Hypo or Hyper?

[ElleMet]

HI - I had a TT 15 months ago due to cancer and also had Hashi's.  Did well first 9 months after on Armour, 5 months spent on 2 grains - thought that was my dose.  About 6 weeks on 2 grains, my labs looked like this TSH  .189 (.45-4.5) FT4 1.04 (.82-1.77) FT3 6.2 (2.0-4.4)  I felt great, no issues, doc said stay there, so I did for 3 more months - then started having symptoms again, thought I needed to raise, but labs looked like this TSH .033 (.45-4.5)  FT4 1.03 (.82-1.77) FT3 4.3 (2.0-4.4).  Doc said to stay put, continued to go downhill, doc would not allow a raise, so he had me decrease to 1.5 grains, OUCH, got VERY hypo with TSH of 1.75 - took me couple months to recover, still felt off on 2 grains, so raised to 2.5 grains, got hyper on that dosage, terrible neck pain, could not function.  Now I am back on 2 grains, after 6 weeks my labs are about the same TSH .06 (.4-4.5)  FT4 1.04 (.82-1.77)  FT3 4.1 (2.0-4.4).  My arms are numb/tingling when I wake up, my legs fall asleep when sitting, my fingers are stiff and sore, I feel hypo again. However, I have had some of these symptoms when hyper so confused as to what is happening.  Tried increasing by 15 mg instead of 30 - heart seemed to race a bit, not sure if that is the answer or not.  Doc thinks maybe I should reduce by 15mg to 105 Armour.  I notice my FT4 seems kinda low while my Ft3 is high - thes labs are done while fully medicated, about 4-6 hours after taking my full dose for the day.

[gimel]

In the words of a doctor that I respect highly, "the ultimate criterion for dose adjustment must always be the clinical response of the patient."   Those heart rate numbers and being sweaty and not sleeping suggest that you may have gone too far with your thyroid meds.   What has your doctor suggested that you should do?  

To me it would be a good idea to reduce by about 1/2 grain and that will show some reduction in T3 fairly quickly, but your  T4 level will take a bit longer.  What you are looking for is the level that gives you neither hypo nor hyper symptoms.  Sometimes this takes a bit of patience to slowly adjust meds and then allow time to notice the effect on symptoms, and then adjust again, as needed.

[dchrist5]

hemi thryroid 2006 -- Hasimoto's Dx 1978

Labs 7-31-12 show TSH 0.06 “ Thyroid AB 901.6.” T3 free 3.2
' Nature thyoid 3 grs".
Heart rate 115 and 125 a minute...sweaty and not sleeping would you recommend lowering the dose?

[ElleMet]

If you get on the t4 before I do, please let me know how it is going. :)

[gimel]

I am essentially thyroidless, since I am told that mine was destroyed over many years by Hashimoto's Thyroiditis.  I am taking 3 grains of Armour.  My Free T3 is 3.9 (range of 2.3 - 4.2), and my Free T4 is .84 (range of .60 - 1.50), and I feel best ever.  I am taking steps to get a script for 25 mcg of T4 to get my FT4 up closer to the middle of the range.  

[ElleMet]

Are you thyroidless as well?  What do your labs look like on Armour when you are feeling good?  This next time I will do my labs un-medicated, I have been buying my own labs lately.

[gimel]

Funny, but a while back when Armour was not available, I was having to try and get by with Synthroid and Cytomel.  I never got the dosage right somehow, and never felt good on those.  

I also had that same question occur to me, so I decided to do a little experimenting.  I started increasing my T3 and cutting back on my T4.  After some time at that, I started feeling just awful.  Don't have any lab test results to know what my levels were, but I stopped that experiment real quickly.  I do know that I was hypo, and among other symptoms, I had the worst acid reflux you can imagine.   Fortunately, Armour came back on the market about that time also, so I jumped back into my old dosage of Armour, and in two days my reflux was gone.

[ElleMet]

Can someone who is thyroidless go on T3 only?  I did an experiment a few weeks ago - added 5 mg cytomel to my 2 grains just to see what would happen, racing heart, felt hard push of medication running in my system, then dizzy the next day.  So felt that was not the answer either. Thanks for the advice.

[gimel]

I understand your FT3 to RT3 ratio.  There are many different ways to calculate it.  By the way previously done, your ratio was 14.8.  There are some recommendations that with that method, the ratio should be over 20.  Others say that it should be between 10 and 20, and the higher the better.  At any rate, you can improve the ratio by increasing your Free T3 level.  I think that if you delay taking your meds until after the blood draw, it will show that there is plenty of room to raise your Free T3 level.  As previously mentioned raising your Free T4 level would be recommended also.  You should also work on raising your Vitamin D above the middle fo the range and keep increasing your B12.  

Please make sure that you get tested for Free T3, Free T4, and Reverse T3 along with TSH.  I would even make sure the lab people know what is to be tested, to be sure they get it right.

As for selenium, it can be toxic in excessive dose, so good to test first.

[ElleMet]

I have Solaray Selenium 100 mcg L-selenomethionine at home, do I take one or two of these daily - with my thyroid meds, or at night?  Thanks....

