Levoxyl vs. Armour with a low tsh level and low free t4 level

I had been on Levoxyl for 19 years after being diagnosed with Hashimoto's. About the time my yearly check-up was due I started having these massive panic attacks. I went to the ER and after bloodwork and other tests they said my thyroid was low. Instead of returning to my yearly check with my Endo. which was a 45 minute drive, I had my GP treat it because I didn't feel up to driving 45 minutes. I didn't feel stable enough. I was also eventually put on Klonopin for the panic disorder. Since then I've also switched to Armour Thyroid and am currently tapering from Klonopin slowly at an 1/8mg every 3wks to a month which is a wicked drug and very hard to taper from. My last thyroid blood test revealed that my TSH is low indicating too much thyroid hormone and my Free T4 is also exactly borderline low. This is not something I've ever had happen before. I feel both Hyperthyroid and Hypothyroid at the same time in addition to my withdrawal symptoms from the Klonopin. I am considering going back on the Levoxyl as I had been on it for 18 years. Maybe my body doesn't react well to the Armour? Or should I just wait until I'm off the Klonopin to make drastic changes due to the severity of the withdrawal. I know low levels of both can indicate Adrenal problems. Can the adrenal/thyroid problem be related to the Klonopin withdrawal? Could switching back to the Levoxyl alleviate some of the symptoms? I'm lightheaded, heart racing, hair loss, tired and can't sleep, my muscles twich a lot, my eye muscles hurt, I am shaky, hungry a lot, weird sensations in the back of my sinuses, & constipated

[Mark Lupo, M.D.]

Many of your symptoms sound like hyper-thyroidism.  The low TSH is consistent with this - most patients on Armour will have a borderline T4 as the T4/T3 ratio is not exactly the same as human thyroid physiology (ie armour has a 4.22:1 T4:T3 ration and normal human thyroid produces about a 6:1 ratio -- this is debated however) -- so you end up with proportionately more t3 than t4 compared to what a "normal" thyroid would do.  

The additional T3 is great for many patients - but perhaps not for you given your symptoms.  That's a pretty slow Klonopin taper - must be a severe situation.  I may be tempted to go back to what worked for years for you -- Levoxyl.  In doing so, you would eliminate the stimulating effect of the T3.

Good luck.

[ArmourGal]

A couple of comments from a fellow Hashi's person who is on Armour...

Armour seems (from many folks' account) to lower TSH in ways that a T4 med would not.  Could be that the T3 that is in it just does that...and yet the current endocinology standards were not done with desiccated thyroid extract in mind?  My own TSH is suppressed and I'm certainly not hyper.  Most of the folks I know on Armour go by their Free T4 and Free T3 for proper dosing.  Sorta like thay do when a person has central hypothyroidism or other problem with pituitary.  Personally, I wouldn't trust my pituitary to tell me a thing.  It took it 20+ years just to get high enough to convince anyone I was sick.

If your Free T4 is also borderline low, my thought would be that your TSH lab is unreliable.  I have seen quite a few folks with psychiatric disorder with the same dilemma.  Perhaps when there are brain symptoms the pituitary is itself hypo?  In addition, some of the psychotrophic drugs affect TSH and thus give another reason for unreliability of the TSH.  

I have known one other person who tried to start Armour when they were on Klonopin and withdrawing...and they did have a difficult time. They sorta had manic type symptoms when they started the Armour...and had to go extremely slow. So it must be true that it is a wicked drug.  That person also had adrenal dysfunction that had to be addressed before upping their initial dosage.

I too, had anxiety and panic with my hypo.  The first six months of treatment were quite difficult as my brain healed from the affects of hypo.  I would be fine one moment and quite unfine the next.  The only way I got thru it was because I was aware that the medical literature says that it can take 2-12 months for the brain to return to normal.  

It is my opinion that a T4 med is undertreatment and always leaves a person with symptoms (like your panic and anxiety.  Another member here, doodlebug, has posted she made the transition after a number of years - so maybe she will have some helpful tips for you.  I was fortunate that a physician started me on Armour right after I was diagnosed...and I think that's one reason why I had such good relief from all hypo symptoms within the first year.

