Levo Dosage Help

[Merrymoo]

Dear all,

Please can I seek your advice on Levothyroxine dosage? I realise now that I haven’t really helped myself with the approach that I have taken to my medication dosage changes, but I’m new to this and am learning!

Following diagnosis of Hashimoto’s hypothyroidism, I was advised by my GP to take 75mg (the usual starting dose of 1.6mg per kg would have been 83mg, so this was reasonably conservative). However, I admit I was somewhat anxious to take this dose, so started on 50mg. After four weeks, my symptoms persisted and I felt rubbish, so I thought my GP was probably right and increased to 75mg as suggested. In hindsight, I now know this was somewhat foolish. After 2 weeks on 75mg (and 6 weeks in total on the 50mg) I had another blood test, the results of which have come back today to show I am now hyperthyroid!

Results below - I did a private blood test the same day as the NHS one, as I wanted to see T3 results. Both were taken prior to my morning tablet, on an empty stomach. The NHS one at 8.30am (venous draw) and the Monitor My Health one at 9.30am (finger prick). I did at least get one protocol right!

I am not sure now whether I should reduce to 50mg or 25mg? I’d be really grateful for advice. Thank you.

TSH:

18/12/2023 10.6 miu/L (0.27-4.20 Blue Horizon)

02/04/2024 20.6 miu/L (0.27-4.20 Blue Horizon)

28/05/24 0.1 miu/L (0.27-4.20 Monitor my Health)

28/05/24 0.1 miu/L (0.27-4.20 NHS)

FT4:

18/12/2023 12 pmol/L (12-22 Blue Horizon)

02/04/2024 11.9 pmol/L (12-22 Blue Horizon)

28/05/2024 29.1 pmol/L (12-22 Monitor my Health)

28/05/2024 26.7 pmol/L (12-22 NHS)

FT3:

18/12/2023 3.1 pmol/L (3.1-6.8 Blue Horizon)

02/04/2024 4.1 pmol/L (3.1-6.8 Blue Horizon)

28/05/2024 5.1 pmol/L (3.1-6.8 Monitor my Health)

Tg:

18/12/2023 263 iu/Ml (<115 Blue Horizon)

02/04/2024 235 iu/Ml (<115 Blue Horizon)

28/05/2024 Not taken

TPO:

18/12/2023 166 iu/mL (<34 Blue Horizon)

02/04/2024 147 iu/mL (<34 Blue Horizon)

28/05/2024 134 iu/Ml (<34 Monitor My Health)

[SlowDragon Administrator]

you tested too soon as outlined in previous post

healthunlocked.com/thyroidu...

How do you feel

What are your actual vitamin results

[Merrymoo in reply to SlowDragon]

Thank you SlowDragon for replying. I know I tested too soon, lesson learnt!

I feel OK at the moment, apart from a persistent sore throat (which I have had for 3 months) and dry eyes. I have felt slightly 'wired' the last couple of days - more energy and less anxiety.

My vitamin results are OK, I think?:

Vit D (2/2/24): 107 (75-200 nmol/L )

Serum Ferritin (8/4/24): 85 (30-148 ug/L)

Active B12 (2/4/24): 127 (37.5-150pmol)

Serum B12 (18/4/24) : 674 ng/L (197-771 ng/L)

Serum Folate (18/4/24): 15.1 (3.9-26.8 ug/l)

Magnesium (2/4/24): 0.89 (0.66-0.99nmol/L)

Selenium (20/5/24): 115 (65-150 ug/l)

RBC Count (18/4/24): 4.06 (3.7-4.8 10*12/L)

[SlowDragon Administrator in reply to Merrymoo]

Yes vitamin levels are good

Either stay as you are and retest in another 6 weeks

Or if you start to feel a bit hyper……reduce a SMALL amount

Perhaps reduce by 12.5mcg 4 days per WEEK

[Merrymoo in reply to SlowDragon]

Thank you SlowDragon and GreyGoose. My GP has just called and left a message advising to drop to 50mcg and retest in 8 -10 weeks. I feel really conflicted over what to do - which is probably not unusual for a newbie! I need to accept the fact that GPs don't always know what's best when it comes to thyroid issues!

[greygoose]

OK, one or two misconceptions, here:

Following diagnosis of Hashimoto’s hypothyroidism, I was advised by my GP to take 75mg (the usual starting dose of 1.6mg per kg would have been 83mg, so this was reasonably conservative).

No, the usual starting dose for someone with primary hypo is 50 mcg. The dose according to weight is the usual starting dose for people who have had a thyroidectomy, because obviously 50 mcg would not be enough for them. But, no-one considers that that should be their final dose, it is adjusted from that point according to their needs.

Your GP was not conservative, he was rather rash. Some people can tolerate a starting dose of 75 mcg but not everybody. So you were right to reduce it to 50 mcg.

However, you should have stayed on the 50 for six weeks before testing. And it was perfectly normal that the symptoms were persisting, as it is just a starting dose. With all hormones we need to start low and increase slowly, otherwise we can find ourselves right back at the beginning again, having to start all over.

So, it should have been 50 mcg for six weeks, retest, increase to 75 mcg for six weeks, retest, etc.

After 2 weeks on 75mg (and 6 weeks in total on the 50mg) I had another blood test, the results of which have come back today to show I am now hyperthyroid!

No, you cannot become hyper. That is a physical impossibility. You have Hashi's, which is slowly destroying your thyroid. The thyroid cannot suddenly regenerate and start producing too much hormone. It doesn't work that way.

