Sister help please

[lisan1]

This is my sisters results. She's on levo only. Does she need to add T3? Or is she converting okOn 88 MCG

Tsh 0.18

Ft3 4.1 (3.1-6.8)

Ft4 18.4 (12-22)

After starting to supplement selenium

TSH 0.05

FT3 4.9 (3.1-6.8)

Ft4 19.8 (12-22)

[SlowDragon Administrator]

were both tests done 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)

She needs to test vitamin levels

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

Is her hypothyroidism autoimmune?

[lisan1 in reply to SlowDragon]

Yes the test was done that way. Her vitamins are optimal except for ferritin. She also has tg ab

[SlowDragon Administrator in reply to lisan1]

What are her actual vitamin results

Presumably she takes supplements to maintain optimal levels?

How low is ferritin

Has she had full iron panel test for anaemia

As she has Hashimoto’s is she on gluten free and/or dairy free diet

[jimh111]

Her fT3 is what you would expect with this fT4 on levothyroxine monotherapy although her TSH is low. Does she still have symptoms and if so what are they?

I no longer support the idea of levothyroxine monotherapy because it is associated with increased cancer and cardiac risk. I think every hypothyroid patient should be given a little T3 as it is safer.

[lisan1 in reply to jimh111]

She feels ok now. Do you think its best for her to stay at this dose or better to take both levothyroxine and a little liothyronine

[jimh111 in reply to lisan1]

Her overall dose seems fine as she is doing OK. I feel a little liothyronine is better as it can keep fT4 in the lower half of its reference interval. However, she is already on a lowish dose and it would be difficult to split small doses of liothyronine. Also, it would be very difficult to get a doctor to prescribe liothyronine. Perhaps a good compromise is that if she needs an increase in the future she could switch to e.g. 75 mcg levothyroxine plus 5 mcg liothyroine (prefrebly split into two doses). (liothyronine is about 3x as potent as levothyroxine).

[lisan1 in reply to jimh111]

Thank you.What would you do in my case? Increase to 100 or add 5 MCG liothyronine

On 87,5 levothyroxine

TSH 0.25

Ft3 4.2 (3.5-6.5)

Ft4 15 (12-23)

When I was on 75levothyroxine

TSH 0.84

Ft3 3.8 (3.5-6.5)

Ft4 14 (12-23)

[jimh111 in reply to lisan1]

If you are reasonably OK I wouldn't do anything. It's not about targeting midpoints as each person has their own setpoint which may be anywhere with or slightly out the reference intervals.

[lisan1 in reply to jimh111]

I have a very heavy period and scaly scalp so I need an increase. Have been on 87.5 for 8 weeks so should have gotten better by now. Would you go for t3 or T4?

[jimh111 in reply to lisan1]

I'd probably go levothyroxine for now.

[lisan1 in reply to jimh111]

thanks! Would that a 12.5 increase of T4 suppress TSH less than adding 5 MCG T3?

[jimh111 in reply to lisan1]

5 mcg LT3 suppresses TSH to a similar extent as 15mcg LT4 although it might have a greater effect if you are not splitting the dose.

[Bearo in reply to jimh111]

“ I think every hypothyroid patient should be given a little T3 as it is safer.”

Do you know if any prescribers agree with you?

I convert well so doubt anyone would agree to let me try a bit of T3.

[jimh111 in reply to Bearo]

I don't think anyone does! The evidence is there, higher fT4 is associated with increased cancer and cardiac risk but doctors don't want to acknowledge it. They just avoid the issue to keep things simple.