Thanks to Rod's post "Time of Day Does Matter For TSH" I came across this study I hadn't seen before about the effects of taking thyroid in the morning versus the evening.
Effects of evening vs morning thyroxine ingestion on serum thyroid hormone profiles in hypothyroid patients.
Bolk N, Visser TJ, Kalsbeek A, van Domburg RT, Berghout A.
Source
Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands.
Abstract
OBJECTIVE:
Standard drug information resources recommend that l-thyroxine be taken half an hour before breakfast on an empty stomach, to prevent interference of its intestinal uptake by food or medication. We observed cases in which TSH levels improved markedly after changing the administration time of l-thyroxine to the late evening. We therefore conducted a pilot-study to investigate whether l-thyroxine administration at bedtime improves TSH and thyroid hormones, and whether the circadian rhythm of TSH remains intact. DESIGN Patients were studied on two occasions: on a stable regimen of morning thyroxine administration and two months after switching to night-time thyroxine using the same dose. On each occasion patients were admitted for 24 h and serial blood samples were obtained.
PATIENTS:
We investigated 12 women treated with l-thyroxine because of primary hypothyroidism, who used no medication known to interfere with l-thyroxine uptake.
MEASUREMENTS:
Patients were admitted to hospital and blood samples were obtained at hourly intervals for 24 h via an indwelling catheter. Following this first hospital admission, all women were asked to switch the administration time from morning to bedtime or vice versa. After 2 months they were readmitted for a 24-h period of hourly blood sampling. Blood samples were analysed for serum TSH (immunometric assay), FT4 and T3 (competitive immunoassay), T4 and rT3 (radioimmunoassay), serum TBG (immunometric assay) and total protein and albumin (colourimetric methods).
RESULTS:
A significant difference in TSH and thyroid hormones was found after switching to bedtime administration of l-thyroxine. Twenty-four-hour average serum values amounted to (mean +/- SD, morning vs bedtime ingestion): TSH, 5.1 +/- 0.9 vs 1.2 +/- 0.3 mU/l (P < 0.01); FT4, 16.7 +/- 1.0 vs 19.3 +/- 0.7 pmol/l (P < 0.01); T3, 1.5 +/- 0.05 vs 1.6 +/- 0.1 nmol/l (P < 0.01). There was no significant change in T4, rT3, albumin and TBG serum levels, nor in the T3/rT3 ratio. The relative amplitude and time of the nocturnal TSH surge remained intact.
CONCLUSIONS:
l-thyroxine taken at bedtime by patients with primary hypothyroidism is associated with higher thyroid hormone concentrations and lower TSH concentrations compared to the same l-thyroxine dose taken in the morning. At the same time, the circadian TSH rhythm stays intact. Our findings are best explained by a better gastrointestinal uptake of l-thyroxine during the night.
I had heard about this or a similar study & decided to experiment by going one step further. As I never fail to get up to visit to loo in the night, I thought that taking my levo then may make a difference. And my, what a difference it has been! I feel - dare I say it - normal! Energy has shot up, mood elevated and intractable neck & shoulder pain is 95% better. Thinking about it, this is the only time my stomach is completely empty but of course there may be other factors involved such as synchronicity with natural ebbs and flows of all hormones. Anyway, if you are a night loo-visitor, you have nothing to lose by trying this method. I just leave my tablets ready at my bedside with a glass of water before I go to sleep.
I take it all then and have a good sleep but if I'm tired at work the next day I will take another 10mcg about 11 am and it sees me through til bedtime. It seems to work for me.
Oh you are genius B/j..being bear of very slow brain had not thought of that. Good for those times when I forget and have cuppa something late evening.
Sometimes the obvious needs pointing out, certainly to me anyway.
HI Barbara, I had started to take my eltroxin at night because I have a lot of muscle and joint pain and when I rise in the morning the first thing I have to do is take paracetamol and a hot drink so I could not take my Levo until later and sometimes I forgot until much later and it was a bit hit and miss, so if I take it when I go to bed It is always about the same time, I think I am a wee bit better when I take it at night, usually about 10pm, however I get really worn out about 4pm and could just lie down and sleep if I could, so I think your Idea might just work because it would mean I would be taking it later and would probably benefit from it lasting longer at the other end of the day, BUT I do get up to the loo some nights and not others and don't always get up at the same time ......so how do you work around that?? do you get up at roughly the same time every night?