It is true low adrenal reserve may be a problem for you now. I checked my cortisol levels with 4x a day saliva testing...and found that to be extremely helpful.

You didn't mention how much Armour you're on...but that info might be helpful.  I know you're confused..because I can see that your symptoms really do look like a mix of hypo and hyper.  

[dturner242]

I was taking 90mg per day five days a week and 60mg per day two days per week up until Friday.  This is equivalent to 950 mcg per week of Levoxyl.  My blood test a few months ago indicated that 125 mcgs of levoxyl per day everyday was not enough.  That
s 875 mcgs per week.  He put me on 90mg per day seven days a week of the Armour and I could tell that was too much without even having my blood checked.  But the blood test I had a few months ago even though the TSH was high, indicated the free T4 just fine. Do you think I should go back on the Levoxyl just during this withdrawal which could go on for another four months. Then once that's over and I've leveled off from the disruption that causes, try the Armour again as it's something I've always wanted to try but not under these circumstances.  Did your friend ever end up making the transition okay?

Maybe for me eighteen years of a synthetic medication then switching in the middle of a Klonopin withdrawal was probably not a good idea huh?  I was looking for something to help ease the pain of the withdrawal but I don't think this is the solution for right now.

[ArmourGal]

Yea, you're in a tough place.  On the one hand, you got the withdrawal thing going on...and on the other hand, Armour is probably better for the psychiatric symptoms than a T4 med only....and yet you're in the middle of the whole thing.

One problem I think you may have had is starting out on 90 mgs (a grain and 1/2) of Armour.  The usual starting dose is usually 1/2 grain....although most folks already on a T4 med can start out at one grain I think.  But that was a whole lot of straight T3 to throw at you at one time.  Doodlebug will probably chime in later on this...and dr. mark may give you the usual starting dose.  it's just hard for folks (especially heart wise) to start Armour at a higher dose if they've been on a T4 med.

Also, Armour does best when it is split into two doses during the day, with the second dose being taken about 6-8 hours after the first dose.  i guess you know about not eating for 30 min. to 1 hr. after or before taking it.  

I'm not sure on the equivalency...a grain (60 mg) has only 38 mg of T4 and 9 of T3...the rest is those other hormones I guess, plus calcitonin.

You asked about my friend making the transition okay...well, your post reminds me that I need to check on him.  But perhaps he did, because I haven't had any desperate emails in the last few weeks from him.  that's a good sign.  

So I think you may want to get the withdrawal out of the way first.  Us hypos sometimes can't deal with too many changes going on in our body at one time.  But I do think the armour would be very beneficial to you...and I think you would be well pleased with it once you're stable off the Klonopin.

[doodlebug1]

Boy, do I ever have the same opinion about Armour and psychiatric symptoms. I've seen folks have anxiety attacks while on T4-only meds, and I've seen the same folks get rid of them when they switched to Armour and took ENOUGH Armour to do so. From what I read, it's the direct T3 in Armour that makes a whirl of a difference.

In my opinion, and if it was ME, I'd do whatever it took to get off that Klonopin with the docs help, and use the thyroid med that best helps when doing it. Then if it was me, I'd get back on that Armour, but multi-dose it, and also do it sublingually. For example, I do 2 grains in the morning, another one grain around noon, and the final 1/2 grain by 2-3 pm. That way, I am better distributing the direct T3 through the day, since it peaks within 2 hours after taking it.

By the way, I'm also of the opinion that some folks need to check their adrenals to confirm or rule out low producing cortisol. I never had the latter, but SO many hypo folks do, and need the extra bit of cortisol to help get the thyroid hormones from the blood to the cells. I've noted that doing a 24 hour saliva adrenal test (I know ZRT labs does one) is much more accurate than a one time test. You can be "normal" one time, and low another time of the day.

[ArmourGal]

now i'm curious...since i never had to make that switch...but can she just switch to a higher dose of Armour...or what do you recommend she start out with?  how did you switch?

