Switching Brands

[Maz-57]

I've been on 2x25mg of Teva for around a year. I requested 1x50mg tablets at my telephone meds review with doctor. Which she agreed to.My question is, the Pharmacy have issued me with two different brands - 50mg Accord and 50mg Mercury Pharma. Is this ok? Only I've read comments on this forum regarding changing brands and it causing problems. I'm not sure whether to go back to the pharmacy.

[SlowDragon Administrator]

Teva is lactose free

If you are lactose intolerant you will need lactose free levothyroxine

If not lactose intolerant, Mercury or Accord might suit you better

Start on one brand

How many tablets have you got for each brand

Ideally do 6 weeks on one brand and retest thyroid levels

if you’re still only on 50mcg levothyroxine a year after starting you are likely not on high enough dose

What are your most recent thyroid results?

How do you feel

For full Thyroid evaluation you need TSH, FT4 and FT3 tested

Also both TPO and TG thyroid antibodies tested at least once for autoimmune thyroid disease (aka Hashimoto’s)

Very important to test vitamin D, folate, ferritin and B12 at least once year minimum

Recommended that all thyroid blood tests early morning, ideally just before 9am, only drink water between waking and test and last dose levothyroxine 24 hours before test

This gives highest TSH, lowest FT4 and most consistent results. (Patient to patient tip)

[Maz-57 in reply to SlowDragon]

Thanks for replying. I have a 2 month supply of each brand. I'm not lactose intolerant as far as I know. I started on 50mg March 2022, but dose didn't suit me, so was reduced to 25, then increased to 50 about a year ago. I feel ok on this dose.

Had thyroid blood test which was ok in September see attached. I take Vitamin D in Winter.

Test result

[SlowDragon Administrator in reply to Maz-57]

Just testing TSH is completely inadequate

And TSH over 2 shows you are ready for dose increase

TSH should be under 2 as an absolute maximum when on levothyroxine

gponline.com/endocrinology-...

Graph showing median TSH in healthy population is 1-1.5

web.archive.org/web/2004060...

Comprehensive list of references for needing LOW TSH on levothyroxine

healthunlocked.com/thyroidu....

onlinelibrary.wiley.com/doi...

If symptoms of hypothyroidism persist despite normalisation of TSH, the dose of levothyroxine can be titrated further to place the TSH in the lower part of the reference range or even slightly below (i.e., TSH: 0.1–2.0 mU/L), but avoiding TSH < 0.1 mU/L. Use of alternate day dosing of different levothyroxine strengths may be needed to achieve this (e.g., 100 mcg for 4 days; 125 mcg for 3 days weekly).

Request thyroid including Ft4 and thyroid antibodies and vitamin levels and cholesterol levels tested 6-8 weeks after changing brand Levo

Book test early morning, ideally just before 9am, only drink water between waking and test and last dose levothyroxine 24 hours before test

[Maz-57 in reply to SlowDragon]

So I should contact my doctor and suggest my THS is too high? Are the numbers in brackets next to my reading the range allowed? I'm not sure I'm confident/understand enough to dispute my dose.

[SlowDragon Administrator in reply to Maz-57]

As you are now starting different brand Levo request new test in 6 weeks time

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).

And here

pharmacymagazine.co.uk/clin...

Discussed here too

healthunlocked.com/thyroidu...

Book early morning

Check your previous test results

See if you have had thyroid antibodies, vitamin D, folate, ferritin and B12 levels tested at diagnosis

If not ….Request these are tested

Or if GP unhelpful test privately

Thousands of U.K. thyroid patients test privately

Examples of private test results

Medichecks results

healthunlocked.com/search/p...

healthunlocked.com/search/p...

[SlowDragon Administrator in reply to Maz-57]

I take Vitamin D in Winter.

Test twice yearly via NHS private testing service when supplementing

vitamindtest.org.uk

NHS Guidelines on dose vitamin D required

ouh.nhs.uk/osteoporosis/use...

GP will often only prescribe to bring vitamin D levels to 50nmol.

Some areas will prescribe to bring levels to 75nmol or even 80nmol

leedsformulary.nhs.uk/docs/...

GP should advise on self supplementing if over 50nmol, but under 75nmol (but they rarely do)

mm.wirral.nhs.uk/document_u...

But improving to around 80nmol or 100nmol by self supplementing may be better

pubmed.ncbi.nlm.nih.gov/218...

vitamindsociety.org/pdf/Vit...

Once you Improve level, very likely you will need on going maintenance dose to keep it there.

Vitamin D mouth spray by Better You is very effective as it avoids poor gut function.

There’s a version made that also contains vitamin K2 Mk7.

One spray = 1000iu

amazon.co.uk/BetterYou-Dlux...

It’s trial and error what dose we need, with thyroid issues we frequently need higher dose than average

Vitamin D and thyroid disease

grassrootshealth.net/blog/t...

Vitamin D may prevent Autoimmune disease

newscientist.com/article/23...

Web links about taking important cofactors - magnesium and Vit K2-MK7

Magnesium best taken in the afternoon or evening, but must be four hours away from levothyroxine

betterbones.com/bone-nutrit...

medicalnewstoday.com/articl...

livescience.com/61866-magne...

sciencedaily.com/releases/2...

Interesting article by Dr Malcolm Kendrick on magnesium

drmalcolmkendrick.org/categ...

Vitamin K2 mk7

betterbones.com/bone-nutrit...

healthline.com/nutrition/vi...

[helvella Administrator]

You might find my blog in this issue of some interest.

helvella - Mixing Levothyroxine Formulations

A discussion about mixing (and switching) formulations of levothyroxine.

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

[SlowDragon Administrator]

guidelines on dose levothyroxine by weight

Even if we frequently start on only 50mcg, 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

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.