Am I overmedicated, undermedicated or high RT3 or?

[faith63]

10 months ago I became over medicated and my doc has been lowering my dose of Tirosint by 12 mcgs ever since.  A week or so ago my eyes had a flare up of swelling, running and aching [have had this when under medicated too] apparently it isn't too common because I posted about this with not much response. Now I have fluid retention else where too [maybe I had too much sodium] and my digestion is slow with reflux again.  I have had the jitters off and on, trembling, racing heart at times, but now feeling tired/slow,, palps have stopped.  My doc lowered my dose again, 4 days ago to 88mcgs Tirosint, I was told to stay at 12.5mcgs Cytomel.  Every lab done before this had had a FT4 at the very top of the range, FT3 has been at the upper 2/3 or higher, no TSH and high RT3.  Here are my labs from last week, before dose lowered:

100mcgs Tirosint 12Cytomel
TSH less than 0.006
FT4 Direct  1.48  0.8-177
FT3 3.3 2.0-4.4pg/ml
RT3 24.1 9.2-24.1ng/dl

Do you think the RT3 could improve as I lower the T4?  Am I over medicted or do I need additional Cytomel for the fluid, vision thing?  Any opinion would be helpful!  I have Hashi's and my last labs where good on iron, D etc...  But I do have some low cortisol in the AM, based on saliva testing.  My last labs on Cholesterol and Trigs where very high, also my A1C was high...which is unbelievable because I eat so well, so I think my thyroid meds are not working at the cellular level, hence the high RT3 [which my doc is not concerned about]  She's about ready to put me on Statins and Metformin.  Had none of this until my thyroid got wacked out..gained 30lbs in 3 months, the vision issue and totally debilitated from pain and my body not functioning properly.  Have not been right since.  I wonder if I may have Graves as well, will ask for that test!  Very concerned that this is causing permanent damage to my organs and bones...put my doctor has no sense of urgency.

Thank you so much for your help!

[Barb135]

I'm not the least well read on RT3, so I won't even touch that.

While your FT4 is still quite high in the range, there's plenty of room to increase FT3; yours is only at 57% of the range.  

I agree that you should have dropped down to the 88 mcg Tirosint, but I don't agree that you should stay at the 12.5 mcg cytomel.  

What type of permanent damage are you concerned about?  I'd be a lot more concerned going on a statin, than I am with having high cholesterol/triglycerides.  Have you paid attention to how your cholesterol levels coincide with your thyroid levels?  I noticed right away that as my thyroid levels and exercise went up, cholesterol went down. Likewise, when thyroid levels go down, exercise tends to go down, as well and  cholesterol goes up.

Have you been diagnosed with metabolic syndrome?  I was recently diagnosed with that.  My doctor is working with me to manage it without extra medications. We're trying to work with it mostly through diet and exercise.  I'm good with the diet (most of the time), but haven't done so well with the exercise this summer.   I try to stay with a low glycemic diet that won't spike blood sugar, which in turn spikes insulin.

[faith63]

I must have figured out the FT3 wrong, being 75% of the range?    If I could relieve my symptoms, by upping the T3 I'd be so thrilled!  How much would you suggest?  Then I could run it up the flag pole!  

I'm not about to try Statins again..no way and Metformin..would be a last resort!  I think the doc needs to get to the bottom of this, the hypo or hyper could be doing all this.  

My concerns are about my bones and possibly my vision from being over medicated for so long, also my heart and my liver has mild diffuse fat now.  She says I'm nearly Type 2 and I'm concerned about that.  Been borderline since 2009, sometimes the tests shows diabetes sometimes not.  I do believe this is Metabolic Syndrome..having all these issues.  I think it's probably that I'm resistant to insulin.  I can't lose the fat in my midsection.  Exercise regularly when not laid up from symptoms.  Had been slim and fit my entire life and everything went haywire.  I know how to eat and be fit, was for 46 yrs.  I did see my Cholesterol drop by 50points in one month when on Armour and it has plateaued now.  I hear the main cause of heart attack is inflammation, namely C- Reactive protein.  Have known of several people with perfect cholesterol having blockages and heart attacks.