[doodlebug1]

Hi Armourgal. I was on .125 Levoxyl, and started on 3/4 grain Armour. My doc was not knowledgeable, and left me on that small amount for 9 weeks. I now know that I should have been raising a little at a time every few weeks, and holding those raises once I got up to 2 grains just for safety and to give the T4 time to show it's conversion results, as well. Glad you asked. It's an important topic, I think.

[obwat]

please please please make sure whoever's giving you the anti-anxiety drugs knows about your thyroid & also how to treat it.

i was prescribed valium in the ER when what i really needed was an adjustment in thyroid meds...


(taken from my post a few days ago)

...there was a snafu with a Rx refill and i ended up taking 7.5 grains instead of 3. i didn't realize until after i started getting heart palps, was unable to breathe, tremors, & experienced this bizarre anxiety freakout that lead me to seek emergency psychiaric treatment. i have been depressed before, but have NEVER had anxiety problems. is not my temperment at all.

the on-call psychiatrist prescribed valium but i told him, no - it's something physical. i'd read somewhere about hyperthyroid symptoms and asked him to check my levels. pretty sure he did it just to get rid of me (he REALLY didn't like me second guessing/rejecting his valium solution). when they came back my TSH was .008 ! (down from .744). T4 had jumped from 1.0 to 2.4.

[ArmourGal]

Wow - you took 7.5 grains all at one time?  It's good you didn't have heart disease. wow. that must have been awful.

[LowMac]

Obwat, Hi,
Quite a number of times, posters on this forum, testify of having toxicity at too high a level of Armour or other thyroid replacement meds. I too had bad reaction even though I built my level very gradually, up to 180mg and stayed there for several months (was prescribed only 120mg). My TSH actually got slightly lower than yours, @ 0.006. I didn't have the severe palps-heart danger or serious breathing difficult you related but I eventually had a very severe fatigue set in, that almost incapacitated me. I also had a couple of spells of not being able to complete a sentence without stuttering. This one scared me, because I have never stuttered in my life. It was as if my brain was processing faster than my mouth could react to.
Anyway, I'm glad other reading, can see the possible dangers with SOME PEOPLE, in titrating dosage too high. You can read this same reaction happening the many others, in the archives of this forum.
Thanks for your input.
Jim

[ArmourGal]

LowMac,
don't you think your problem may have been your low cortisol?  Folks with low cortisol can have problems utilizing the thyroid hormone.  I say this because it appears quite unusual for someone to have symptoms of toxicity on less than what the thyroid gland makes anyway...which is said to be 4 1/2 to 5 grains.  So it would appear your situation was a bit different than someone all of a sudden starting to take more than twice their usual dosage.

[doodlebug1]

That incident must have been very scarey, Low Mac!! But I'm seeing the same thing as Armourgal stated. I've noticed continually that it's not "toxicity", per se, that happens to folks who are working to find their optimal dose of Armour. Instead, it's the inability of the thyroid hormones to enter the cells because of low cortisol or low Ferritin....neither of which the docs who are working with him understand is going on. Thus, the thyroid hormones build too high, and symptoms result.

I'm on 3 1/2 grains, and when I tried to go up to 3 3/4, I got palps a few days later. But I wouldn't call that "toxicity"--instead, I was simply too high, and went back down. I have no adrenal problems, and have corrected my Ferritin issues. I don't know what happened to you Lowmac, that you would be on 3 grains for a few months, then suddenly have that fatigue. But you may simply have been on slightly too much, or...you have other issues that need to be corrected before you can get up where you need to be successfully.

