Guidance on levo dosing

[Uptime]

Hi All ,

I'd really appreciate any guidance/wisdom that could help me with the next step on my Thyroid journey!..

To summarize, I have been subclinical hypothyroid (TSH comes back in 4-5 range) several years. I started on Levothyroxine in January this year to try feel better, and have kept a log of progress and test results. Testing and dosing are done privately without a GP (long story short I was diagnosed and prescribed the initial 25mcg by a Doctor in a different country, but now in the UK and subclinical hypo not recognized.

My strategy has been to take a Thyroid blood panel every 6 weeks, then decide to maintain / increase / or decrease the levo dose based on results and how well I'm feeling.

Overall this has worked well so far, and in retrospect the recent 6 months since I began taking Levo have been a huge improvement over the previous decades spent subclinical Hypo.

However, in the recent weeks I've had quite a rapid & uncomfortable increase in anxiety levels , decline in concentration etc. which has left me unsure whether it's normal part of adjustment , or a sign of overmedication - I'm on a relatively low dose, currently 50mcg Euthyrox I'm 40m / 70kg, but I'm also conscious my starting TSH is also comparatively low (e.g. just 'slightly' hypo starting point.) so maybe it would not take much to tip me out of the Goldilocks zone into being Hyper (?)

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Summary & Labs:

*Edit- Added Lab Ranges:*

Free T3 (Capillary) pg/ml 2.02 - 4.43

Free T4 (Capillary) ng/dL 0.93 - 1.71

TSH (Capillary) µIU/mL 0.27 - 4.2

25/01/24: TSH (uIU/ml): 4.17 Free T4 (ng/dL): 1.27 Free T3 (pg/ml): 2.37 Dosage (prev 6 weeks): starting point - unmedicated Comments: Symptomatic

08/03/24: TSH (uIU/ml): 3.39 Free T4 (ng/dL): 1.11 Free T3 (pg/ml): 2.52 Dosage (prev 6 weeks): 25mcg Euthyrox daily. Comments: Small decrease in symptoms, overall OK

17/04/24: TSH (uIU/ml): 3.38 Free T4 (ng/dL): 1.25 Free T3 (pg/ml): 2.40 Dosage (prev 6 weeks): 37.5mcg Euthyrox daily Comments: noticeable decrease in symptoms, overall pretty good

29/05/24: TSH (uIU/ml): 1.85 Free T4 (ng/dL): 1.12 Free T3 (pg/ml): 2.02 Dosage (prev 6 weeks): 50mcg Euthyrox daily Comments: Still feeling overall much better , until 03/06/24 when started feeling increase in overstimulation & anxiety

May Blood results:

Ferritin: 135.9 ng/ml

B12: 766 pg/ml

Folate: 8.83 ng/ml

Vitamin D: 118 nmol/L

Charts attached with corresponding Levo doses added for reference

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Now I find myself a bit confused where to go next with dosing, decrease, maintain 50mcg or increase... My TSH is coming into a 'good' range , but weirdly my Free T3 and Free T4 are both right at the bottom.

I'm leaning toward dropping back to 37.5mcg daily , as I felt good for a long while on this dose , but also conscious this recent anxiety could be 'normal' when tapering up and body adjusting - maybe I need to hold out or even increase??

If anyone has any insights , or can share their own experiences to help me find clarity I would truly appreciate it!

Thanks all!!

[greygoose]

I'm on a relatively low dose, currently 50mcg Euthyrox I'm 40m / 70kg, but I'm also conscious my starting TSH is also comparatively low (e.g. just 'slightly' hypo starting point.) so maybe it would not take much to tip me out of the Goldilocks zone into being Hyper (?)

Nah, it doesn't work that way. Doesn't matter what your TSH was, over 3 is hypo. You can't be a little bit hypo anymore than you can be a little bit pregnant. Either you are or you aren't. Doctors make a big song and dance about TSH being over 10 but the sad fact is that that's just because they don't want to diagnose hypo!

Aslo, if you are hypo, you cannot just 'tip over' into hyper. Thyroids cannot regenerate and suddenly start making too much hormone.

You can be over-medicated but highly unlikely on just 50 mcg T4. As soon as you start thyroid hormone replacement - levo - you reduce the TSH so the thyroid makes less and less hormone. And that dose of levo doesn't just 'top it up', it pretty much replaces it.

And your symptoms sound hypo, rather than hyper - anxiety is a very common hypo symptom. And on 29/05/24 your TSH was 1.85, which is rather high for someone on thyroid hormone replacement. I can't comment on the FT4/3 because you haven't given the ranges, but they're not going to be high with that TSH. So, pretty sure you need an increase in dose.

