no instructions, please advise me on Liothyronine, right now Mercury Pharma

[thyr01d]

Having moved house and surgery I am no longer receiving the instruction leaflets in my liothyronine. What I can't remember is which brand says not to cut them in half but to dissolve one tablet in water, drink half and discard the other half. At first I had a brand I knew but now have been given Mercury Pharma and am wondering if I need to be dissolving. I know some of you will say it doesn't matter, you can cut them in half, but I actually discovered that I needed to be dissolving after wondering why, having been given a different brand, I was feeling so much worse, then better again when back to the previous brand, so I read the leaflet and discovered that if I dissolve I feel fine. Thanks all for reading and for your help.

Note: I have now found online the instructions, and here they are in case anyone else is looking:-

Liothyronine Sodium Tablets are taken by mouth. They should be swallowed with a glass of water.

• If you have been prescribed a dose lower than 20 micrograms, you should allow a tablet to

dissolve/disperse in 20 mL of water for 10 minutes, in a small measuring cup.

• You should gently swirl the solution occasionally to aid the dissolution/dispersion.

• You should then swirl the solution for a few seconds prior to using a suitable oral syringe

to withdraw the amount of liquid corresponding to the dose prescribed (5mL for a 5mcg

dose; 10 mL for a 10mcg dose) and squirt the liquid directly into your mouth by gently

pressing the plunger.

• Any remaining liquid should be discarded.

[GlowCoach Administrator]

Some brands suit some people better than others. Are you sure it wasn't just that the brand that you didn't dissolve didn't suit you?

The dissolving method is a more precise way of taking a fraction of a tablet that a pharmacist would tell you but its horribly wasteful and expensive!

[thyr01d in reply to GlowCoach]

Hi Jaydee, I am fairly certain the problem is that not dissolving, as you say, results in unequal distribution of the amount of T3 in each piece of tablet. I'm not, as far as I can tell, sensitive to anything in the way of food or additives and I'm fine with this brand when I dissolve the tablets. I agree with you totally, and posted about it on here as well as alerting my previous surgery, it is so horribly wasteful of a product that was so expensive.

[arTistapple in reply to GlowCoach]

This is interesting. I think I need tiny doses of T3. Which tablets are soluble or is it the capsules only? Any of the usual could be cut smaller and dissolved creating less waste? Curious too that the ‘power’ of T3 is such that the smallest dose (in tablet form) seems to be 5 mcg.

[GlowCoach Administrator in reply to arTistapple]

The trouble with smaller doses such as 5mcgs is that they are very expensive.

Perhaps thyr01d could tell us which brand they were dissolving that helped them? I don't have any experience of dissolving T3.

[thyr01d in reply to GlowCoach]

Hi arTistapple and Jaydee, I don't quite understand what you wish to know but here goes. As far as I can tell there is only disadvantage in having to dissolve to obtain the correct dose. All and any T3 works for me and it suits me to carry the split pills with me when out so that I can take them as necessary wherever I happen to be. It's a nuisance to carry pills, water, syringe, and container to be able to dissolve (etc as per instructions) out on a country walk, likewise if you have to stop on a long drive to an airport and faff about! The pills that have to be dissolved if you need to split the dose are Mercury Pharma. I need 20 mcg early am then 10 mcg late am and another 10 mcg mid-pm. Since I am prescribed 20mcg tablets I therefore have to split them. That's no problem at all with a pill cutter for all brands I've had other than Mercury Pharma. The problem with MP is that they have to be dissolved and half the resulting liquid swallowed and the other half thrown away, it can't be saved to use later in the day. If I've given the impression MP are in any way better, that's unintentional, all brands seem equal to me, as I said, I don't suffer from sensitivities/allergies. I hope that helps but if I haven't answered what you wanted to know, please just ask again.

[thyr01d in reply to arTistapple]

Hi arTistapple, please see my reply to Jaydee

[SeasideSusie Remembering]

Having moved house and surgery I am no longer receiving the instruction leaflets in my liothyronine.

Point out to the pharmacist that any medication must come with a patient information leaflet however it is dispensed:

gov.uk/guidance/medicines-p...

Patient information leaflets (PILs)

Unless all the information is on the pack, all medicines must include a PIL, regardless of how patients get them. PILs must:

* be easy to understand

* not contain personal information that can identify an individual, including names of staff members or digital signatures

Each product authorised under a marketing authorisation must have its own leaflet as explained in our best practice guidance on patient information leaflets. Also see MHRA guidance document always read the leaflet - getting the best information with every medicine (PDF, 588 KB, 173 pages).

No excuses, they must provide you with a leaflet.

[thyr01d in reply to SeasideSusie]

Thanks for your reply, I am sure they will, but I can't be absolutely certain there wasn't a leaflet in the first box I opened and threw straight in the bin, assuming there would be leaflets in all of them. Anyway, I have found online what I was looking for so needn't have troubled anyone here.

