Please help with advice on Levo dose and vitamin levels.

[ChickieBaker]

Hello.I was started on Levo at 75mg about 10 days ago. My doctor wants to do a blood test after 8 weeks. Last time I was given a 2 month trial and because my TSH came down ( they don't care about antibodies so those weren't checked ! ) they took me off the Levo. Now I've gone to a different, much more understanding doctor this time who said I would be on the Levo for the 'long term' so I don't think that going to happen again but my question is, how will he know whether to increase the dose or not ?? My symptoms aren't likely to have changed within 8 weeks I shouldn't think, so I'm not sure what to do. I think it was slowdragon who suggested that I might be on too low a dose but how will he decide what dose I should be on. Do they just keep increasing it until you go hyper and then set it back ?? Perhaps he'll go by both the TSH and my symptoms ? My symptoms may well be related to other problems that I have, large amounts of stress, digestive problems etc.

I have Hashies, latest numbers are Thyroglobulin 462 ( range 0-115 ) and Peroxidaise 113 ( range 0-34 ). I have been gluten free for about 2 years, tried dairy free and it doesn't make a difference but I do drink Oatly so don't have a lot of dairy in my diet. I'm not sure that my vitamins are in the optimal range. Also how can I tell if I'm taking enough magnesium without doing a blood test. I currently take 3 magnesium bisglycinate ( not near the Levo ) totalling 240mg and a little magnesium spray. I take it to help with sleep and muscles and and pains.

My vitamins etc on my test end of July are :

CRP - 5.18 ( range less than 3 )

Ferritin -272 ( range 30-150 )

Folate -40.7 ( range 8.83-60.8 )

Vit B12 active - 150 ( range 37.50-188 )

Vit D -139 ( range 50-250 )

TSH -4.87 ( range 0.27-4.2 )

Free T3 -4 ( range 3.1-6.8 )

Free Thyroxine -13.3 ( range 12-22 )

Had my blood test done with Medichecks.

Any suggestions gratefully received.

[SlowDragon Administrator]

Dose should be determined by

A) improvement in symptoms

B) Ft3 and Ft4 test results.

It typically takes 9-12 months to work slowly up to full replacement dose

Even if we frequently start on only 50mcg or in your case 75mcg …..most people need to increase levothyroxine dose slowly upwards in 25mcg steps (retesting 6-8 weeks after each increase) until eventually on, or near full replacement dose

NICE guidelines on full replacement dose

nice.org.uk/guidance/ng145/...

1.3.6

Consider starting levothyroxine at a dosage of 1.6 micrograms per kilogram of body weight per day (rounded to the nearest 25 micrograms) for adults under 65 with primary hypothyroidism and no history of cardiovascular disease.

Also here

cks.nice.org.uk/topics/hypo...

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.

Come back with new post when you get results after 2 months on 75mcg

Which brand of levothyroxine are you taking

[ChickieBaker in reply to SlowDragon]

Sorry for the delay. I’m on Teva and MercuryPharma. I would have asked for both the same but the prescription had already been filled. According to my current weight ( which is too high! ) I should be aiming for 110mcg.

Do you think my vitamins are O.K, the D looks as though it could be higher ? I will certainly post again with the new results and stop pestering folk now 😊

Thanks.

[helvella Administrator in reply to ChickieBaker]

Weight calculation is NOT a target - it is an estimate of what you might need.

Once you are taking levothyroxine, I consider it wrong to use dose by weight except as what is often called a "sanity check" on dose. Pretty much: Is your dose massively higher or lower than a formula suggests?

And there are loads of formulas. Each one producing different doses (at least, some of the time).

helvella's calculation document and spreadsheet can be can be found by following this link:

helvella - Estimation of Levothyroxine Dosing in Adults

A discussion about the use of formulas to estimate levothyroxine dosing. Includes link to a downloadable spreadsheet which calculates several of these.

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

[ChickieBaker in reply to helvella]

Oh gosh I hadn't realised it was so complicated. I'm going to read through your blog and hopefully I will be a little more educated. Thanks.

[SlowDragon Administrator in reply to ChickieBaker]

Teva brand levothyroxine upsets many people

see how you get on

Many people find Levothyroxine brands are not interchangeable.

Most easily available (and often most easily tolerated) are Mercury Pharma or Accord

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, 

Wockhardt is very well tolerated, but only available in 25mcg tablets. Some people remain on Wockhardt, taking their daily dose as a number of tablets 

Lactose free brands - currently Teva or Vencamil only

Teva makes 25mcg, 50mcg, 75mcg and 100mcg

Many patients do NOT get on well with Teva brand of Levothyroxine.

Teva is lactose free.But Teva contains mannitol as a filler instead of lactose, which seems to be possible cause of problems. Mannitol seems to upset many people, it changes gut biome 

Teva is the only brand that makes 75mcg tablet.

So if avoiding Teva for 75mcg dose ask for 25mcg to add to 50mcg or just extra 50mcg tablets to cut in half

But for some people (usually if lactose intolerant, Teva is by far the best option)

Aristo (currently 100mcg only) is lactose free and mannitol free.

March 2023 - Aristo now called Vencamil

healthunlocked.com/thyroidu...

List of different brands available in U.K.

thyroiduk.org/if-you-are-hy...

Posts that mention Teva

healthunlocked.com/search/p...

Teva poll

healthunlocked.com/thyroidu...

Once you find a brand that suits you, best to make sure to only get that one at each prescription.

Watch out for brand change when dose is increased or at repeat prescription.

Government guidelines for GP in support of patients if you find it difficult/impossible to change brands

gov.uk/drug-safety-update/l...

If a patient reports persistent symptoms when switching between different levothyroxine tablet formulations, consider consistently prescribing a specific product known to be well tolerated by the patient.

academic.oup.com/jcem/artic...

Physicians should: 1) alert patients that preparations may be switched at the pharmacy; 2) encourage patients to ask to remain on the same preparation at every pharmacy refill; and 3) make sure patients understand the need to have their TSH retested and the potential for dosing readjusted every time their LT4 preparation is switched (18).

Discussed here too

healthunlocked.com/thyroidu...

[roukounasGK in reply to SlowDragon]

Just a quick note: i have read somewhere that the initial dosing per weight is not for your current weight. It is for the weight you would have for a BMI 23-24. So even if overweight, the initial dosing is roughly the same. So if for example you have a height of 175 cm, the target weight based on a bmi of 23 should be 72 kg. And the dosing should be 1.6x72=116 mcg. Which is much more logical as an initial dose than the very large numbers resulting from this function using our actual weight.

[SlowDragon Administrator in reply to roukounasGK]

That’s very interesting …….makes sense

Never seen this before

[roukounasGK in reply to SlowDragon]

Yeah it struck to me when i read it (since it resulted to a much more logical number, pretty close to the dose i am on with normal lab values). So since i have not seen it before here thought it would be good to share!