TSH up after Synthroid increase

[ttreefrog]

Hi all, I am wondering if anyone has had an increased TSH, lower FT3 & FT4 when increasing Synthroid dose.

Some context (apologies if too much, if more needed please let me know)

I was diagnosed with hashimoto's in December 2020, labs as follows (range in brackets):

TSH 10.29 (.32-5.04 pmol/L)

FT3 4.6 (3.00-5.90 pmol/L)

FT4 11 (10.6-19.7 pmol/L)

TPO Ab 284 (<35 IU/mL)

B12 460 (153-655 pmol/L)

Ferritin 28 (15-247 ug/L) no other iron labs were run at this time

Magnesium .98 (.64-.98 mmol/L)

No Vit D done at this time

I have been on 50 mcg since Aug 2021 (titrating up from 25 mcg in Apr 2021) and attemtping to add in some liothyronine (currently only at 2.5 mcg SR daily)....suspect adrenal issues at play and have yet to determine how to sort out (tried a short period on hydrocortisone and helped at first and then waned, so stopped taking).

June 2023 labs (same ranges as above)

TSH 2.9, FT3 4.5, FT4 13.6

March 2023 labs (same ranges as above)

B12 348

Ferritin 53

Magnesium .89

Vit D 84

I am still dealing with fatigue/body pain/swollen tongue/dry skin, lung congestion not accounted for by anything else so far, etc. My doctor is not comfortable with liothyronine (I had been previously working with a private ND and they came to the end of their comfort level as well), and I suspected I am still under-dosed on levo after reading many of your posts here, so we added 25 mcg on Saturday and Sunday (she talked about a week half life that made sense to me, so essentially adding additional 50 mcg per week )...so I'm 7 weeks in and recent labs (Aug 15 2023) are :

TSH 4.62, FT3 4.1, FT4 11

B12 285 (153-655 pmol/L)

Iron 13.8 (10.6-33.8 umol/L)

Iron Saturation .23 (.13-.50)

Ferritin 40 (15-247 ug/L)

Magnesium .96 (.64-.98 mmol/L)

No Vit D done at this time

I am just so perplexed that adding more T4 increased my TSH and lowered FT3 & 4? I have not felt well in the last few weeks in particular...more heart palps, fatigue, BP lowered (not in a dangerous zone). The only other thing I changed was starting a CPAP trial, which by all accounts has helped immensely with sleep and could be contributing to the lowered BP, even this quickly....anyways, appreciate any thoughts as not sure where to go with it all next. Should add that I am also post-menopausal, so likely other hormones playing a role.

[tinkerbell22]

Hello, I'm sorry you're struggling and worried about this change in your results. Did you have the tests done at the same place each time?So is your dosage 50mcg levothyroxine 5 days a week and 75mcg 2 days a week? And with liothyronine daily 2.5mcg.

If you're swapping between 50mcg and 75mcg I wonder if this is like when I tried alternating between two doses every other day as I struggled with that. I wonder if you'd feel better and your test results stabilise if you were on 75mcg all the time.

Hope you get some answers here that help

[ttreefrog in reply to tinkerbell22]

Thank you for your kind reply. All the tests were done in the same place, fasted and between around 8:30 am, although the current one was the earliest at 8:15 am. Yes, exactly...5 days at 50mcg and 2 days at 75mcg (that's a much simpler way to say it, lol). I'm sorry you struggled too, it's so disheartening. Thank you for sharing your experience. It made sense to me at the time that the effect of Levo isn't absorbed quickly enough to cause issues and the weekly total is what would be most important. Have been highly sensitive to other medications in the past, so stands to reason with this as well. Upping to 75 mcg everyday seems counterintuitive in a lot of ways, but weight wise makes sense to go higher. Thank you for taking the time to reply.

[tinkerbell22]

Also, if you're alternating between two doses of levothyroxine, are you using the same tablet to do so, both synthroid and both say 50mcg? So there's no difference in ingredients.