[helvella]

The information is all available online.

The main problem with dissolving is that you end up throwing half the medicine away. Which is very wasteful given its cost.

I can't see why you couldn't split the tablet and then dissolve the half tablet. That way, you could take the other half tomorrow (or whatever). Indeed, if dissolving helps, you could do that with whole tablets if it gets to the right dose.

The issue the MHRA and manufacturers were trying to address was that splitting is inherently uneven and can lose crumbs. Many here are not convinced that it is a significant issue.

helvella's medicines documents (UK and Rest of the World) can be found here:

helvella - Thyroid Hormone Medicines

helvella has created, and tries to maintain, documents containing details of all thyroid hormone medicines in the UK and, in less detail, many others around the world.

This link takes you to a page which has direct links to the documents from Dropbox and Google Drive, and QR codes to make it easy to access from phones.

helvella.blogspot.com/p/hel...

[arTistapple in reply to helvella]

OK. So daft question maybe. Any T3 is soluble in water? I have some T3 Uni-Pharma 25 mcg and T3 Thybon Henning 20 mcg. Actually I was hoping to cut the dosage right down, e.g. Thybon Henning to 2.5 mcg and then dissolving and therefore being able to reduce the dose to 1.25 mcg by losing only another 1.25 mcg. Minimal waste. Even if I lost half the liquid, it’s better than them all sitting in the cupboard unused.

[helvella in reply to arTistapple]

Roma Capsules state T3 is modestly soluble in water. And use that to justify their advice that you can open a capsule and dissolve the contents in water. (Though the intention is for you to do that to avoid having to swallow the capsule - not to adjust dose.)

[arTistapple in reply to helvella]

Ah, just the capsules after all. Well I will check out dissolving the tablets (or parts) anyway. After I sent the last query I was thinking they must dissolve in our digestive tract anyway!

[helvella in reply to arTistapple]

I didn't mean "just the capsules". If capsule T3 dissolves, so will tablet T3! Just mentioned Roma because I was more or less quoting their words.

You just have to make sure it is suitably dispersed - e.g. ground down whether as a dry powder or within the liquid. (I have not got any to experiment with!)

Dissolving in our digestive tracts is massively affected by stomach acidity and alkalinity in the intestine. You cannot go from neutral tap water (or near enough) and apply that to our digestive systems - nor vice versa - well, not without extra information and maybe experimentation.

[arTistapple in reply to helvella]

ok. It seems like this might be worth experimentation for me. I have other issues at the moment but if/when I do this I will report back. I surely can’t be the only person who needs tiny amounts? I am thinking I probably need more eventually but I must get over the starting line first. Thanks helvella.

[helvella in reply to arTistapple]

I agree!

Amazing it took over fifty years for a UK licensed product of less than 20 micrograms to appear! Especially as the USA has long had 5 microgram tablets.

[arTistapple in reply to helvella]

Again (my theory) is that the starting dose (especially by NHS trained endocrinologists) is too high for some and that is why so many people (allegedly) do not succeed with T3. Therefore ‘failing’ the trial period. It damn well suits the powers that be for this to happen! pennyannie I think, (apologies if it’s someone else) says that she continues to get more well on her dose long after, it sounds like, her dose became optimal. This might not be a forever dose but it sounds like an excellent response to me. I have on very little evidence, I can assure you, that a few days and no more of T3, I definitely continued to feel effects, good and bad for weeks. The short interlude has left good things behind and I feel I should give it another go - when I am ready. Hence looking for a way for minimal dosage.

[thyr01d in reply to arTistapple]

Not sure if I've replied to this Tirstapple but I think you are right, my endo started me on a very low dose and very slowly increased it over years. Is this what you are doing on your own?

[arTistapple in reply to thyr01d]

Yes my private endo just scuttled away after telling me I could not take T3 - without any examination of any ‘evidence’. And they added, I was unlikely to benefit from any increase in levo. Honestly it was like a death sentence. However this ‘disease’ and living with it, I have found, gives us a certain resilience. Hence the forum. After suffering hypothyroid goodies for many years and fighting to be ‘normal’, we truly know how to make an effort and privately what that effort costs. I have discussed this self medication route with my husband although it’s difficult for him to understand (and he is not keen, hence the original private endo route) not the symptoms because he sees them every day but the utter lack of medical help/communication. We have agreed we will discuss it again when the decision needs to be made. As he says he needs the car etc to be ready for a trip to A&E (he is not joking re: recent experience). My sense is that nearly every endo in this country is NHS trained and they bring all that to the consulting room even when they are boldly prescribing T3. This includes the fear instilled in many of T3 or even thyroid hormones perse. My private endo told me they trained and studied under the very endo in my area (who in my opinion has far too much ignorance and power, a heady mix) and who allows no T3 anywhere in his jurisdiction. The stats back that up. So even when brave enough to prescribe it, at the first problem……!! Sorry it’s all just an open would really. Reading Broda Barnes book at the moment. It’s extremely enlightening about all the background. So far no problems about dosage discussed in it. I hope it is discussed otherwise it all tends to be ‘magic’. Only reference so far is he is obviously using animal sources. I wish I had a medic of his curiosity and interest as my medic. All doctors of mine seem not to give a toss that I had a heart attack (now I am certain associated with all this hypothyroid stuff when I was subclinical) but the private endo just about wet themselves at the T3 reaction - while I was further traumatised. Maybe I should be asking you to PM me about your private endo but I think now that horse has bolted. As soon as they know my history they will want to back off.

