I posted on her about a week ago about trying T4 split dosing and it made an instant positive difference which is very encouraging! Don’t get me wrong, I’m not swinging from the lampshades quite yet and feel I still have a way go until I feel fully well but this is a very welcome discovery 🙂
My current dosing (for one week) is 25mcg T4 at bedtime and 112.5 on rising. I’m wondering if I’ll feel better taking more T4 at night so it’s less all in one go in the mornings as I do still struggle a couple of hours after taking Levothyroxine.
I wondered what the general advice is on how to trial different dosage splits. E.g. I’m not sure whether I should stay on the regime I’m on for longer and then shift the balance very gradually (say 37.5mcg at night & 100mcg on rising & hold for a few weeks) or if it’s fine to make bigger changes more quickly (say 62.5mcg at night and 75mcg in the morning). I guess if I did this, the first day on 75mcg might be tough as of the drop in Levothyroxine though….
I’m very grateful of the amazing advice on this forum to try this approach! 🙂
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TiredMummy
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You are not the only one splitting their T4 dose, but is is towards the unusual end of the scale!
I suspect almost everyone has simply stumbled through various guesses and adjustments.
It strikes me as likely that more even makes sense. And that dose splitting needs to be considered along with whether you are on an adequate dose. If you are not on sufficient, you might be making it a rockier ride than if your total dose is close to what you really need. But this is just me mumbling on.
Hopefully, some others who have tried will drop in and reply.
I found splitting my T4 dose helped. I took the bigger dose at night because I read that allowed for better absorption. It led to deeper sleep for me, and some others. I took the smaller dose in the morning. I also tried bigger dose in the morning and top up in the afternoon to try to stop the afternoon drop. That worked to an extent as well. As helvella indicates, all this messing around with timings was really a way to try to improve being under medicated. I’m now trialling combination therapy so doing a lot more experiments with timing. My current system still involves the t4 at nighttime for better absorption and sleep. Good luck with the trials. Given that t4 is a steady state drug I shouldn’t worry too much about changing the amount at each time by tiny increments. Decide what you want to try, do it and stick to it long enough to give it a chance.
You need to check with a pharmacist for interactions. There is a pharmacy times link below with the worst known medications, but a pharmacist can assess if others are likely a problem.Generally it is calcium ions that are the problem (see link for other things, some antacids, some iron supplements, some antibiotics etc).
The issue with thyroxine and food & drink I think are sometimes overstated. You don't absorb anywhere near the dose of thyroxine you take, and the amount you do take in is surprisingly variable day to day even if you follow the "with water an hour or more before food" religiously.
What matters most is consistency in how you take it (and consistency in taking it! - this can be hard especially if you are symptomatically hypothyroid and can't remember if you took it or not 5 minutes after you've taken it).
Seen people anxious over whether they can take it with black coffee with thyroxine, or coffee with a little milk. All probably fine, if you always take it with your morning coffee, and eventually you'll adjust dose if this mean you absorb a few percent less each day.
Take mine at night, with water, before I clean my teeth. I try not to snack before that, I often fail. Interested in the splitting idea, that usually works like a slight dose increase with most meds.
Thankyou . Really appreciate your insight. I don’t eat after 6pm. So food won’t be an issue but take SSRI and sleeping pill at 10pm. I’ll take a good look at your link 🙏
I’m not under medicated technically, that much I know. I was on 150mcg T4 with good T3 conversion but my free T4 was too high. I subsequently dropped to 137.5mcg and my T3 conversion held well but the test showed my T4 levels still to be too high. What I’ve discovered with the split dosing is I have more energy and better cognitive function. Im finding for the first time in years that I’m not reaching for my pillow at 8:30pm. Some days this week I have felt like I’ve had a double espresso though….preferable to feeling hypo but, obviously not a good thing long term. It’s almost as if split dosing is letting me ‘feel’ the dose may be too much rather than too little but things may settle down and I’ve read these kind of symptoms wrong on so many occasions.
I think on balance, I may try 50mcg tonight and 75mcg tomorrow morning. This would be a 12.5mcg drop overall bringing my 24 hour dosing to 125mcg from 137.5mcg. I’ll see how it goes….and if it goes well….I’ll stay on the 125mcg for a couple of months and then do a blood test. It’s always such a gamble all this!
My biggest worry is feeling well enough to go into work on Monday! I often feel….’if I could just hideaway somewhere for a few months with various thyroid meds, a calendar, note book, pen, internet access and an iPad to access this forum’, I might actually get there! I’m sure we all feel like that. Oh well, here’s to the next experiment!