[LowMac]

Hi Ladies, that is a possibility that my low cortisol levels (which I do have), interferes with my thyroid hormone utilization. I've had 4-saliva tests, that check both the 8:00AM & 12:00PM levels of cortisol/dhea and two were borderline low, one was very low normal and the fourth was cinlically low. For example, on that clinically low one, the range for 8:00AM, was "0.21 to 2.06 mcg/dl", my result-"0.23". On the 12:00PM one, range was "0.03 to 0.50", my result was <0.03/actually undetectable. The other as I say weren't that low but very low-normal. I did get a 24-hour urine cortisol test, with result "10.7" (range for men, up to "119").
Now just last month (9-27-05), I did another morning-only test, this time through ZRT Labs, the previous ones being the BobyBalance Brand ones by Great Smokies Diagnostic Labs, Inc., and my result again was loe, @ "1.7 ng/ml", range being: 3 to 8 ng/ml.  The comment sheet provided by ZRT stated: "Morning cortisol is very low...symptoms of chronic low cortisol...fatigue, allergies. chemical sensitivity, joint pain, cold body temp and sugar craving." This describes me to a "t" but having passed an ACTH Stim. Test, seems in the mind of most Dr.s, to rule out adrenal insufficiency and yet my cortisol levels have been persistantly low. ZRT also stated in the comment sheet; "Low cortisol is often associated with symptoms of thyroid deficiency as normal physiological levels of cortisol are essential for optimal thyroid function."
I took this last morning only test, just to see what my latest increase in thyroid med, did to my levels. Thyroid med, can lower already insufficient cortisol levels, even further. I've read this even on Armour and Synthroids websites!
I wanted to relate this to you ladies but also: Dr. Mark. I know I'm cheating a little because I've already gotten two questions answered but you have any ideas about my low cortisol?? ONE REALLY BIG hint that sticks out on ZRT's sheet, was that "sleep deprivation" is a cause. I have an early morning stub-haul route, from 2:30 to 6:00AM but I get at least 8-hours and usually 9-hours slepp, but is broken up. Could this be the key to my ongoing low cortical??? I've done this work 11-years. Hard to give up, I have other contract jobs I do, this one pays $30,000.00 a year for less than full time but if I thought it would correct my adrenal, I'd give it up in a heart beat!
Comments are well appreciated ladies!!! You especially Dr. Mark, if I'm allowed!

[LowMac]

above header didn't print all the way but was to Doodlebug and Dr. Mark also. Thanks much!!

[LowMac]

Darn, I saw a mistake, range on my test that was flagged low, wasn't 0.21 to 2.06, it was "0.27 to 2.06". Sorry bout that.

[doodlebug1]

Lowmac, yes!! Bingo!! Low cortisol DOES interfere with the ability of thyroid hormones to get to your cells!! I've seen it in so many folks on the Natural thyroid site. Docs generally have no clue about low-functioning adrenals, thinking that the STIM test is an adequate way to test it--they are looking for something major like Addisons, and failing to see what is going on. So when folks overreact to normal doses of Armour, they come to the erroneous conclusion that "Armour is not for everyone" or "Armour is too hard to regulate", or several other wrong conclusions that we have heard! Armour works, but sometimes a person has to discover and correct their low-functioning adrenals, or low Ferritin, to get the full benefits. You are perhaps one!

[ArmourGal]

Ditto on what Doodlebug said.
Yep, all the standard tests are geared to detect adrenal failure, not weakened adrenals which it for sure sounds like you have.  

Quite a few of the docs (some holistic, some not) who write about thyroid seem to understand this problem with low adrenal reserve and thyroidal folks, so I don't know why mainstream medicine doesn't address it.  Maybe cause it's hard to determine with a blood test, although I think an early AM test can be helpful if it is low.

I think Dr. Shames in his new book "Feeling Fat, Fuzzy or Frazzled" mentions it...and I know David Brownstein does too in his book "Overcoming Thyroid Disorders".  

I've seen a little bit of hydrocortisone just in the AM make a huge difference for folks..and of course some folks have to use it 3x a day.  But you start low, and work up only if you need too.  I believe the recommendation is up to 20 mg. a day so as not to suppress adrenal function.  

It ordinarily doesn't have to be used forever, but just for a period of a few months perhaps.  Dr. Peatfield has said that some folks may need it up to two years.