[ElleMet]

cortisol saliva test results were :
a.m. 13.4 (3.7-9.5)
noon 2.7 (1.2-3.0)
evening 1.3 (.6-1.9)
night .6 (.4-1.0)
10/10/11 I had the RT3 test done: TSH .1 (.3-5.1) FT3 3.9 (2.3-4.2) RT3 264 pg/ml (90-350)  Ferritin was also done then and was 98 (10-220).
Testing was done coming off of being VERY hypo after reducing to 1.5 grains for 6 weeks - these tests were back at 2 grains a while, painfully working my way back.  No Ft4 was done

[gimel]

vitamin D needs to be above middle of the range.  Barb says that she needs for her B12 to be at the very high end of the range or even over the range.

Can you locate the actual Free T3 and Reverse T3 numbers that supposedly came out as a ratio of 14.8?  If so, please post.

[ElleMet]

I was tested for everything but Selenium this Fall, I am going to retest everything now again, so will make sure selenium is on there as well. Selenium is in my multi and I do have a bottle of it at home I haven't taken it lately, began to fear that maybe all the supplements were making me worse - my Reverse T3 ratio was 14.8 in Oct.  Should I test iodine, too? My iron labs in Oct were:
Serum Iron 88 (35-145), UIBC 254 (155-300), TiBC 342 (250-450) %iron sat 26 (20-50) Ferritin 132 (10-220)  Ferritin was higher before total thyroidectomy, and vitamin D was way lower, 18, now 40.  Cholesterol numbers were bad before surgery, now almost completely normal. B12 was mid range in OCt, I have been supplementing with that as well.
Thanks for all of your advice - anxious to get some new labs here...

[gimel]

Well before the insurance company thinks of cutting you off, LOL, another thing I have neglected to cover is that hypothyroid patients often find that they are deficient in other areas as well.  For that reason if you haven't already been tested, then I suggest testing for Vitamin D, B12, ferritin, a full iron test panel, and selenium.  Deficiencies in these areas can contribute greatly to not feeling well.  Just being in the low end of the range for D and B12 is not sufficient, either.

You mentioned Reverse T3.  Were you tested for that?

[ElleMet]

Sounds good - I noticed when my FT3 was above range, (apparently I was making more when I first started on thyroid meds after the surgery)  I felt better.  Not sure why I would now be making less T3 on the same dosage, my fear is I am busy converting to RT3 now and that's why the labs have changed and i no longer feel well..
I only stayed at 2.25 grains for 2 weeks, as the racing heart and high pulse had me concerned.  I had stayed at 2.5 grains for 2 months this past Fall and was not functional at that dosage, didn't get out of the house much.
I suppose I could either split the 15mg tablet, seems silly, but may work in the long run? or give 2.25 grains another try for a longer period of time.  Right now i feel terrible, hard to say if if was from trying the 2.25 grains or from being hypo.  This stuff is NOT FUN, especially when I know I felt good before at this dosage for almost half a year...I have had every test under the  sun done now, been cleared by Rheumatology and Infectious Disease, MRI's, colonoscopy, CT scans, nerve conduction studies, adrenal testign, ATCH stim test and saliva, hormone testing, the list goes on, my insurance is going to cut me off soon :)

[gimel]

No, I would just increase the Synthroid.  If some of that is converted to T3, and shows up as a slightly increased Free T3 level, that is all good.  

When you made the change to 2 .25 grains, how long did you give it to see the effect?  The reason I ask is that sometimes when you get close to your optimum dosage, you have to make increases in very small increments and allow some time to become acclimated.  

[ElleMet]

Thanks!  Going to Dr. tomorrow and going to ask about 25 mcg Synthroid - would you reduce to 1.5 grains Armour with the 25 Synthroid added in?  The frustrating problem for me is I can't seem to raise the Armour - tried 2.5 grains and was miserably hyper.  2.25 grains makes my pulse high and heart race, so I am feeling trapped at a a dose which gives me hypo symptoms.

[gimel]

Since you took meds before blood draw, your Free T3 would be a bit higher than the real average effect on that dose.  So, you have a bit of wiggle room to tweak your Armour upward if you still have hypo symptoms.  I'd be more inclined at this point to ask the doctor for some T4 med to raise the Free T4 level to around the middle of the range.  Also, increasing your Vitamin D, and B12 levels might help.  Don't forget to have the RBC magnesium test at next opportunity.

Suppressed TSH is a frequent occurrence when taking significant doses of thyroid meds.   A suppressed TSH does not mean that you are hyper, unless you do have hyper symptoms, due to excessive levels of Free T3 and  Free T4, which you do not have.   So don't let the doctor be swayed by TSH level.  It is almost meaningless when taking thyroid meds.

[ElleMet]

Thanks for responding!  Should I consider reducing my Armour and adding T4 as my FT4 levels seem low?  ALso, I tried raising to 2.5 grains and was very hyper, raising to 2 1/4 grains seemed OK, but heart is racing - any sense in halfing a 1/4 grain??  My Vit D is up from 18 to 40 - B12 is 660 (250-1100) Iron labs were OK, ferritin high but in range, whereas ferritin used to be out of range before TT.  About to repeat all those labs....

[gimel]

Taking your Armour before the blood draw for the tests will artificially raise your Free T3 level.  It is better to hold off on meds until after the blood draw.  Regardless of that, the important thing is how you are feeling.  

Your tests look pretty good, subject only to the need to tweak to relieve hypo symptoms.  I would suggest that you also get tested for Vitami D, B12 ferritin, a full iron test panel, and RBC magnesium.  Those tests may reveal the need to supplement those levels.