What do these lab results suggest to you please

[Noelnoel]

Later today husband will be speaking to GP regarding latest TFTs which have been erratic this past 3 years. He’s not taking any thyroid replacement yet but I’m expecting - or should I say hoping - GP is going to prescribe something based on over range TSH, although I know they often wait for it to climb higher

It seems he’s converting reasonably well. My questions are:

Given that FT3 isn’t too bad should he just wait to see if ferritin improves and maybe helps nudge thyroid function

D3, folate and B12 are high in range but ferritin is only just about within range with the rest of his iron panel suggesting no farther capacity for supplementing. However, GP has asked him to continue with Thorne bisglycinate @ 50mcgs daily for the time being

TSH 7.19 (0.35 - 5.5)

FT4 13.9 (10.5 - 21) 31.73%

FT3 5.2 (3.5 - 6.5) 56.67%

So far, antibodies haven’t been tested. The above were carried out at 8.45am

I have asked husband to join the forum but I’m not holding my breath

[tattybogle]

fT3 will usually be ok even when thyroid is failing , because TSH is high (it asks the thyroid to make as much T4 as possible AND it also asks thyroid to increase the ratio of T3 :T4 that it usually makes.. so that is why ft3 usually looks relatively good in early hypothyroidism)

It is clearly time they tested his thyroid antibodies to see if autoimmune hypo is the reason for this increasingly high TSH.

It is possible for them to prescribe levo once they have 2 over range TSH's... even if they are both still under 10.... and even if fT4 is still in range.... IF there are symptoms of hypothyroidism that are causing significant problems.

This is not dependant on having raised TPOab ,, but it obviously helps convince them it's not likely ot get better on it;s own .. so they are more likely to prescribe Levo with TSH under 10 if TPOab are positive .

i can see from older posts he has had a couple of TSH slightly over 5 in the last couple of years,, you said it's been erratic ... how ?.. has TSH gone back into range in between these tests ?

[Noelnoel in reply to tattybogle]

Thank you tattybogle

I can’t remember or find the older labs but they were up and down within the normal range, with it once being over range but only slightly. This latest one is more significantly raised

GP has just called and prescribed levo x 50/day asking him to repeat labs in 6 - 8 weeks, to include iron panel and for now to continue supplementing iron. He’lbe sure to ask it also includes antibodies as you suggested

I listened in on the call and asked for a lactose and mannitol free prescription but she unfortunately couldn’t tell us which those would be. She mentioned something about a green prescription and to ring around pharmacies asking. Do you happen to know the mannitol and lactose free brands?

Thanks again for your time and help

[GlowCoach Administrator in reply to Noelnoel]

Lactose and mannitol free brand would be Vencamil. GP can write it in the first line of the prescription to ensure he always gets that brand. It only comes in 100mcg dose size so he will have to get a pill cutter to cut it up. GP likely to need to rewrite prescription specifically.

Be sure he takes his Levo 4 hours away from iron. he could try taking his iron with some orange juice to help it absorb better.

When someone isn't on Levo its not possible to asses if they convert well as the mechanisms are different with natural hormone production. You will need to test his FT3 once he has begun treatment, and it will be better to assess that closer to when he is optimally replaced.

Your GP has done the right thing prescribing Levo now.

Exactly what were his vitamin results with ranges?

Lucky hubby having you to guide him!

where to write brand on prescription

[helvella in reply to GlowCoach]

Aristo supply both generic Levothyroxine and branded Vencamil.

The tablets are 100% identical.

I happen to get the generic. Others get Vencamil. The prescriber might have reasons for choosing to state one rather than the other!

[GlowCoach Administrator in reply to helvella]

I'm glad you pointed that out. Will Aristo always be around or in time will it be phased out?

[helvella in reply to GlowCoach]

Aristo are producing a branded version so that prescribers can more readily prescribe it. Otherwise, I think they'd have been perfectly content to supply only one product.

As they are pretty new to the UK thyroid hormone market, I don't think they are planning on dropping anything. And they do exactly the same within Germany (but a different brand name - I'll not repeat it to try to avoid fostering further confusion).

[helvella in reply to helvella]

All four (German and UK) products are listed in helvella's medicines documents (UK and Rest of the World) which 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.

The UK document contains up-to-date versions of the Summary Matrix for tablets, oral solutions and liothyronine available in the UK.

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

You might be surprised at quite how many countries Aristo supply to. And I'm still collecting and collating information.

[Noelnoel in reply to helvella]

Thanks hellvella

[Noelnoel in reply to GlowCoach]

Thank you for that Jaydee

We called back to request the change of script and have received a text saying: done! I really can’t complain about our surgery, they’re sometimes incompetent but they always try to be helpful

Will reserve judgment then on whether or not he’s a good converter, until after his first test

4/02/23

Ferritin 23.4 (22 - 322) 0.47%

Serum iron 26.2 (11.6 - 31.3) 74.11%

Transferrin 2.67 (2.15 - 3.65) 34.67%

% Sat 43 (16 - 50)

Folate 8.34 (>4) replete >6.13

D3 97.5 (>50 adequate)

B12 wasn’t done for some reason but in recent years it’s been 70+% and once it was over range

He’s incredibly lucky to have me guide him, if only he knew the struggle he’d have without guidance but I’d be nothing without you and the many other knowledgeable contributors, so how lucky am I!

[Noelnoel in reply to GlowCoach]

Hi Jaydee, are you able to further advise please? Have visited out local Lloyds and spoken over the phone to an independent and in both cases they say they don’t offer it and one saying GP has put info incorrectly. Unfortunately there was a language barrier in both cases and so I’m left unsure of the reason GP’s info wasn’t enough and also why there’s a problem getting it

At Lloyds they dispensed me something but when I opened the packet it was wrong

[GlowCoach Administrator in reply to Noelnoel]

So what did they send you?