Be very wary of dosing by weight. It's only a very rough guide, to be used with discretion.

[Uptime in reply to greygoose]

Hi greygoose,

Thank you taking the time to review and respond - I really appreciate it. I've added the lab ranges now for reference too.. (it's nice to see the TSH high range is 4.2 instead of 10 at least for this lab!)

Free T3 (Capillary) pg/ml 2.02 - 4.43

Free T4 (Capillary) ng/dL 0.93 - 1.71

TSH (Capillary) µIU/mL 0.27 - 4.2

This really helps make sense when you put it like that, I hadn't really considered it from the perspective that endogenous T4 production would be falling while Levothyroxine dose increases - so another 'unknown' variable in the equation to account for with dosing I guess

[greygoose in reply to Uptime]

29/05/24:

TSH (uIU/ml): 1.85 (0.27-4.43)

FT4 ng/dL 1.12 (0.93-1.71) 24.36%

Free T3 (pg/ml) 2.02 (2.02-4.43) 0.00%

In future, can you lay out the results in the way I've done above, please? It makes it so much easier to see at a glance what we're dealing with. Otherwise, one has to spend ages just sorting out the numbers.

Are you sure you didn't get the ranges for FT4 and FT3 the wrong way round? Because that just doesn't look right.

(it's nice to see the TSH high range is 4.2 instead of 10 at least for this lab!)

No lab ever has the top of the TSH range at 10. The highest I've ever seen is 6, and that was only once. It's usually about 4.5. The 10 is just an NHS invention to avoid diagnosing as many people as possible.

Anywaay, looking at those numbers, you're definitely not over-dosing! You are under-medicated and need an increase in dose. But please check those ranges again.

[Uptime in reply to greygoose]

Hmm I double checked the lab results and those are the correct numbers and ranges (!) Attached the report above. The charts in the 1st screenshot are generated from the lab's site, it does seem a bit weird T3 is falling gradually , not sure why that could be - at the moment TSH seems to be the only metric heading the right direction!

Lab Results - Latest

[greygoose in reply to Uptime]

And TSH is the least important number. Anyway, with that FT3 right at the bottom of the range, there, you are still hypo, whatever the TSH says. And your symptoms are therefore hypo.

[SlowDragon Administrator]

Anxiety is common HYPO symptom

TSH (uIU/ml): 1.85

Free T4 (ng/dL): 1.12

Free T3 (pg/ml): 2.02

Dosage (prev 6 weeks): 50mcg Euthyrox daily

Please add ranges on Ft4 and Ft3

Suggest you increase again by 12.5mcg daily

Retest again in 6-8 weeks

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)

I'm 40m / 70kg,

70kg x 1.6mcg Levo per kilo suggests eventual daily dose likely to be around 112.5mcg per day

[Uptime]

Hi SlowDragon ,

The advice from yourself and greygoose has helped clear things up a lot , Instead of dropping back down I'm now planning to hold my current dose @50mcg for the couple of weeks more until next re-test .. then expect to increase up again based on results.

Thank you both for very much for your time & insights , and I've edited in the lab ranges now:

Free T3 (Capillary) pg/ml 2.02 - 4.43 - I'm bumping along the bottom for T3 levels! and now right on the very bottom of T3 range .. weirdly this has gone down since started levo.

Free T4 (Capillary) ng/dL 0.93 - 1.71- Seem to be stuck hovering around 25% mark

TSH (Capillary) µIU/mL 0.27 - 4.2 - I'm roughly middle of range now .

Thus far I've been night-time dosing , but tests taken early AM - so in reality the Levo is probably only 7-8 hours before the tests .. hopefully hasn't skewed things too much but I will be sure to observe your recommendation for future tests!

[greygoose in reply to Uptime]

Thus far I've been night-time dosing , but tests taken early AM - so in reality the Levo is probably only 7-8 hours before the tests .. hopefully hasn't skewed things too muc

Ah! But it has! You've got false 'high' FT4 results there. In reality, your FT4 is much lower than that, but impossible to guess by how much. So, you really are very under-medicated, and not such a poor converter as was at first suspected.

[Uptime in reply to greygoose]

ah well spotted sir!! I will be sure to skip before the next tests , thanks again for the advice! Onwards and upwards!

[greygoose in reply to Uptime]

Ummm... actually, I'm Lady Goose, not Sir Goose. But, as you say, onwards and upwards!