How were you diagnosed with Metabolic Syndrome?

Well Barb, we have certainly been through the ringer!  It sound like you are on top of things and fighting the good fight!  

I have had hair regrowth and a significant increase in energy.  Don't know about weight, afraid to look, but I seem some smaller in some places.  

I keep reading that a switch to Dessicated would fix all this..just don't know what to do.  

This is my 4th Endo and they just seem to be clueless on some things and there is no sense of urgency to get me well.  But, after all these years and blood draws sometimes monthly and all the issues, I have become fearful of having some of the testing and have put it off for months.  Sometimes I just can't take anymore bad news.  That must sound ridiculous!

[gimel]

Switching to dessicated is not gong to fix things for you.

There is lots of good info available that says that serum thyroid hormone levels may not reflect tissue thyroid levels.  Further, that the very best measure of tissue thyroid levels is the ratio of Free T3 to Reverse T3.  

Understand that Reverse T3 is a natural result of conversion of T4.  Under some conditions, the body will convert too much T4 to Reverse T3.  Excess Reverse T3 is a mirror image molecule of T3, but RT3 is biologically inactive.  When RT3 is excessive, it tends to offset the effect of Free T3.  If the ratio gets too low, then the result can be hypothyroid symptoms.  

When taking a T3 type med such as Cytomel, it is hard to know what a representative result is for Free T3.  It depends a lot on when you took the med and when blood was drawn for the test.  That is one of the reasons that it is recommended to wait until after blood draw to take T3 meds.  

If I assume that your Free T3 is a representative result, your FT3 to RT3 ratio is about 1.36  (3.3 divided by 24.1, times 10).  The recommended level is more like 1.8 or higher.  There are several ways to treat this.  Your case is quite like mine from some months ago.  My ratio was too low, mainly due to high RT3.  My T4 dosage was reduced, so there was less T4 available to convert to RT3, and my T3 med was increased to raise my FT3.  This worked very well.  My ratio is now well above the range, and I feel better than before.  

Not saying that the FT3 to RT3 ratio is the sole issue for your weight gain, but if you get it to the right level it will certainly be a good start.

[Barb135]

I went back to my calculation of your FT3; the 57% was a typo; it's actually only 54%.

Because T3 med works quickly, it's always best to raise it slowly, in order to keep from getting it too high.  I, personally, wouldn't increase more than 2.5 mcg at a time.  

Metformin is a standard script for Type II diabetes, so if you can prevent that, you're ahead of the game.  I've seen a lot of people lose quite a bit of weight once they  get on it, though. I wouldn't mind giving that a try, but my doctor doesn't want to go that route yet, because my blood sugar levels are still in the "pre-diabetes" stage.

Typically, the damage to bones, heart, etc is from having too high levels of FT3, not low TSH.  While your FT3 may have been too high, at one time, it isn't now, unless you feel like you're having hyper symptoms. Not everyone needs FT3 high in the range. Mine's at 3.4 (2.3-4.2) and I do get some palps and pounding heart once in a while; when that happens, I have to back down the T3 med for a couple days, then I'm okay.

I was diagnosed with Metabolic Syndrome, because I have all of the components of it, which are high blood pressure (or being treated for it), high cholesterol/triglycerides, insulin resistance/high blood sugar, overweight around the middle. Having just one of the components doesn't constitute metabolic syndrome, but 3 does. I have all 4.

I was slim and fit for 58 yrs of my life, so I know how to eat right and exercise, as well, but once we get a certain set of issues, a lot of things we did before fly out the window.  I have a family history of both Type I and Type II diabetes and heart issues, etc, so I guess I should have seen some of this coming.  

It's possible that the RT3 issue is a big part of your problem - may be some of mine, as well, but my doctors don't test for it and I haven't made up my mind to spring for it, out of pocket yet; however, insulin resistance also wreaks havoc with your metabolism (insulin is often referred to as the "fat storage" hormone).  It's more difficult when you're fighting something on 2 different levels.