Its likely that his prescription says 50mcgs because that is what the dose is that he should take. vencamil/Aristo only comes in 100mcgs so you would just need to cut it in half to get that dose.

GPs also often dont understand the need for having the brand name in the first line of the prescription.

Were you asking for vencamil and did you ask if they have Aristo?

[Noelnoel in reply to GlowCoach]

Apologies, thought I’d included the photo

Photo

[GlowCoach Administrator in reply to Noelnoel]

They've written it at the end. It needs to be after the word tablets.

Do they pharmacies have any stock of vencamil?

[Noelnoel in reply to GlowCoach]

Thank you for promo response Jaydee

So far, none of the pharmacies I’ve tried, stock

One of the local independents is going to call me back

[GlowCoach Administrator in reply to Noelnoel]

Ask if they have Aristo as is the exact same thing under a different name.

His ferritin is terribly low. Nice state a levle of under 30 is deficient. GP may prescribe iron tasblets which must be taken 4 hours apart from Levo.

His folate is also low so a good methyl B complex would help him.

[helvella in reply to GlowCoach]

When it is prescribed as a specific branded product, I think it should be:

Vencamil 100microgram, 28 tablets

The problem comes from mixing generic prescribing by recommended International Non-proprietary Name (iRNN) [which is Levothyroxine sodium] with prescribing by brand.

Not entirely sure if they should put it as "Aristo Vencamil" or just "Vencamil".

But I am in no way trained or experienced in prescription writing!

My UK medicines document includes the PIP codes which just might help some pharmacies work out what they are doing.

[GlowCoach Administrator in reply to helvella]

I think there were some language difficulties but perhaps if Noelnoel could get the pharmacy to write down how it needs to be written?

[SlowDragon Administrator]

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

what vitamin supplements is he currently taking

Do you happen to know the mannitol and lactose free brands?

The only brand that’s lactose and mannitol free is Aristo, also listed as Vencamil and only available as 100mcg tablets

Is he lactose intolerant?

[Noelnoel in reply to SlowDragon]

Thank you SlowDragon

No idea whether he’s lactose intolerant but requested lactose and mannitol free on my suggestion. He’s reluctant and in denial enough about being hypo without giving him an excuse to stop taking it should it give him problems. Want him to have the best possible chance of success with it because I’m anticipating that initially he might start feeling off on only 50mcg. He’s about 86kg so should in theory may end up on about 125mcg, possibly more, possibly less

It’s often said on here that 50 is a starter dose but is that irrespective of weight? Obviously it would be a bit reckless to prescribe 125 straight off the bat but I can foresee some niggles because despite labs he’s feeling fine, so I imagine introducing thyroid replacement will upset the applecart at first. Having said he’s feeling well, he’s quite tired but equally this could be caused by, or at least contributed to because of his very low ferritin

Last labs were 4/02/23, results in reply to Jaydee. He takes:

Vit d k2

B complex

Iron bisglycinate

Mag citrate

[SlowDragon Administrator in reply to Noelnoel]

Well you can’t get any 50mcg that are lactose and mannitol free

Most easily available (and often most easily tolerated) are Mercury Pharma or Accord. Both are mannitol free

Mercury Pharma make 25mcg, 50mcg and 100mcg tablets 

Mercury Pharma also boxed as Eltroxin. Both often listed by company name on pharmacy database - Advanz 

Accord only make 50mcg and 100mcg tablets 

Accord is also boxed as Almus via Boots

His ferritin is very poor. Have you significantly increased iron rich foods in his diet

[Noelnoel in reply to SlowDragon]

Not sure you saw my response and question yesterday SD

It’s often said on here that 50 is a starter dose but is that irrespective of weight? 

[SlowDragon Administrator in reply to Noelnoel]

Yes

And if over 60 years old starting on 25mcg levothyroxine initially

[Noelnoel in reply to SlowDragon]

Thank you SD, that’s interesting. He’s 66 and has been started on 50mcg

[Noelnoel]

It’s often said on here that 50 is a starter dose but is that irrespective of weight? 

Thank for the info on availability. On calling various pharmacies it became apparent that 50mcg isn’t available. Surprising that no one seems to stock lactose and mannitol free however, GP changed prescription to Vencamil 100mcg (or whatever the other name is) and is ok with him pill-cutting them

Ferritin is indeed extremely poor. We eat red meat often and liver weekly. Also lots of fruit, green veg, eggs. He also drinks acerola with iron capsules to aid absorption but none of this seems to helping much at the moment. May change to orange juice as suggested by Jaydee to see if this makes a difference. Perhaps it will improve if/when thyroid hormones rise because I don’t think it’s an absorption problem given that other nutrients are good

[helvella in reply to Noelnoel]

The Aristo product doesn't literally need cutting!

The tablets have a score line. In most countries, the patient information shows a picture and words like:

Notice about divisibility

Place the tablet on a flat, hard surface with the groove facing up. To divide the tablet press with your thumb directly into the middle of the pill.

Personal emphasis: Make sure it is a hard and flat surface and that you thumb is dry!

The UK's MHRA seems very unwilling to support splitting tablets.

How to break an Aristo levothyroxine tablet.

[helvella in reply to Noelnoel]

Information directly from Aristo in last few minutes:

The ONLY way of any patient being guaranteed to receive our version of levothyroxine is for it to be prescribed by brand.

The listing that doctors therefore need to choose on prescribing systems is;

Vencamil 100micrograms 28 tablets

GlowCoach