[ttreefrog in reply to tinkerbell22]

Oh, right...it's not the same pill, so I will check the ingredients for both...it's a different color so there is at least one different ingredient. Thank you!

[helvella]

Has anyone ever seen a medical reason to change dose at the weekend, and not just one of the days, but both?

I can it is as convenient, but not sensible.

While I know many do fine on all sorts of dosing regimes, I'm not keen on alternate day dosing, let alone any more uneven approach.

If you take 75 on Saturday and Sunday, your FT4 might well go up noticeably. But when you revert to 50 it will drop. And I suggest it could drop lower than it was on the Friday before.

If any alternating schedule is unavoidable, I'd have gone for two days of 50 and one of 75. Or literal alternate days. Not putting the days you take 75 next to each other. (Though I suspect you need to get to 75 every day, then re-assess. It looks like your levothyroxine dose is likely too low.)

For almost all patients, a TSH of 4.61 is a strong indication you are under-dosed. Given that liothyronine tends to push TSH down even more, that adds to the message you are under-dosed.

[RedApple in reply to helvella]

'Has anyone ever seen a medical reason to change dose at the weekend, and not just one of the days, but both?'

I don't recall seeing any 'medical' reason, but I've come across these 'medic' reasons:

1) Patients need KISS dosing instructions, otherwise they won't take their meds.

2) Levothyroxine doesn't have any noticeable immediate effect. It's just like putting tins of tomatoes in the store cupboard to be used 'as and when'. Close the cupboard door and you don't know they are there. So it doesn't matter when you put them in the cupboard.

3) Doctors themselves are mostly incapable of figuring out more complicated dosing and prescribing instructions anyway!

[helvella in reply to RedApple]

1) Of course it is easier all round for KISS instructions. But we have seen many members who, once they have things explained and develop their own understanding, could and would keep to any schedule that worked for them!

2) Am sure you know, at the back there will be one that says "BBE 10/1993".

3) If ever there was a piece of succulent, low hanging fruit, a relatively simple computer app that helped doctors with working out doses would appear to be it. Little things like realising a 28-day prescription doesn't last a calendar month (except 3 in 4 Februaries). And if someone does need 100 one day, 125 the next, it makes more sense for their prescription to cover 56 days than 28 which needs them to split packs to get 14 * 25 tablets.

[ttreefrog in reply to helvella]

Oh my goodness, the lack of math calculations to ensure prescriptions durations make sense ...that's the kind of complication I don't have patience with at all!!

What does BBE10/1993 mean?

[helvella in reply to ttreefrog]

Best Before End 10 (October) 1993

Typically found on foodstuffs

[ttreefrog in reply to helvella]

helvella, thanks! Good heavens there is so much waste in all this experimenting. I started out paying for compounded levo in order to avoid any additives and it was soooooo expensive it pained me to not be able to use it all.

[ttreefrog in reply to RedApple]

RedApple, your response made me laugh right out loud in a very hysterical/macabre/I feel seen kind of way! Thank you!! My doctor is very sweet and is very practical and very scientifically oriented and the tin of tomatoes is precisely how she thinks (at least on the scale of a week) and a bit of #3 in that she doesn't feel comfortable with liothyronine dosing at all...gah!!!

[tinkerbell22 in reply to helvella]

Helvella "If you take 75 on Saturday and Sunday, your FT4 might well go up noticeably. But when you revert to 50 it will drop. And I suggest it could drop lower than it was on the Friday before."I saw something like this happen in my test results years ago when I went down a dose. My TSH sky rocketed! Is that because on a higher dose of levothyroxine the thyroid doesn't have to work so hard? So then when you drop the dosage your thyroid is stuck in a pattern of not working so hard? And maybe takes a while to take over responsibility again and works harder to compensate? That's how I've seen it but not sure if that's right.

For me it sounds like your thyroid is confused. I know alternating works for some so maybe it's about finding your rhythm. Though I do wonder again if no liothyronine and more levothyroxine might be wiser at this stage.