Hi gigi - yes, I do - usally around 3-4 am. You could maybe take it on waking and then wait for a few hours to eat (don't like the idea of that myself!) or you could set a nice gentle alarm tone on your phone that wouldn't wake your hubby
I recently had a complete thyroidectomy and was taking my levothroxine at 7:00 am and waiting until about an hour before eating. 8-8:30 My Dr has said he wanted me to take my levothroxine 3 hrs after I eat my evening meal, meaning if I eat at 6:00 pm I would have to take my pill by 9:00 pm. So I'm destined to either eat earlier or stay up much later. And I guess I can drink between 6-9 but no food. How is this better? Whether I wait 3 hrs before I eat breakfast or wait 3 hrs after my evening meal, ( meaning no snacking after 6:00).
Thanks and sorry if I'm rambling. I am new at this.
Found I could not have my stomach empty at bed time so leave at side of bed and take when I waken through the night. not dramatic improvement but there, also means I can eat when I get up .
Despite ALL the evidence that the vast majority find the Levothyroxine is more effective taken at night, still, still, the Patient Information Leaflets and the doctors and the endocrinologists are telling people to take it in the morning. For most people who follow this advice, this is inconvenient and more importantly reduces the effectiveness of their medication.
What does this tell you? They don't care. They are also not open to new ideas. No wonder we are suffering.
I eat sometimes at 7pm because my husband has to eat something then to take his own medication, so we have a drink and a small snack, often just a banana. I then take my thyroxine later when he take his next lot of tablets - usually around 10pm. It seems to work OK for me.
It certainly is better than when I used to follow the 'expert' advice.
I'm not sure, though, if this is long enough. Has anyone any thoughts about if I should miss out the 7pm banana to be more sure it is more effective?
It is, of course, open to anyone to email the manufacturer/product licence holder and/or the MHRA and point this out!
I have put in a complaint about the most recently released PIL (for Teva Liquid Levothyroxine) and added time of day and how long after can you eat as additional questions/points.
I have a feeling that if they received 7905 complaints/suggestions something would change.
Marram, The usual recommendation is to leave at least two hours after eating, and yours is a three hour gap. So no, I seriously doubt you would get any benefit from not having your banana at 7pm. Eat it and enjoy
I'm guessing it takes awhile to take effect? I switched to taking it at night, last night, and feel very tired this morning with three days of hard work ahead of me. I will give it a couple of weeks to see if it improves!
I have switched to night time dosing, usualy about 10,30 but I sometimes forget, and eat a bowl of cereal about 8pm......it realy doesent seem to make much difference, I still feel like crap most mornings, still tired, and little energy,
I have been taking my 125 thyroxine at night for 2 years now ,and see a definite improvement ..i feel much more alive in the mornings ....I know its worked for me ,so i reckon its worth a try ..but to be fair you must give it a couple of months to kick in...I was diagnosed with Hashimotos .. 15 years ago...J
I have changed to nights, I don't get hot sweats any more, they kept me awake most of the night.
My experience is it makes a difference for the good in many ways.
Just one is when taken around 7a.m. I fall back into a sleep of the dead and could stay in bed all day. Taken at night can get up early and function fairly well.
I stopped taking at night as after couple weeks as was awake until dawn but this time..third trial will lower the dose if that happens. .. simples.
Have had autoimmune disorder. Currently thought to have just hypothyroidism diagnosed just under a year ago. Heres hoping all else improves and I wont need that long awaited Endo appointment.
Thanks for study PR4now just what I signed in to look for and why I feel so sleepy when take it a.m.? Someone asked that Q a while back cant remember who or where.
I have been taking my thyroxine at night for many years now after complaining of feeling 'hungover' all day. A friend of mine told me it was much better if taken at night. I tend to have a drink for bed at around 10pm and take my tablets after that before bed at 11pm. I find it much better. The only downside to it is if I have a disturbed night waking up after 3 or 4 hours of sleep, I find it messes me up and I feel tired next morning. I really need a full sleep to sleep off most of the effects of the thyroxine.