The hair on my head has mostly grown back, and overall, I feel pretty good; I've even gone for a couple months, now, without needing a nap in the middle of the day. The weight issue is the main thing I deal with now and I believe my cholesterol level is tied to that, as well. I feel relatively sure that if I could lose 10-15 pounds cholesterol would come back into normal ranges.

Will be interesting to see what your doctor says.

[faith63]

Thanks for your help.  My doc won't let me go up on the T3, but I'm so bad off that I will do it anyway.  She had prescribed 15mcgs and I've cut the pills and I'm only at 12.5, will go up by another 1.25 for 3 days and if no improvement go to the whole 15mcgs.  She wants my TSH to raise, she thinks I'll get Osteo and also believes that people do well anywhere in the FT3 range.  I don't buy this and I've been sick too long to follow this advise.  I took a prescription water pill on Tues and by Wednesday, my eyes weren't puffy and achy anymore so this just screams Hypo!  I too, have a heart that is sensitive to the T3 increases which makes it difficult to raise.  Small doses of Propranolol helps that somewhat.  I do believe this fat in the stomach is related to the higher blood sugar, but I did have the high sugar for over a year, but didn't get the fat until my thyroid went out..so who knows for sure.  As for RT3, I guess I'll just see what happens as my T4 drops.  Oh, throughout this whole ordeal, my eyebrows never have regrown and about 1 yr ago my tongue got swollen and it never leaves.  I use Rogain to have fill in my eyebrow.  I know it shouldn't be that way if my dosage was correct.  The dizziness is back for 2 days now didn't have it when my FT3 was 3.7 last month.  

[faith63]

I have noticed that when hypo, I get acne and if you noticed a sudden increase in skin wrinkling?  This has happened to me when I first got hypo and continues..acne comes and goes as levels change, oh and hot flashes and hot when trying to sleep too.  All stop when i get the T3 in a better range.  Any one else?

Thanks

[Barb135]

It sounds like you really could stand to find another doctor; yours will probably keep you very ill.  

Low TSH doesn't cause osteoporosis; it's abnormally high levels of Free T3 that do that.  She's also wrong that anywhere in the FT3 range is good; it's not....  we're all different and we need different levels.  For instance, we have some members who need to be at the very top of the range, and some who feel better at the bottom of the range.  I, personally, do best somewhere near the middle or slightly above; if I go too low, I have hypo symptoms, but if I go too high, I get the pounding heart and palps.

[faith63]

I agree that this doc may very well keep me ill and is wrong about osteo and heart damage and so are the last 4.  I think it will be unlikely that I find one who does things differently.  At least this one returns calls and gives refills and even gave me bio identical female hormones..shes the only Endo in the city who would think to do that.  My compounding pharmacist was blown away.  I think, with persuasion I may be able to keep her from cutting my T4 too low.  I have bought T3 from Mexico in case she won't let me go up, they have T4 too.  It really is a pity that it's like this.  How can this happen?  Apparently they aren't being properly trained properly.  She told me some of her patients have Fibromyalgia and Arthritis nd see a Rhemy, which was a warning sign to me because she should have told them to increase their T3..that's what takes my pain away.  When my lower back went out, I went to a doc who takes care of the Cincinnati Reds and he said my discs had the usual degeneration for my age and to the pain was mostly from under-treatment of thyroid, same with the Plantar Facitis, very minimal but too much pain.  I knew then that I would have to take matters into my own hands, but can't afford the thousands it would cost to see a Nature-path or Alternative med doc.  How did you find your doc?

[faith63]

My doc will do the RT3, at my request but doesn't think the results are of importance.  Do you know where I can get info that she may find worth looking into?  Have been surprised to learn that FT3 levels reflect some RT3 and aren't as accurate as I'd hoped.  Had been reading this lately.  

I had took my last T3, 20hrs before my blood draw.

I had heard there was a more accurate FT3 test..I think it may have been the "direct dialysis",  like they have for FT4.  Do you know of this?  I know labs aren't as important as how a person feels, but my doc has me lower meds without asking me my symptoms..maybe she assumes I'd call if I had them.  