The palpitations I wonder if that means sometimes you feel overmedicated, which could mean you're on a correct dose of levothyroxine at 75mcg but then the liothyronine tips you into overmedicated feelings even though your results don't suggest that. Just when I take liothyronine these days I get palpitations too. So I've stuck to levothyroxine which feels a softer delivery method for me. Though everyone is different. Hope this makes sense

[helvella in reply to tinkerbell22]

Well I think we are agreeing in general. Something like that!

Every change - to what our bodies need, to what our thyroids produce, to our TSH, etc., takes time. The increased dose on Saturday might not really affect TSH until Monday or Tuesday. At which point it actually needs to compensate for the lower weekday dose but has been put off course by the increased weekend doses...

[ttreefrog in reply to tinkerbell22]

tinkerbell22 I have read that the palpitations that follow taking liothyronine can be adrenal related as well...that our adrenals can't keep up with our body utilizing the t3 I think. I don't have answers yet, or really even any clarity, but it seems to be a part of the puzzle for me.

[ttreefrog in reply to helvella]

Thank you helvella, so appreciate your taking the time to reply to me. I wondered about this post weekend dosing drop as this most recent lab was taken on a Tuesday morning, so not much time after the weekend 75mcg. Weight wise I am under dosed by a lot. At 81 kg should be at 129 mcg, given what I've read here. Although I am overweight at 81 kg and not sure what role that plays in determining correct dosing, but 75 mcg doesn't seem a stretch, does it? For the past year, on 50 mcg daily I've been fairly steady at a lower TSH (2.9 ish) and slightly higher ft3 (5) & ft4 (13.6)...my doctor is reluctantly willing to experiment with levo, but literally knows nothing beyond get the tsh into range and is 100% not comfortable experimenting with t3 - and our medical system doesn't think there is anything between healthy adrenals and addison's disease or that 2.5 mcg of liothyronine is enough to make any difference whatsoever and the recent heart palpitations make me nervous to go higher with any dosing. When I've tried increasing lio in the past, I have headaches and heart palpitations so went back to the levo, but honestly feel like I'm flailing around in the dark hoping not to run into a wall.

[radd]

ttreefrog,

I agree with helvella that a consistent dose is more likely to bring consistant/expected results.

Thyroid physiology is complex and complexities become magnified when we are under/over dosed. The numbers are a guide to ensure safety but not alway representative of exactly what is happening on a long term basis.

TSH can also be influenced by antibodies in assay interference. I wouldn’t pay a lot of attention to these results but just keep increasing meds slowly and watching the thyroid hormones levels raise.

Another aspect is meds(hormones) that aren’t working effectively aren't always just excreted but have other negative repercussions. Hence maybe the temporary elevation of TSH until you are more optimally dosed.

[ttreefrog in reply to radd]

Hi radd, I wondered about this too...that this is a temporary issue and titrating up (in a more uniform way, I now understand might be better) and see what happens. I have to say, the heart palpitations are really disconcerting though. Thank you so much for replying. It really adds to the confidence I have to keep trying with the Levo. I think my doctor my hesitate also as the prior TSH at 2.9 was so in range, they all think it's possibly dangerous to add more levo.

[Gingernut44]

What I don’t understand is why you are only on 50 mcg Synthroid since being diagnosed in December 2020! The sensible thing would have been to titrate your dose upwards by 25 mcg per day until your TSH was 1 or under and your FT4 was at least 75% through the range before knowing whether you needed to add T3.

No wonder you don’t feel well, your TSH is far too high and your frees are too low. Adding T3 at the point you did will have the effect of lowering your TSH and probably your FT4 which will only muddy the waters! I would be inclined to stop the T3 and increase your Synthroid up to 75 mcg per day and retest in 6/8 weeks to see where your results are. Continue titrating up until your TSH is 1 or under and your FT4 is at least 75%. Only then will you know if you need to add some T3.