[dturner242]

I am definitely having hyperthyroid symptoms. First I thought both hypo and hyper, now I'm sure more hyper than hypo if even at all hypo.  I'm having heart racing, palpitations, shortness of breath(this is wierd and feels way wrong), can't get good nights sleep, lightheaded, my hands and feet swell sporadically, my hair is light and airy and I'm losing more hair than normal, hot flushes, I also think I've actually had a couple chest pains, and my arms and legs are just tired and weak.  I didn't even take any thyroid today I'm feeling so bad. I'm just going to switch back to the Levoxyl 100 mcg per day and go back to my traditional/conventional Endocrinologist a week from Friday. I have been with an Altern. Med doc for the last few months and it bothers me that when I said "So I should reduce my dosage right?" he said "If you want, it's up to you".  If my TSH is .15 and normal is .35-5.50 I feel he should have at least done a good exam on my thyroid for swelling, reflexes, made a dosage recommendation, and then gave me a lab slip for a re-test in a couple months. I even had to ask for the lab slip. Then he also said I could try Iodine supplements.  I think that was wrong too.  A person who is potentially hyperthyroid probably shoulnd't take iodine.  My Free T4 is .80 with a normal range of .80-1.80. It's borderline low.  It's never been borderline low or even close to low in my whole 19 year experience with this disease.  What I should say is that while on Levoxyl it was never low. A few months of Armour and now it's low?  Why? I just hope it corrects itself and it's not more indepth than that now. I know the shortness of breath is not related to Klonopin withdrawal but I know the Klonopin is a factor. I just need a professional who is experienced at this point.  Everyone on here is so knowledgable.  I love this forum and I'm glad I found it.  It's great to read other's experiences and knowledge.  Dawn.

[dturner242]

Oh yeah, and I forgot to mention, I smoke a pack a day and I'm sure that's really helping my symptoms a lot too.  Dawn

[ArmourGal]

if a doc recommended iodine to you, a Hashimoto's patient, I would be inclined not to go back to the doc anyway.  

You're a puzzle for sure.  And odd that your Free T4 has dropped.  But with the Klonopin withdrawal, I just don't know what might be going on.  I would safely withdraw from that before making any other major changes.

[dturner242]

I agree. I think my levels have been bouncing around ever since I started taking the Klon. and during the withdrawal. I think it's important that my thyroid levels be monitored during this withdrawal though or my symptoms will be too intense to ever finish what I've already started.  What's really sad is that when I came home from the doctor the other day I actually took an Iodine pill like he told me to.  I should have known better.  He's been pushing Iodine at me ever since I started there.  I'm pretty sure I read in the Mary Shomon book that there have never been any studies that have confirmed the importance or benefits of Iodine supplements when taken by thyroid patients.  She should know.  She's researched the disease in and out and has the disease herself.

[doodlebug1]

Dr. Mark, you mentioned that most patients on Armour will have a borderline T4. That hasn't been at all the case with me on an optimal dose of Armour, nor am I seeing it on the large forum I am on. Instead, those of us who are on enough Armour to completely rid ourselves of symptoms have a free T4 of around 1, or right around the middle of the range. We also have a free T3 towards the top of the range when we rid ourselves of symptoms. Dr. Dommisse in Arizona also adds T4 to his patients on Armour to get BOTH at the top of the range. But I haven't yet felt the need to do that.

[Mark Lupo, M.D.]

A T4 around 1 is borderline low -- besides, most of the time Armour patients I see have a detectable TSH -- I agree that if the TSH is suppressed I on Armour I would expect the T4 to be in the mid range and the T3 high for the same reasons I mentioned above.  I have added t4 to armour in some patients with success.

[doodlebug1]

I guess I should have clarified---that the "1" I mentioned is mid-range in the particular lab range that I use. i.e. it's right in the middle of my lab's range. Have noticed the same on others--that when they include the range, they are also mid-range in their particular labs.

[ArmourGal]

I believe on the iodine...it's that if you have hypo from iodine deficiency, it would be helpful.  But for Hashimoto's folks, the iodine seems to aggravate the condition.