You could be over-medicated but after just too weeks on 75 mcg it was far too soon to tell. It takes a minimum of six weeks for the dose to settle. So, that test was null and void. You have no idea what your real levels are.

That said, you do have Hashi's, so it could be a Hashi's 'hyper' swing causing your FT4 to go over-range and nothing to do with your dose of levo. One wouldn't really expect a dose of 75 mcg to take the FT4 that high - assuming, of course, that you left a gap of 24 hours between your last dose of levo and the blood draw.

A Hashi's 'hyper' swing is only temporary. The excess hormone will be used up/excreted and you will become hypo again. So, if you feel the need to reduce your dose - not everyone does - do it yourself, don't involve your doctor or you might have trouble getting it put up again when you need it! But only reduce by 25 mcg maximum in one go.

So, how do you feel with those levels?

By the way, that is not the best layout for blood test results. It makes them very difficult to read because we need to see the three results together on any one date, and interpret them in conjunction with each other. Disconnected results like that make it difficult to see what's going on. It would be easier for us if you did it like this:

Date:

TSH 'result' (range)

FT4 'result' (range)

FT3 'result' (range)

etc.

[Merrymoo in reply to greygoose]

Hello Greygoose, thank you for your message. You have provided a really useful and succinct explanation.

I feel OK at the moment, apart from a persistent sore throat (which I have had for 3 months) and dry eyes. I have felt slightly 'wired' the last couple of days - more energy and less anxiety.

I realise that I messed up and I should have stayed on 50mcg for 6 weeks - ho hum! Given that I am where I am now, would you advise dropping back down to 50 and then re-testing in 6 weeks? (The test was taken 24 hours after my last tablet).

PS: I'm sorry about the results layout - it didn't occur to me. I'll remember for next time - I'm sure they'll be one!

[greygoose in reply to Merrymoo]

Now you're on 75 mcg, I'd stay on it if I were you. Then retest after six weeks. No point in going backwards.

[Merrymoo in reply to greygoose]

Thank you SlowDragon and GreyGoose. My GP has just called and left a message advising to drop to 50mcg and retest in 8 -10 weeks. I feel really conflicted over what to do - which is probably not unusual for a newbie! I need to accept the fact that GPs don't always know what's best when it comes to thyroid issues!

[greygoose in reply to Merrymoo]

I'm afraid they don't, no. Which is why we have to learn as much as we can about our disease and make up our own minds, following our instincts and what our bodies are telling us. Personally, I would say you've been on 50 mcg long enough, and staying on a starter dose for too long is not good, either. But you must do as you feel best.

[HealthStarDust]

I think based on your levels, your increase was premature and influenced by the dose change before test.

I think it would be more sensible to go back to 50mcg, stay on it for 6 weeks, and test again. The symptoms you described could be due to too much medication at this point.

Realistically, unless you have enough levothyroxine for 6-8 weeks for a 75mcg increase you won’t have any other choice but to go back to 50mcg as that’s what your doctor will prescribe.

Now, unless you have reason to believe your GP won’t be on board with your decision (to stick with 75mcg), I also think it’s best to involve your GP with your decision and start your thyroid journey as you mean to go on with you guiding the treatment with open discussion. I was diagnosed a year ago ish and I have done that throughout. It’s perfectly possible! My numbers were worse than yours for TSH and GPs even agreed to increase (I didn’t anyway but still it was good to have the choice and lead my care).

But, with where you are at now, if you can manage it I would withhold your dose for a week to deplete the FT4 and hopefully increase TSH, and resume on 50mcg.

There is no point in risking overmedication.

Good luck!

Edit: clarify and tidy typos Merrymoo

[Merrymoo]

Thank you HealthStarDust for taking your time to reply. I think you are right - the increase was premature. I don't have enough Levo for 6-8 weeks, so yes I do foresee a problem there! I shall continue to mull it over, but you have given me something to think about ...

[HealthStarDust in reply to Merrymoo]

Your welcome. As I see it, you will have to engage with your GP throughout your thyroid journey which will be a very long time! So, until it seems futile to engage and foster that relationship, start being a partner or leader in your care.

For example, if it was me, and if I wanted to continue on 75mcg instead of going back to 50mcg then I would speak to the GP explaining my reasons for it eg testing too soon, etc. However, due to your FT4 and what your described as possible overmedicated symptoms, I think it wise to go back to 50mcg and give it a proper go. At least no change in dose a couple of weeks before test!

Next time if you are tempted to change dose, call your GP to let know what you have done and agree a new schedule for retests that’s what I have done.

Hope that helps.

[Merrymoo in reply to HealthStarDust]

Thank you! That's good advice. I am definitely dropping to 50. Since I wrote my original post I have very unpleasant symptoms of over medication...racing heart and my usual optimal BP is now hypertensive. I'm tired but can't sleep and feel so much worse than being under. I spoke to a pharmacist (GP closed) who advised that going back to 50 would be the best course of action, but to expect my symptoms of over-medication to continue for around another week or so. He said it wasn't a good idea to drop by more than 25 in one go.

[HealthStarDust in reply to Merrymoo]

Wise.

I always find the best way to resolve overmedicated symptoms quickly is to withhold your dose for a few days to around week.

It’s actually advice from the BNF, and it does work.

See it as a blessing to learn of your personal overmedicated symptoms early on in your experience.

Best.

[Merrymoo in reply to HealthStarDust]

Thank you HealthStarDust!