Have increased my T3 to just under 15mcgs.  I have acne and odd red oozy sores and the swelling, feel off and sea sick..I'm not waiting another 4 weeks for labs to see what she says.  

How did you find a good doc?

[flyingfool]

The lowering of the T4 IF you have a reverse T3 dominance is the right direction.  

But I think this is really just by accident that your Dr. is doing this.  Rather than reducing your T4 due to the conversion dominance to Reverse T3. Your Dr. I suspect is doing it in an effort to raise your TSH.

The problem is that with the T3 you are taking. It is amost a sure bet that the T3 medication alone is suppressing your TSH.  So no amount of lowering the T4 will likely "cure" the suppressed TSH.

They sypmtoms you still have are all consistent with being  Hypo.  So my OPINION would be to raise the T3 and lower the T4.  Which it sounds like the Dr is doing one part of that and you are self medicating the other.  It is always best to have the Dr. on board but understand in certain circumstances as a last resort and inability to  find such a Dr.  a person has to take things into thier own hands.  Unfortunately even has the possibility to do that because of the inability to obtain medicine without a prescription which you need the Dr on board.  If the Dr is not then a person often times is out of luck.  On the other hand self medicating can lead many to bad, bad consequences which is the whole point of requireing prescriptions from credentialed people.  the "rub" lies in the circumstances like Thyroid when so few Drs know how to properly treat thyroid patients.

[faith63]

Yes, the doc thinks I'll get Osteoporosis etc..and keeps lowering my T4 for that reason only, not even asking my symptoms when lowering the meds by phone.  I have no confidence that my 6th Endo would be any different.  I do think it's possible if I explain the swollen eyes and body, acne etc..she might not object to the raise of T3, but I'm so warn out by the whole begging pleading crap, I have gone through for 3 years.  I recently found old labs from 2011 and I was barely in range on any testing and my doc not knowing why I had all these symptoms.  I will have to take things into my own hands in order to feel well enough to function.  She's not especially concerned about my high cholesterol and trigs, my sugar is high too, probably from my slow digestion[which is horrible].  Have you had luck finding a doctor?

[Barb135]

Here's one article that you could show your doctor, if you think she might be willing to read it.

http://www.ncbi.nlm.nih.gov/pubmed/16269872

[faith63]

Thanks!  Hoping to get some RT3 info as well as to debunk the TSH crapola.

[Barb135]

I don't think RT3 info will debunk the TSH ideas, because a lot of doctors don't put any stock in RT3.  

Try this one about suppressed TSH; it's pretty short.

http://www.ncbi.nlm.nih.gov/pubmed/8252740

[faith63]

Thanks so much!

I do wish they would look at RT3 as it seems to be pretty important.

[faith63]

How long could it take to find relief once raising the Cytomel?  It's been a few days and the edema is getting terrible.  Was at 12.5, now 15mcgs.  I can't believe my doc is doing this to me!

Thank you

[flyingfool]

Osteo is 100% unrelated to TSH levels themselves.  UNLESS the Dr Has Immaculate TSH belief.  That is that the TSH is a 100% accurate reflection of your motabolism.  

Osteo is a underlying separate problem.  the only reason why it speeds up due to thyroid is due to the speeding up of the metabolism. To the transporting removal of the bone occurs at a higher rate simply due to the fact that everything is happening at a higher rate.  I think gimel has a letter from a Dr about that so you may want to try to Private Mesage him with that.

You have pretty much proven at least to yourself that the TSH is NOT reflective of your current matabolism.  Your low TSH in a perfect world would by its number indicate you are Hyper. Yet you are pretty clearly Hypo.  So your matabolism is actually slower than it should be.  And your Dr is trying to slow it down even more.

The fact that your Dr is willing to increase your T3 to speed up  your matabolism while trying to raise TSH indicates to me that your Dr does not know what is going on. You are in a tug of war battle and your Dr. is pulling on both ends with you tied in the middle wondering why you are in distress!