Hi TiredMummy. if you split if more or less 'half and half' , i wouldn't worry about having 'less in the morning' being problem throughout the day ... since you already took the 'other half' at bedtime previously and it does last a long time in the blood .
i split my 112.5mcg 62.5mcg on waking / 50mcg at bedtime.
i have done better over the last couple of years since i've been splitting my dose . just seems to make sense to me.
In health, the thyroid produces slightly more T4 in the very early morning (sort of 3-6am ish) than it does for the rest of the day .. it is producing T4 all the time of course , but the level does increase in the later part of the night (before we wake) . shortly following the high point of TSH around the middle of the night (the higher TSH is what drives the thyroid to make more T4).
When we swallow the whole days dose ( or the majority of it ) at eg 7 am ..it then takes approx 2-4 hours to increase the level of T4 in the blood .. so we will get the highest levels of T4 all at once at approx 9 - 11 am (and this high level is going to be higher than it would be in health where the total amount of T4 is delivered more gradually over the course of the whole day with slightly more 3-6 am)
I just reckon the body might know what it's doing by design , and is quite probably doing 'something useful' with 'more T4 before we wake up' ... rather than 'more T4 at 10 am'
That’s very interesting and increases my confidence to try 50mcg pm and 75mcg am. I totally agree about this approach making more sense in its alignment to our natural rhythm. It’s very strange how one approach works well for one but not another. I tried night time dosing (entire dose pm) on a few occasions over the years for example, works wonders for quite a few folk as I understand it, total disaster for me. Same with all in the am…..fast forward 4-5hours and I look and feel extremely unwell and exhausted. Reduce T4, add in T3, another complete disaster historically that was so bad I was suicidal. I remember a thyroid surgeon a saw many years ago (not for surgery, he did general consulting also) saying to me after trialling T3 ‘It’s almost like your body is refusing to accept the T3. I think your body wants to make the T3 by itself’. It’s all such trial an error for us all. It’s lovely to be individual but int he case of thyroid medication, I wish it was a one size fits all. The important thing is not to give up. One day, if we keep on trying and reaching out for help, we’ll all get there 🙂
personally ,, i'd not change the total dose at this point i'd stick at 137.5 and do it more or less 50/50 am/bedtime . if you lower the dose now you won't know what effect is due to the split dosing and what effect is due the lower total dose.
Give the split dosing a good 3/4 months of stability and monitor how you feel over that time .. then test and see what's happened with fT4 /TSH levels (and fT3 if poss) before deciding on any dose alteration ( unless you are getting consistent signs of overmedication before then)
it's an interesting comment about "split dosing allows you to 'feel ' it better" ... i know what you mean. Hard to describe what i mean exactly , it's subtle .. but i definitely know what you mean .
If i forget my bedtime dose , i wake up about 4 am ....not sure if that's really my body saying "where is it?" .. or whether it's just my subconscious saying "i think we forgot to do something"
Good thinking, best to change one thing at a time and see if the hyper feeling subsides although might need to reduce reasonably swiftly if I absorb and convert better at night (more usable thyroxine in the blood with the increased night time T4 dose). I’ll soon know if I’m bouncing off the walls or not! So I’ll try 75mcg tonight and 62.5mcg tomorrow morning. Sounds like a plan, will see how it goes
ok, I took 75mcg Levothyroxine last night around 9pm and 62.5mcg around 6am this morning. I slept much better but I feel more hypothyroid…..brain not working as well, tired and groggy. My body feels like it needs a boost of something. I’m trying coffee but I know that’s not the answer. Perhaps 62.5mcg isn’t enough for me first thing so I’m tempted to shift 25mcg from the nighttime dose to the morning one: 50mcg bedtime, 87.5mcg on rising. However, is it possible to need a higher dose generally when split dosing or is this me grasping at straws……again.
needs to be assessed on the same sort of timescale you would use for a more significant dose increase/ reduction.
ie do 'x' consistently for 6 weeks , note at the end of each week how you felt .. THEN decide.
trying to asses your response to 'x' on a day to day basis , (especially during the first couple of weeks) ,is usually going to lead to making the wrong conclusions about what effect 'x' has on you .
if i change anything i now EXPECT the first few days/ weeks to throw up all sorts of weirdness............, anything from altered sleep pattern , to feeling hungover in the morning when i was preciously ok ,to getting constipated for a few day when i wasn't before, to unexplained headaches, to suddenly going flop half way round Aldi, and feeling bright as a button at bedtime. anything ... usually temporary and replaced by a random 'somthing else' a fewdays later.