You also need to work on your vitamins and minerals to help your thyroid hormones work.

[tinkerbell22 in reply to Gingernut44]

I was thinking similar gingernut44 but going off liothyronine might make it harder to get back on it. I made a similar decision myself to try liothyronine too early and it didn't end well! It worked better for me to raise levothyroxine first by itself. And I was also wondering at the long wait to start treatment initially. Though this would have happened to me too but I changed doctors and insisted on immediate treatment.

[Gingernut44 in reply to tinkerbell22]

But, I don’t think a dose of 2.5 mcg is doing any good, probably making the situation more complicated. Much better to get TSH and FT4 where they need to be before introducing T3. That’s just my opinion of course.

[ttreefrog in reply to tinkerbell22]

This is helpful for me to know it worked better for you to go back to just levo and well done on insisting for immediate treatment for yourself!! I am gaining info and steam to do the same.

[ttreefrog in reply to Gingernut44]

Thank you!! The lab ranges they work with where I am in Canada means that anything under 5 TSH and they think it's all fine (including private pay ND's). What I have read here and other thyroid information most definitely agrees with under 2 and like you, some say under 1 (I think that would cause fits in my doctors office)...I appreciate your clarifying how adding t3 too early may have muddied the waters. Yes to workign on vitamins and minerals...I stopped taking all supplements to see what, if any gains would hold...magnesium is the only one that has, so I will be back on iron, B and vit d supplements this week.

[tattybogle]

Hi treefrog , so your current levo dose is aprox 57 mcg / day .

Highly unlikely to be enough .

labs June 2023 showed 50mcg was not enough,

TSH 2.9 [0.32-5.04] ... this is still too high, dose should have been increased to 75mcg / day

FT3 4.5 [3.0 -5.90] 53%

FT4 13.6 [10.6-19.7] 33% (still pretty low)

In Autoimmune hypothyroidism the thyroid is progressively damaged over time, and becomes unable to keep producing the same mount of T4 as it was doing before .... It's reasonable to assume more damage has occured since your diagnosis and the tiny Levo increase to 57mcg day (+ 2.5mcg T3) is just not enough to make up the difference ... hence your TSH has continued to rise further, and your fT4 is lower despite the increase.

(most people will end up on a dose of somewhere between 75mcg and 150mcg when things finally stabilise)

7 weeks on 57mcg + 2.5mcg T3 Aug 2023 :

TSH 4.62 .. dose inadequate ,so TSH has continued to rise

FT3 4.1 38%

FT4 11 4% (lower, due to less production from your own thyroid)

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If i was you, i would :

Keep T3 dose at 2.5mcg since you have already started .

increase levo to 75mcg / day .. retest after 6 wks ...

if TSH is still over 1 and still feeling naff , then increase further to either 87.5mcg or 100mcg /day depending on results.

(my comments based on assumption you tested 24hrs after last dose levo.. but even if you didn't , it doesn't make much difference at this point ..as dose is clearly too low )

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healthunlocked.com/thyroidu... explanation-of-what *high-tsh-is-telling-us-when-our-ft4-level-is-normal-on-levothyroxine-the-shoe-size-analogy. (*over-2.5-3-ish)

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healthunlocked.com/thyroidu.... list-of-references-recommending-gps-keep-tsh-lower-in-range

[ttreefrog in reply to tattybogle]

Thank you tattybogle! Yes, testing was done 24 hrs after last dose and yes, the idea was that it would average over the week...originally we thought about adding 12.5 daily but concerns about over doing it, ironically, led to adding the 25mg 2x week. My TSH has actually held pretty steady at 2.5 -3 ish for a year at 50 mcg, and only went up with this latest 75mcg 2 days a week experiment. Perhaps the weird heart palpitations were down to the drop in t4 as the week went on...it's confusing to me as it falls into the realm of symptoms of being over medicated. Thank you so much for the links, I'll have a look tonight. The consensus is strong that I am under medicated and seems the route to try next in a more uniform way. Many thanks!