[thyr01d in reply to arTistapple]

Hi arTistapple, I think the swirling immediately before swallowing the solution is important.

[thyr01d in reply to helvella]

PS Helvella, I think splitting first then dissolving would lead to the problem I had with splitting and then taking half a tablet - the T3 doesn't seem to be distributed evenly enough in each tablet, or at least that's my conclusion from the ups and downs.

[helvella in reply to thyr01d]

That is, of course, possible. But I was considering whether the dispersing/dissolving itself helped with absorption.

If they can't make tablets which are in themselves reasonably even, I wonder how accurately they can control the dose even in whole tablets?

I can see that a slightly uneven distribution plus a slightly uneven break could result in 20 dividing into 11:9, or 12:8. But finding it difficult to accept any worse than that.

[thyr01d in reply to helvella]

I don't think the dispersing/dissolving was to help with absorption because when you need the full 20mcg dose the instructions are as normal, just take the tablet, no dissolving.

Your comment about the uneven distribution has me wondering if some of us might be sensitive to even that slight difference but I find that difficult to believe.

[helvella in reply to thyr01d]

I agree - I don't think it is their intention or expectation. Just that it might be the case!

[arTistapple in reply to thyr01d]

It’s Ok about absorption, luckily that’s not my problem! I think I beg to differ on the uneven distribution thyr0id issue though. Honestly I would rather risk that at a low dose than be unable to take T3 at all, which my private endo has told me and scuttled away. I think I am living proof of that particular sensitivity - dosage. Luckily I seem to have no problems with brands! I know this has nothing to do with your original post really; it just happened to spark off a train of thought for me, as a solution to my very knotty problem. I thank you very much for your posting. Honestly. Fab.

[sparkly]

Omg didn't realise about this dissolving malarkey when splitting a tablet. Do we know the reason why?

[Musicmonkey in reply to sparkly]

My cynical guess is that pharmaceutical companies can see the cash roll in if they tell patients that they can't split tablets other than dissolving the whole tablet and throwing the other half away!!

[sparkly in reply to Musicmonkey]

I'm sure my gp will be very happy with me throwing 15 mcg down the sink every day.What a load of bunkum!! Been on t3 for 9 years, just recently prescribed and always used a pill cutter. Ok some quarters might not be equal but nothing detrimental to how I've felt.

[arTistapple in reply to sparkly]

No sparkly. You do not have to dissolve it when splitting a tablet. I was just wondering if I could attempt a lower dose by dissolving it. It’s impossible to really get the tablet smaller than 2.5 mcg. If I dissolve 2.5 mcg and halve the liquid it’s dissolved in I would get my 1.25 mcg I want. Sorry if my question caused you any problems or upset. Go on doing your splitting to your hearts content. Glad to know you have felt no ill effects of quarters not being equal. It’s so tiny by the time we get to 2.5 mcg it makes very little difference, probably for most people. Especially when you have been on it for so long. It’s just too much for me at 2.5 mcg.

[sparkly in reply to arTistapple]

Having been on t3 for so long was just shocked to never reading about dissolving before. I understand you needing smaller dose. I have felt the difference if had an unequal quarter but I always feel fantastic when the day I raise my dose fir a couple of days.

[arTistapple in reply to sparkly]

I had read it before but there is such a lot of info about, I find I have to filter some of it out. Then surprise surprise one day a ‘penny drops’ and I find it useful. Just where else would this have been discussed? Thank goodness for the forum! Yes I do not see a problem with the uneven dose at that amount. A day or two with a little boost would not go amiss. Our own bodies (when well) I am sure deal with bigger swings. I hopefully only need to do this for about a month until I can take the whole 2.5 mcgs - at least that’s the idea - titrate very slowly.

[Gingernut44]

I’m absolutely gobsmacked that you are actually tipping the equivalent of 20 mcg of T3 down the drain each day. What’s wrong with saving the 10 mcg dissolved T3 from your mid morning dose in the fridge to take for your afternoon dose, so long as you swerve it initially. I wonder how many people are doing this.