None of these signs in the first few days /weeks can tell you anything about what that new dose / or change of timings will actually be like once the body has adjusted itself and got used to it .
I imagine the body going "eh? WFT just happened?" and running round like headless chicken for a while .
So in my experience it' s best to pretty much ignore what happens until at least week 4 or 5.
Just make a note each week for reference , but other than that, don't pay much attention until week 4/5 onwards . And don't fiddle about 'tweaking it' .... just keep going and 'wait and see' ...., or you'll get hopelessly lost .
I now know that in the past i've made my mind up far too soon (2 weeks) about whether a new dose/ time was an improvement or not ...i now know that if i allow the body and brain time to accommodate the change , then after week 4/5 the picture will become clearer .
it it was a change in 'the right direction' then things will be improving by that point and will possibly continue to improve over the following few months.
if it was a change in 'the wrong direction' then things won't be getting better after week 4/5 and they will probably be getting worse .
Hi Tattybogle, the voice of reason. OK, thank you, I need your steadying hand more than you’ll ever know and hugely appreciate it! That’s the clearest I’ve ever had explained to me or perhaps it’s finally sinking into my thick, foggy brain. My mindset is as much of the issue as the illness. I’ve always panicked and tried too hard to correct. It’s a control freak thing. I will keep the dosing as is and see how I go. As long as I’m well enough to work, I’ll just have to keep the faith. I will find this extremely hard as it goes totally against my nature…..I have to perpetually ‘fix’ things. Ok, baton down the hatches, I’ll go on this ride and see where it takes me*
*subject to very scary, I absolutely cannot function, I can’t hold down a job feeling. And there it is, control freak already pursing it’s lips.
obviously i'm nowhere near as good at 'steadying myself' ... and i only know what i do now because i did it wrong so often in the past 20 yrs ....and only realised my mistakes in the last 3 yrs since i came here and put 2 and 2 together properly once i had access to my historic blood results .
you just have to "commit and ride it out" to see where it gets you ..(like getting on a roller coaster ... you're on it ~ you can't get off till the end of the line) .... then you learn about your own personal responses and signs.
Over the years you can hopefully figure things out quicker , with smaller clues, but initially you really do need to take the time to observe how 'you' react in response to thyroid hormone changes.
I found great success in splitting my levothyroxine daily dose. I’m on liquid levo so very easy to split my dose. I take half at 11.30am and half at 4.30pm. Liquid is also very good at absorbing. I don’t think it matters how much your split dose is or at what time as T4 levothyroxine generally just builds up in your body until it’s called for to make the most important hormone T3. It has a long half life too. I like to keep my T4 level mid way in the range and I do this also for T3 as I’m taking T3 liothyronine also. My TSH is usually good at around 1.00. Normally I feel very well and energised, so long as my medication supply is good. Recently I’ve had an issue with my liquid being in stock out and had to switch to tablets. Suddenly I felt the worst I’ve felt in ages. It seems I don’t absorb the levo tablets very well. I’m back on liquid as of yesterday after tracking down some supply.
liquid Levothyroxine sound very interesting McPammy…how did you go about getting that? Can you get it on the NHS or is it private only? Interested also why you take your morning dose at 11:30 rather than first thing. Can I ask why that is?
I get my liquid levothyroxine through my NHS GP after it was suggested I switch to it from tablets by my private only endocrinologist. It’s more expensive than tablets
I can’t remember exactly why I chose 11.30am and 4.30pm to take my split doses of levothyroxine It has worked out well though as nowhere near my food intake I also split my liothyronine which I take on waking and at 3pm Sounds like a faff but once I got into it I instinctively know when to take it At first I set reminders on my mobile
I’ve honestly not had any issues except recently when there was a stock out problem with my liquid
Thanks McPammy, and may I ask, we’re your blood tests ok on tablets and you just didn’t feel good or was the poor absorption reflected in your bloods? Apart from my T4 being too high, my T3 conversion on T4 only is pretty good currently.
congratulations on finding improvement and great that you shared this. It’s the ‘hold for 6-8 weeks’ that is most challenging.
I hear you on the ’need to be ready for work on Monday’ feeling. Spoils my weekend …. Must try different weekend routines to see if I can shift the dread.
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Should I revert back to morning T4 dosing now?
T4 Rising
Split dosing/blood tests, may I check please?
Thought on T3/T4 dosing 