Fortunately for you your Dr is unknowlingly I think going in the right direction.  It won't however result in a raising of your TSH.  So be prepared for that.

T3 acts WITHIN HOURS.  in terms of it getting into your blood stream.  So it is nearly immediate. It is not like T4 which takes 6 weeks or so to build up into your blood and have to convert etc.

That said however any medication increases can cause a shock to the body and initially you may feel a bit worse or not notice any improvement for a while.  Unless things get really worse, I'd wait a few more days or a couple weeks to get a better reflection of how the increase is doing for you.

[Barb135]

While T3 is a fast acting, it can still take a while for it to be in our system long enough to feel a difference.  I was on T3 for an entire year, before I could a difference between taking it and not taking it. It was almost that long before my FT3 level started coming up, too.  Your dosage was raised a very small amount, so the effect you feel from it could be minute.

Are you doing anything for the edema?  You need to talk to your doctor about that; edema that doesn't go away can be serious.  

I take dandelion tea or capsules, when I have edema; you might ask your doctor if that's okay.  I have my doctor's blessing.

[faith63]

Thanks Flyingfool and Barb!

I surely hope that the 15mcgs does the job, because the doc won't let me go higher without dropping the T4 more..which who knows maybe I can get away with 76mcgs or so.  I was feeling pretty good until my FT3 got to 3.2 [2.0-4.4]  once i got this low my health has been deteriorating.  Last time it was at 3.7, so i know my target range is about there.  

I used some prescription water pills for the Edema and I'm out now.  Would really like to try the Dandelion tea.  Does it treat pretty severe edema too?  How is it used?  

[Barb135]

Your FT4 is high enough that you could probably drop to 88 mcg and still be okay, if you need to increase your T3 med.

Yes, the dandelion teas will help with severe edema.  My feet/legs were swollen to the point that you couldn't even tell I had ankles and I was desperate to do something, so I tried the dandelion tea.  I get it from my health food store.  You buy the tea bags and simply steep them in hot water for a few minutes.  I add a bit of stevia for sweetening, because the tea is a bit bitter.  Then just sip  a couple of cups/day.

Since my swelling was pretty severe, it took a couple days before I noticed a lot of difference, but once the swelling started coming down, it went pretty fast.

[faith63]

Left a message for my doc telling her about the severe swelling, pain etc..and that my FT3 is too low for me at 3.2, did well when at 3.7 and can i raise the cytomel a bit. and that i had 3 good weeks at that level for the first time in years. Requested a diuretic also. The message i received back was: "that your level is fine at 3.2, am not comfortable giving you a water pill, will discuss this at our appointment on Sept.5"  I'm very angry!

My dose was lowered to 88mchs Tirosint about 2.5 weeks ago, because of her fear of the TSH being too low.  Just incredible!  But this will help me RT3 inadvertently, just hope she stops lowering it.

So encouraged about the tea!  I have got to get to the health food store ASAP!

[Barb135]

Wow - I don't blame you, I'd be angry, too.  I can't believe your doctor wouldn't even give you a diuretic.  Did she give any reason for not being comfortable with that?  There are OTC diuretics you can get, but I've never used them and would be afraid to suggest any.

I'm afraid you're going to have to find a different doctor, because while this seems to be trying to work with you, she's still stuck on TSH and the fact that she's willing to leave you with severe edema (which can be a sign of hypo or a sign of heart issues) scares me. Have you had a heart work up to make sure you don't have issues there?  Congestive heart failure, as well as other conditions can also cause edema.  

Just for your info, my health food store (I go to several of them, but mostly Vitamin Shoppe, because it's closer to me) also carries a Dandelion Root capsule that might work a bit faster for you than the tea.  The brand I use is Nature's Way, but I'm sure there are others.  I keep both on hand.  If any of this information gets "bleeped", I'll send you a PM.... lol  

Did you happen to talk to your doctor about the dandelion tea?  As I said, my doctor gave me his blessing for both the tea and the capsules, but of course, it's best to get your own doctor's blessing.