.Just think how much T3 is entering the water supply 😱

[arTistapple in reply to Gingernut44]

No idea about saving it unless just putting it in water deactivates it whilst it is lying in wait for the next dose. It goes off? You are right to perhaps query about the water supply. I read a while ago that women (particularly) on the pill are filling the water supply with hormones (oestrogen) and this is contributing to men becoming less fertile. Can’t give a quote because it was ages ago I read it. T3 in the water supply does not seem to be helping me yet.

[Gingernut44 in reply to arTistapple]

It’s the utter waste that gets me, especially as so many of us have been refused T3 on the NHS and I find it unbelievable that people are being told to tip the excess away - what are all those hormones in the water doing to children's health.

[helvella in reply to Gingernut44]

I am not aware of proper published studies of the issue keeping dissolved/dispersed T3.

However, I think we need to consider that not only has it been dissolved/dispersed but it will also be subject to oxygen and light. These are both well-known to affect levothyroxine (T4) and it is perfectly sensible to suspect they might also affect T3.

I'll note that the only officially approved liquid T3 product I know of is Liotir, in Italy. And that has a fair amount of alcohol in it - which could make a big difference. So we can't look at existing products to try to understand.

[arTistapple in reply to helvella]

I am not surprised if there are no studies about this. There appear to be few studies of dosage. Everything we know about dosage is discussed right here (and as far as I can tell - only here). I was just replying to another post when I was reminded of a remark on one of the Facebook sites of a comment from the incoming President of The British Thyroid Association which implied that dosage is an area she wanted looked at. So once the powers that be get to what is sluiced down the toilet we will hopefully be in a much better informed state all round. Ha!

[Gingernut44 in reply to arTistapple]

I won’t hold my breath !!

[thyr01d in reply to Gingernut44]

I absolutely agree Gingernut, which is why I wrote to the surgery where I used to live about it and asked not to be given the brand that needs dissolving when split. I think Helvella has the answer, if you look at her comment below. Perhaps we should post about this and then all those of us who need to split T3 tablets could ask for the other brands. What do you think admins?

[Gingernut44 in reply to thyr01d]

I agree with SlowDragon ’s reply. You’ll probably find that, if asked, all manufacturers of T3 would say the same. Big Pharma’s way of increasing profits. If their production is so sloppy that all the active ingredient is totally separate to the excipients within the tablet then questions should be asked. (By the way, Helvella is a he 😊).

[SlowDragon Administrator]

This ridiculous idea of dissolving T3 in water only came about after high percentage of NHS patients had T3 prescriptions stopped when Mercury Pharma price was increased 6000%

A cynical attempt to drive up number of tablets used and wasted

And no suggestion as to where the “waste” T3 water should be disposed of either. It shouldn’t be tipped down the sink

Just cut tablets in 1/4 with sharp craft scalpel

[arTistapple in reply to SlowDragon]

This T3 adventure has been a rocky ride for many patients. Even for those patients who remain oblivious to its history. Your answer has added yet another interesting anecdote to our knowledge.

For my part I have found that it’s impossible to cut the pills to any less than 2.5 mcg with a crumb or two here or there. I am certain I need T3 but so far (due to mistakes in dosage and full understanding) I have been unable to tolerate it.

I have just been reading Broda Barnes. He refers to thyroid patients treatment by doctors. “They include many being fed stimulants, tranquilizers, or other medications which serve only to somewhat dampen symptoms without getting at the cause. They include many who are considered neurotics or hypochondriacs. They include many who are victimized by heart disease …….”. I admit after a life time of being treated in exactly this manner, I may be more than a little neurotic about dosage. However it is my suspicion that many thyroid patients (not just myself) are losing out on effective T3 by mismanagement, purposely or otherwise, by dosage issues.

Honestly I would also like to add that the stultified attitude and ignorance and ‘fear’ in the medical community is directly transferred to vulnerable patients. Patients who are through the nature of the illness itself and already subjected to the above mentioned treatment are offered the complete opposite of help!

As I have said in a previous post, this forum, as far as I am aware, is the only place dosage is discussed. This is huge and gratifying. This discussion came about almost by accident and I am grateful for it.

[thyr01d in reply to SlowDragon]

SlowDragon, that's what I was doing, in my innocence, just as I do with all other brands, until, having noticed that I wasn't well on that particular brand I read the leaflet. To elaborate, once I realised this just occasionally the surgery couldn't get my full quote in other brands so would give me Mercury Pharma. I would then use the Mercury Pharma for the 20 mcg dose and take the other brands for my 10 mcg doses, and I felt fine. Do you have another explanation, because I can't think of one.

[SlowDragon Administrator in reply to thyr01d]

well different brands don’t suit everyone

Or are not necessarily interchangeable

It often takes several months to settle on to a different brand of T3 or Levo