"High TPO AB, High TSH, Low FT4 & Low Borderline FT3

Question

Hi, My mother recent med. test results shows:

FT3 - 2.42 (2.3-4.2)    - Borderline
FT4 - 0.79 (0.89-1.76)- Low
TSH- 6.9 (0.55-4.78)  - High 
TPO Ab- >1300 (<60)- Very High

She is on Thyrox -50 medication from past one year. She was being treated for TSH by her doctor. She has her doctor appointment about an hour from now. Kindly suggest what shall we ask her doctor. 

Should there be any change in treatment, as I assume the doctor will only increase the Thyrox dosage from 50 to a higher value. 

Please interpret these results in laymen language, specially High TPO & Low FT4 & FT3 (borderline).

des900 · Answer

What you might be saying may be correct but what patients or doctors can do if T3 or desiccated thyroid medicines are not available to buy like that in USA, UK etc? This is the main reason why levothyroxine still the preferred medicine irrespective of their not resolving symptoms. Me myself is very keen to get those dessicated one but I am from such country India, where such medicines not available to buy. I found some sites which ship worldwide but unfortunately it require international credit card which is very rare to get in such countries and the credit cards issued by most banks in India can only be used within India.

gimel · Answer

You cannot know if the evidence for change is adequate or not without spending a lot of time going through all that is available.  Which I have done.  I just sent you a PM with info on that.  To access, just click on your name and then from your personal page, click on messages.

des900 · Answer

Yes the evidence and results are not overwhelming enough to change present guidelines which means its still work for most people and saying TSH is useless test and treatment based on TSH doesn't work for any as gimel said in previous posts is incorrect.

handsinclay · Answer

The scientific evidence is coming in to support using Free T3 and Free T4 along with symptom relief as the better scenario for many (most?) hypothyroid patients.  Guidelines from the thyroid associations (or any association) are slow to change until the evidence is overwhelming.  Patients demanding a better quality of life can drive change too!

One cannot overlook the underlying reasons for this slowness to change.  Some might be that: 
1. they will be admitting they have been wrong, 
2.) they will have to change their relationships with the T4 only med pharmaceuticals, 
3.) and (more cynically), as patients symptoms (ie. anxiety, HBP, palpitations, sleep issues, sweating, etc.) dissipate from proper thyroid meds, then there will be fewer prescriptions and doctor visits needed.

des900 · Answer

If AACE/ATA guidelines were wrong why still its not abolished? Why your quotes statistics result doesn't able to do that?

gimel · Answer

You have to know a lot about statistical analysis to understand if a sample size is significant or not.  I do.  The study results are very valid.  Plus it is only one of many studies that conclude that TSH does not correlate at all with tissue thyroid effects (symptoms).  

No, I wouldn't say that the people at the ATA are foolish, just wrong.  I have given you a number of links to studies showing that TSH is most frequently suppressed below range when taking adequate doses of thyroid med.  Also, as mentioned above I can give you numerous links to studies that show that TSH does not correlate with tissue thyroid effects (symptoms).  I can also give you links that show that TSH does not correlate well with either Free T4 or Free T3, the biologically active thyroid hormones.  

Most of our members are here because of doctors who follow the ATA/AACE Guidelines, which are wrong in several areas.   The doctors' application of that incorrect information caused the members' continued suffering with symptoms.  So what value is there for you to continually give those members the same, ineffective information from the ATA/AACE Guidelines?   Obviously it did not work for the members.  Instead we try to give them facts that will guide them in the right direction.  We strive very hard here to make sure that everything we say here is supported with scientific evidence, not just words spoken by someone or some organization.  Otherwise we challenge the validity of the information. The success of our efforts here speaks for itself.

If you try to find scientific evidence that supports some portions of the AACE/ATA Guidelines you will not find it.  That includes using TSH/FT4 as the predominant diagnostic, T4 as the only thyroid medication, and for most hypothyroid patients treatment only as needed to get TSH back within range.   There is voluminous scientific evidence to the contrary, which I found during my research over the last 5+ years.

des900 · Answer

You are wrong those studies are limited to a very small population.

http://www.thyroid.org/patient-thyroid-information/what-are-thyroid-problems/q-and-a-tsh-thyroid-stimulating-hormone/

'In most patients on thyroxine replacement, the goal TSH level is between 0.5 to 2.5 mU/L'

Now don't say American Thyroid Association are a bunch of foolish people.

gimel · Answer

Well, raising thyroid med dosage in order to get TSH around 1-2 is better than some of the stories we have heard so much in the past, where the doctors just prescribed enough to get TSH back within range: however, the reality is that TSH is a useless test when taking thyroid medication.  Our bodies evolved with a continual flow of hormone from the thyroid gland, mostly T4 and some T3.  Taking once daily doses of T4 changes relationship between Free T4/ Free T3 and the output of TSH.  In addition TSH does not correlate well with either Free T4 or Free T3, much less correlate well with symptoms, which are the patients' prime concern.  

So instead of targeting a thyroid med dose to try and achieve a TSH level, which doesn't really work well for the patient, it is far better to treat clinically for symptoms first and Free T4 and Free T3 levels second.  As an example of how futile it is to use TSH as the method to dose a thyroid patient, have a look at this link.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1341585/pdf/bmjcred00253-0040.pdf

In the study, 148 patients on thyroxine were extensively evaluated with a full history and clinical examination and with use of a modified Wayne clinical diagnostic index.  From the total 108 were classified as euthyroid, 22 as hyperthyroid, and 18 hypothyroid.  The TSH ranges for the 3 groups were 
.1-19.7, .1-14.4, and .1-123.5, respectively.  Clearly TSH varies so much that it is useless to try to use it to medicate a thyroid patient.  

In the words of a good thyroid doctor, In the best tradition of clinical medicine, a physician should prescribe thyroid hormones as needed to eliminate the symptoms and signs of hypothyroidism without producing any symptoms or signs of thyroid hormone excess.

gimel · Answer

Your mother's B12 is too low.  She should supplement as needed to raise it into the upper part of the range.  The ferritin is also too low, it should be 70 minimum.  And the Vitamin D is much too low.  It should be about 55 minimum.  Optimizing these, along with getting her Free T4 and Free T3 optimized will make a huge difference in how she feels.

gimel · Answer

That increase of 25 mcg of T4 is going to do essentially nothing for her levels. What will happen is that the increase will decrease her TSH level and thus the output of natural thyroid hormone will be decreased, essentially offsetting the increase in thyroid med.  The serum levels will not start rising until the TSH is very low in the range, or suppressed below range.  

Rather than wait for 2 months to see little progress, I would tell the doctor that her levels are so low in the range, taht the 25 mcg increase is not going to raise her levels enough, and ask for another 25 mcg.   Even that is not likely to be enough, but better than 25 mcg.  

As she continues to take higher doses of T4 med, it is likely that the Free T3 level will lag behind changes in the free T4 level.  If that occurs, she will need to add a source of T3 med.  I know that is difficult  to get in India.  When it gets to that point, there are a few options we can discuss.  

What about testing for B12 and ferritin?  Those are very important.

gimel · Answer

Sorry I did not get to this any sooner.  I assume that your mother has hypothyroid symptoms from those thyroid hormone levels.  She definitely needs an increase, and not just 25 mcg of T4, but 50 for this increase, and will likely need more in another 6-8 weeks.  

The TPO ab test shows that she has Hashimoto's Thyroiditis.  With Hashi's the autoimmune system erroneously identifies the thyroid gland as foreign to the body and produces antibodies to attack and, over an extended period, destroy the gland.