I find it males a diffeence , I wake up almost "normal" take 100mcg at bedtime , on waking i take 10 of t3 and Then at 1pm another 10 of t3 , .. just wish I could lose weight , brain Fig as gone , I can read again .. anyone had Any luck losing weight , Tips please ..
I did switch to night medication after reading it on this forum; I felt really tired all day the next day and really struggled at work and from noon onwards I just want to go sleep. I tried for 3 weeks and switch back to morning med however I must add that I take first thing when I wake up around 6.15 am and don't have anything to eat until 7.45 and sometimes later. This seems to work for me.
Was your stomach empty when you took it at night like it is at the time you take it now? It may have been that you weren't absorbing it efficiently if you were still digesting your evening meal. Just a thought.
I usually eat around 6 pm and would take the meds around 10.30 just before I go to bed. I would have tea before bed time -may have interfere with absorption.
I have switched to taking my levothyroxine at about 10.00pm. I have been doing this for about a month now. I am sleeping so much better and don't seem to be getting up in the middle of the night for a loo visit.
I take mine around 10pm too, but find sometimes I am getting very tired about 4pm the next day, but I like the new regime of taking my Levo at night because I can take my paracetamol and a hot drink first thing in the morning.......I have a lot of muscle and joint pain which is worst first thing in the morning and before when taking my Levo first I had to wait for at least an hour after taking it before I could have a hot drink etc.
, which in the winter is not good because I can't have a drink and my pain killers as soon as I rise And since I live in Scotland it is perishing first thing (I am very often up around 5 or 6am)
By the way Daisymoo are you a papercrafter by any chance???
Hi Im new to this site ....I take mine in the morning...I have a cup of tea about five minutes later. I know not to eat for a while should I wait longer before my morning cuppa?
Of course, given inertia, most people still take in the morning. But the range of responses is quite large and includes both those feeling better, and those feeling worse, with bed-time dosing.
The reason for your need for thyroid medication shouldn't have any bearing on this. Not everyone finds night-time dosing beneficial, but the only way to find out is to try it!
I take my throid meds ,Erfa, spread out but interestingly enough I do take a small dose before going to bed and nearly half of my daily dose in the early hours of the morning. Doing that made a big difference to me. Maybe taking the levothyroxine at night also helps with the circadian rhythm for the adrenals glands?.....this is why i take my night and early morning dose of Erfa. Improving the effectiveness of the adrenals would also mean that it would help with the uptake of the thyroid hormones....am I right about this Rod....you're more on the ball than me with research?
Can Levothyroxine Be Taken as Evening Dose? Comparative Evaluation of Morning versus Evening Dose of Levothyroxine in Treatment of Hypothyroidism.
Rajput R, Chatterjee S, Rajput M.
Source
Department of Medicine VII & Endocrinology, Postgraduate Institute of Medical Sciences, Rohtak, Haryana 124001, India.
Abstract
152 drug naïve primary hypothyroid patients were divided into morning (Group 1) and evening (Group 2) dosing group and evaluated for change in biochemical profile, physical functioning and Quality of Life during the course of 12 weeks of study. At the end of 12 weeks 70 (90.90%) subjects in Group 1 and 72 (96%) in Group 2 achieved euthyroidism. On evaluation clinical symptoms and total clinical scores improved in both the groups at the end of 6 and 12 weeks. Significant improvement in thyroid profile was seen in both the groups at the end of 6 and 12 weeks (P value <.0001). On intergroup comparison, no significant difference in thyroid profile was seen at 6 and 12 weeks between the morning and the evening dose group. Similar dose of levothyroxine was required to achieve euthyroidism in both the groups. Though an early restoration of euthyroidism was seen in evening group, the difference when compared to the morning group was not statistically significant. On assessment of QoL, statistically significant improvement in various parameters was seen in both the groups. Hence, from the study we inferred that evening dose is as efficacious as morning dose and provides an alternate dosing regimen.