[obwat]

i don't know what's "normal" for armour or whether or not what you're feeling is hyper...i DO know that what you're experiencing sounds very familiar. when i swung from hypo to hyper it started with insomnia - i'd just lay there for hours, wide awake. not really bothered by anything - just AWAKE. normally, i enter a sleep coma as soon as horizontal. added to the insomnia i was really fidgety in a weird kinda way. couldn't sit still. mind wasn't really racing yet, but it was all over the map & i didn't feel like myself at all. i didn't pay attention to any of it really.

then the breathing thing started along with a really strong heartbeat. felt like my whole body was beating. great when combined with insomnia! i couldn't walk up a flight of stairs without getting winded when weeks before i was doing 8-10 mile trail runs just fine. and normal breathing was strained - like i couldn't get a full breath. would breathe deep but it still felt like i wasn't getting much/enough air. i finally ended up at the ER (visit #1) after using my asthma inhaler before run (i'm stubborn - was trying to be "normal"). about a mile from home i just couldn't breathe (inhaler never been a problem - i have exercise induced asthma never a big deal). after about 15 minutes of not being able to breathe & watching my heartrate monitor blink 190 at me i had a policeman take me to the hospital. by the time in got in, EKG was normal.

hot flashes followed (weird for someone who's been freezing for the past few years & i'm 32 so no menopause) and shaking/tremors & leg weakness (i remember trying to hold leg on tub edge to shave legs in shower was really a big effort).

i don't know your details but am concerned they put you on an anti-anxiety drug to try and fix things; i was Rx'd valium. the anxiety stuff that followed the onset of my physical symptoms was BAD. in the middle of a job interview a voice in my head (seriously) said: this is not going well. tell them we should all just go home right now. and i felt really, uh, heavy (?) with this sense that all was bad & something was wrong. since you don't know me this won't mean much, but for context's sake - i once got in a horse accident, broke teeth, arm & pelvis yet was perfectly content to feed my horse before driving myself to the hospital. i don't get bothered by much so this sudden feeling of doom was unnerving. i ended up getting the job so whatever "i" was freaked out about didn't even exist!

as for labs, my t4 has always been and remains low/normal between .8 and 1.0 with lab range of (.8 - 1.8). during that hyper period it jumped to 2.4 (different lab with range of .8 - 7.7).

think i've rambled enough but i feel so much better whenever i read something another person has posted and think - YES! that's it - that's what's wrong with me too! odd sort of comfort i guess, but comfort just the same :)

[ancientmariner]

A lot of the symptoms you have described were, for me, low adrenal function, specifically low cortisol. The shortness of breath can be hypo OR hyper OR adrenal. And the hot flashes and shaking/tremors & leg weakness can be, too. For me, an adrenal whol glandular, an herbal supplement and DHEA 10 mg once daily helped tremendously. But, I did have the adrenal saliva testing first, which showed low all day, and after being on the supplementation for 2 months, I was normal at all times but the morning. So, you might want to investigate the adrenal component, too - the adrenals and the thyroid are connected, and it takes a delicate balance of the two to feel well!

[dturner242]

What brands of medication are you both on?  I'm a little worried about taking any kind of Adrenal Supplement during the Klonopin withdrawal.  I'm a mess.  I also lay there wide awake all night kind of hyper yet really, really tired.  Actually I'm really just wired sort of.  My body is shaky and I just hope that one day it will all just start going the other way.  I don't want to dwell on it but I do.  This has been going on for three weeks.  You had indicated that you had been given an anti-anxiety med (valium).  Was it long term or short term?

[obwat]

valium>

not sure what the course was meant to be; i refused the Rx because i knew it wasn't addressing the problem...knew it was physical & had strong suspicion thyroid. knew enuf to worry valium would just mask whatever was going on. luckily, i followed my instinct. chances are, i would have ended back in the ER again if i just took the valium & went on my merry (albeit sedated) way.

if panic attacks/anxiety is WAY out of line for you (you knou "you" better than anyone), came on suddenly with no apparent cause or connection, and along with all the other symptoms you described - i'd really really bug your doctor about looking closely at your thryroid levels/meds.

obviously am not a Dr but what you're describing is sadly familiar...


cortisol>

i've had mine checked. all normal there. tried a course of cortef just to be sure. aside from making me even MORE bloated, no change occurred.