Oh -- one more thing...... do you happen to eat licorice or take any supplements that contain licorice extract?  I ask you this because I was taking a supplement recommended/sold by my doctor that contained licorice extract and I swelled up like a balloon and we  had to double my Lasix dosage and it still didn't do anything.  Took a while to figure out what was doing it, but as soon as I started researching the ingredients in that supplement, I knew what the problem was, so I stopped it. The swelling went down and has been "almost" normal, so I just tried that supplement again last week and, again, I immediately started swelling.  It won't affect everyone that way, but it will some of us.  It can also lower potassium levels enough to cause muscle cramps; it does that to me; at the same time I started swelling, last week, I got muscle cramps that were coming so fast and furious it was unreal.  I popped an OTC potassium pill, which quelled the cramps and since I haven't taken that supplement again, I haven't had any more.

We don't think about some of the things we buy OTC that can cause adverse reactions. It took a very good friend to remember that when I eat licorice I get cramps.

[Barb135]

Have you ever tried soaking in a warm tub, with about a cupful of epsom salt?  Epsom salt tends to pull excess moisture from your tissues.  Again, best to check with your doctor, but I find, sometimes that soaking my feet or hands in epsom salt, reduces swelling; we replaced my bathtub with a shower stall, so I no longer have the option of soaking my whole body.

[faith63]

No, my doc gave no reason for the refusal of the diuretic.  I have had my heart checked, stress tests, ultra sounds,EKG's etc..because when this all started I had hyper symptoms, trembling, diarrhea and racing heart with weight loss for about 8mos, then came the hypo with the weight gain and fluid retention, palps. Last check was 1.5 years ago.  They just think I'm nuts and have emotional problems..which I do now from all I've been through and dealing with doctor's.  Maybe it was the Hashi's..i will never know, I guess.  The heart doc only checked my TSH!  It was .45 and .63 which then it was pronounced normal.  So even the Cardiologists aren't testing correctly..can you imagine how many thyroid sufferers are left to suffer?  How many psyc. patients have thyroid issues that are over looked and on all kinds of drugs!  It really is concerning!  My friend has never had a FT3 test and is on Morphene and Lyrica and doesn't even try to find out why she's like this.  My pain is gone when I'm treated correctly and she still won't listen.  Her Cholesterol can't be lowered with Statins either.  I truly suspect thyroid issues.  Her willingness to be drugged just blows me away!

Yah, she's willing to leave me sick, but so were the last 4, so I don't know what to do.  No point in talking to her about any natural remedies, she won't be helpful there either.  My boyfriend got me the tea, thank goodness.  Will start it today.  It says to steep for 12min!  Wow!  The tea will be good as pills are just a bit much..so sick of them.

I have taken many supplements and have had no luck with them.  I have had Licorice in some and have never had an issue yet.  I love Licorice but realize it can raise cortisol levels and Bp etc.. I swelled before taking the last supplement containing Licorice, so that isn't it, but thanks for alerting me!  Am down to just whole food vitamins, fish oil if i can remember and Selenium, Cinnamon for high blood sugar..have you investigated that yet?  I hear other countries have good success with it.  My doc never called it insulin resistance but says my A1C is too high.  Do you know how the 2 are different?  I had none of this until my Hyper like episode in 2009..i feel it's related to the thyroid issue,I really do.

Why are you swelling so much, if you don't mind my asking?  Is it the thyroid crapolla?  And, how did you find such an open-minded doctor?  

Epsom salts didn't help much, but the real bad swelling is around my eyes..can't hold my breath long enough to try it ..HAHa.  When my eyes swell my vision gets worse.  No doc believes me that it's thyroid related, even the eye doc!  When the hypo hit in 2010 it was one of my first symptoms, with the 30lbs in 3 month gain, distended stomach and acne.  Took another year of searching for help to get it. In 2011, I had to ask my to run thyroid tests and had to tell him which ones..he didn't even know!  Unbelievable!  My GP said I needed a dietitian and a dermatologist and refused me testing.  It's been just awful, Barb.