Indian J Endocrinol Metab. 2012 Jul;16(4):522-4. doi: 10.4103/2230-8210.98001.
Thyroid diseases and Ramadan.
Raza SA, Ishtiaq O, Unnikrishnan AG, Khan AK, Ahmad J, Ganie MA, Azad K, Baruah M, Pathan MF.
Source
Shaukhat Khanum Cancer Hospital and Research Center, Lahore, Pakistan.
Abstract
In the month of Ramadan, patients with thyroid diseases, most of the time, do not need treatment adjustments and can fast safely without any health hazards. Patients with hypothyroidism taking thyroxine can take their tablets on an empty stomach at bedtime instead of half an hour before Sehr. Patients with hyperthyroidism, on methimazole/carbimazole can continue their dose in once or twice daily regimes, while those on propylthiouracil need to be switched. Hyperthyroid patients with severe symptoms should start treatment immediately and can avoid fast for few days after a consultation with their religious scholar.
Rod, a couple of interesting notes from the first of your two studies above. "For calculation of sample size, results from the pilot study conducted by Bolk et al. was used where it was found that to get a significant difference in TSH of 1 mIU/L in both the groups at the end of study with a power of 80%, 75 subjects should be enrolled in each group." So with a large enough group the differences between the groups disappear, it would seem. Also of note, "The relative amplitude and time of the nocturnal TSH surge remained intact." And somewhere in one of your posts you mentioned something about this. "Moreover, Persani et al. [21] showed that bioactivity of TSH has a circadian variation with less bioactive and differently glycosylated TSH molecules secreted during night." So if the bioactivity is less at night and the amplitude of the pulse is more at night does that equal a zero net effect from the larger amplitude of the pulse? Or have they quantified how much less the bioactivity is. PR
I'd have to go and trawl through, but I think they are saying that in order for the difference to be deemed to be significant (i.e. achieve statistical "significance") they would need 75 in each group.
The glycosylation of TSH is a whole extra and fascinating ball-game. It seems unlikely that the TSH would produce TSH with different levels/types of attached sugars, in patterns that can be identified, and associated with different circumstances, and that difference not have some "meaning".
I have often speculated that the glycosylation of TSH would actually affect the proportions of T4 and T3 produced. Somehow it would make sense in my head if were the case but I have absolutely NO evidence for it!
But one of the difficult thyroid issues is that science has looked at the 24-hour issues - but much less at the multi-day impacts. For example, we tend to think of T3 having effects for, maybe, up to two days. But actually it appears that the changes in gene expression that T3 causes ripple on for around seven days in mice.
The last Dr Lowe used to take his large dose of T3 at bed-time - all in one go.
Several people here have said that their sleep improved by taking at least some of their non-levothyroxine thyroid hormone (desiccated or T3) at bed-time.
Have been taking 50mg Levo in the evening - 2 hours after last hot drink - then balance of 25mg in the morning - half an hour before first cup of coffee, since dosage reduced from 125mcg to 75mcg 4 weeks ago; weight has stayed the same (which was my main concern as have always struggled with this) and no hangover feeling in the mornings
I had been splitting my T3 dose (I take 20mcg daily) am & pm but sometimes found that if I had just one small glass of wine in the evening, I felt pretty awful the next morning. I also sometimes ate late and found I was taking the T3 too soon after a meal so decided to go back to morning dosing. In addition to T3, I take 50mcg of levo. What I have noticed (and this may be a figment of my imagination(!)) is that when I make a change, for a few days, I feel energised but then start slipping back. I only started T3 in October and perhaps need to fine tune the dose.
Re the question Twinkles asked about her morning cuppa when taking medication in the morning. Like her, I have my tea shortly after taking meds, how long should you wait? Half an hour or more?
The general rule is at least one hour before eating and 2 hours after eating. You might see if waiting 1 hour before tea makes any difference. It always comes down to finding out what works best for your body. Regarding T3 many people find split dosing works best with taking some just before bedtime but as Rod noted above Dr. Lowe took all of his in one shot at bedtime so again you have to experiment a bit and find out what works best for you. PR
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Clinical trial - using body weight to adjust t4 versus t4 + t3 dose
