a B complex such as Thorne Basic B with active/methylated vitamins.

[Butterflycake1 in reply to Jaydee1507]

Hi Jaydee, her bloods were taken on 22/11 and she switched to NDT on 1/12. She was on Levo 75mcg prior to the switch.

[Jaydee1507 Administrator in reply to Butterflycake1]

Apologies I have brain fog myself. Anyway, if she has switched to NDT the bloods are relatively irrelevant as starting from scratch now. Might have been better to stick with Levo and just slowly increase the amount she was taking whilst optimising vitamins. She'll need to retest 6-8 weeks after starting NDT. She will need several dose increases on NDT to find her optimal dose.

[Butterflycake1 in reply to Jaydee1507]

Thanks Jaydee. I was thinking her doctor may up her dose to 1.5 grains in early March.

[Jaydee1507 Administrator in reply to Butterflycake1]

Come back when she has new blood results. As patients we need to take charge sometimes and if we have remaining symptoms ask for a dose increase. Don't let the doctor dictate this too much, push for it.

[Lotika]

I think she is likely to end up needing somewhere around 1 and 3/4 grain NDT longer term and also think her dose should be increased after 6-8 weeks. 1 grain won’t be anywhere near enough.it is 38 mcg T4 and 9 mcg T3 which equates to around 68 mcg levo; we’ve seen from her previous results that 75 mcg levo wasn’t enough. She might do well to take her second dose of NDT early afternoon. I find this is suiting me quite well.

(Just editing to say that I think 1 & 3/4 grain will likely be the minimum she needs - more likely 2 or higher.)

[Butterflycake1 in reply to Lotika]

Thanks Lotika. It makes sense that the dose is low. Do you know where I could find a conversion chart between NDT and Levo?

[Lotika in reply to Butterflycake1]

I can explain how I convert! So, these days - and it is only a rough guide - more enlightened endos work with a ratio of 5cg T3 being equivalent to about 15 mcg T4. I used this to do the maths in my head so I’m a fraction out. Also, it’s not unusual to raise the dose with NDT by 1/4 grain a week, but of course you don’t want to upset the endo. I suspect she should add .5 grains in the afternoon sooner rather than later, though. No point being woefully under medicated for longer than necessary. Wishing you and your sister a happy 2023!

[cabro2 in reply to Butterflycake1]

Conversion charts tend to be notoriously inaccurate. My endo and I have calculated the dosage for years as follows.

Each grain of NDT contains 38mg T4 and 9mg T3. T3 is about 3 times more potent than T4. So, to find the dose equivalent (or conversion) I add up: 1) the total milligrams of T4 in the prescribed amount of grains plus 2) the total milligrams of T3 X 3. There are some people for whom the T3 is 4 times as potent, so YMMV.

For many on NDT, the T3 tests a bit too high. My endo finds the dose that keeps Free T3 well within the upper 1/3 of the reference range. Then if Free T4 results in too low a level, we supplement with 25mcg levothyroxine (yes, synthetic T4!) a few times a week to bring it up to my optimal range.

Hope this is helpful.

[Butterflycake1 in reply to cabro2]

Thanks so much. I can see how easy it is to be under medicated.

[Butterflycake1 in reply to Lotika]

Yes. I was thinking 2 grains from those calculations and she should see him in early February not early March. He’s away until early Feb. Is upping the T3 an issue though - are there unsafe levels in regards to side effects? I don’t know as I haven’t researched it. Thanks again.

[Eddie83]

GF is a good step. Try dairy-free too and keep watching TPO and TG antibodies to see if they come down.

It is common for patients to be under-dosed on levo and/or lio due to uneducated docs. The "full replacement dose" of levo is approx 1.7mcg/kg body weight. Multiply her body weight in kg by 1.7 and see what dose that suggests.

[Butterflycake1]

Thanks Eddie. It’s 107.95 so 100 mcg should be fine.