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Low T4 while on Cytomel for depression
My question is whether having a very low free T4 is harmful when taking Cytomel? About a year ago I was started on Cytomel by my psychiatrist as an adjunct for resistant depression. I had my TSH tested in the past to screen for thryoid problems, but they had always been "normal" (lab range 0.27-4.20 mIU/mL, results = 2.61 in 2010 and 2.87 in 2013).
The Cytomel worked really well for my depression and my energy increased. But, in March 2013, I had several bouts of heart palpitations and I went to my family doctor. My family doctor was against me being on Cytomel and told me that the Cytomel was causing my heart palpitations. At that time and while on the Cytomel my labs were: TSH 0.33 (range 0.27-4.20 uIU/mL), free T3 2.71 (range 2.57-4.43 pg/mL), and free T4 0.24 (range 0.92-1.57 ng/dL). I was ordered to immediately stop taking the Cytomel and I underwent an EKG in the office, a stress EKG, and 48 hours of Holter monitoring. All the heart tests came back normal (I wasn't told more than this). 9 weeks later and after being off the Cytomel during this time, my thryoid labs were: TSH 3.64 (range 0.27-4.20 uIU/mL), free T3 2.79 (range 2.57-4.43 pg/mL), and free T4 0.57 (range 0.92-1.57 ng/dL). I was told to have my levels checked again in 6 weeks.
By summer of 2013 I was feeling very depressed again, and my family doctor had left her practice, leaving me without a family doctor. My psychiatrist again suggested starting Cytomel, since we had been reassured by my normal heart tests. I started the Cytomel again and started feeling better again. In August, 2013, I went for a physical with a new doctor in the same practice. She was very against the Cytomel and also stated that by reviewing my labs she thought I might actually BE hypothyroid and need Synthroid (T4 replacement). I was on the Cytomel again and my labs were: TSH 0.79 (range 0.27-4.20 uIU/mL), free T3 2.92 (range 2.57-4.43 pg/mL), and free T4 0.25 (range 0.92-1.57 ng/dL). She told me to stop taking the Cytomel and I started on 25mcg of Synthroid. 6 weeks later my depression was worse, with suicidal thoughts. I had my thryoid labs repeated while I was on the Synthroid and they were: TSH 2.40 (range 0.27-4.20 uIU/mL), free T3 2.79 (range 2.57-4.43 pg/mL), and free T4 0.85 (range 0.92-1.57 ng/dL). My new doctor told me to start taking 50mcg of Synthroid since my T4 was still too low. A week later I was so depressed I was unable to work, had no energy, and was in a very dark mental place. My family doctor reluctantly agreed to let me start the Cytomel again. My psychiatrist started me on 25 mcg of Cytomel. I felt better for one day, and then everything went down hill. I started having night sweats, shaking, constantly sweating during the day, chills, some wheezing at night when laying down, and a productive cough. My temperature never went higher than 99.0 F. I called my family doctor and I was told to stop the Cytomel and continue the 50 mcg of Synthroid, but I wasn't asked to come in and no labs were ordered.
I didn't understand this advice, since my symptoms seemed to indicate I was going hyperthroid from too much thyroid medication. I finally had enough, I stopped both thyroid meds, and I made an appointment with a new doctor at a different practice who was recommended by my psychiatrist (but it will take 3 weeks to be seen).
The Cytomel was really helpful and I want to start again, but my question is whether the low free T4 levels I have while taking it will be harmful? I'm also not sure what my lab results mean, since everything I've read says that a low T4 is normally accompanied by a low T3 and high TSH. I don't know if I really have hypothyroidism or not, and if I do, would it be better to start on a combination of T3/T4, but with lower doses?
The Cytomel worked really well for my depression and my energy increased. But, in March 2013, I had several bouts of heart palpitations and I went to my family doctor. My family doctor was against me being on Cytomel and told me that the Cytomel was causing my heart palpitations. At that time and while on the Cytomel my labs were: TSH 0.33 (range 0.27-4.20 uIU/mL), free T3 2.71 (range 2.57-4.43 pg/mL), and free T4 0.24 (range 0.92-1.57 ng/dL). I was ordered to immediately stop taking the Cytomel and I underwent an EKG in the office, a stress EKG, and 48 hours of Holter monitoring. All the heart tests came back normal (I wasn't told more than this). 9 weeks later and after being off the Cytomel during this time, my thryoid labs were: TSH 3.64 (range 0.27-4.20 uIU/mL), free T3 2.79 (range 2.57-4.43 pg/mL), and free T4 0.57 (range 0.92-1.57 ng/dL). I was told to have my levels checked again in 6 weeks.
By summer of 2013 I was feeling very depressed again, and my family doctor had left her practice, leaving me without a family doctor. My psychiatrist again suggested starting Cytomel, since we had been reassured by my normal heart tests. I started the Cytomel again and started feeling better again. In August, 2013, I went for a physical with a new doctor in the same practice. She was very against the Cytomel and also stated that by reviewing my labs she thought I might actually BE hypothyroid and need Synthroid (T4 replacement). I was on the Cytomel again and my labs were: TSH 0.79 (range 0.27-4.20 uIU/mL), free T3 2.92 (range 2.57-4.43 pg/mL), and free T4 0.25 (range 0.92-1.57 ng/dL). She told me to stop taking the Cytomel and I started on 25mcg of Synthroid. 6 weeks later my depression was worse, with suicidal thoughts. I had my thryoid labs repeated while I was on the Synthroid and they were: TSH 2.40 (range 0.27-4.20 uIU/mL), free T3 2.79 (range 2.57-4.43 pg/mL), and free T4 0.85 (range 0.92-1.57 ng/dL). My new doctor told me to start taking 50mcg of Synthroid since my T4 was still too low. A week later I was so depressed I was unable to work, had no energy, and was in a very dark mental place. My family doctor reluctantly agreed to let me start the Cytomel again. My psychiatrist started me on 25 mcg of Cytomel. I felt better for one day, and then everything went down hill. I started having night sweats, shaking, constantly sweating during the day, chills, some wheezing at night when laying down, and a productive cough. My temperature never went higher than 99.0 F. I called my family doctor and I was told to stop the Cytomel and continue the 50 mcg of Synthroid, but I wasn't asked to come in and no labs were ordered.
I didn't understand this advice, since my symptoms seemed to indicate I was going hyperthroid from too much thyroid medication. I finally had enough, I stopped both thyroid meds, and I made an appointment with a new doctor at a different practice who was recommended by my psychiatrist (but it will take 3 weeks to be seen).
The Cytomel was really helpful and I want to start again, but my question is whether the low free T4 levels I have while taking it will be harmful? I'm also not sure what my lab results mean, since everything I've read says that a low T4 is normally accompanied by a low T3 and high TSH. I don't know if I really have hypothyroidism or not, and if I do, would it be better to start on a combination of T3/T4, but with lower doses?
Hello,
I am so sorry to hear that these doctors took you off of Cytomel (T3) hormone and put you on a T4-only drug given your symptoms and lower-than-optimal T3(active hormone) levels. It seems to me that you may have been suffering from high reverse t3 issues (where the ratio of free t3-reverse might have been less than 20) while in t4 drugs. NDT or t3-only drugs will be a better option for lowering reverse t3 levels, and they should have checked those levels on you!! You shouldn’t have to live in depression that comes with being in what is clearly a hypo state. Please fire any doctor and find a new one when they do or order a full thyroid panel that includes free t4, free t3, Rt3, and antibodies for Hashimoto’s or Graves!! And if they ignore symptoms and sinlply only go by bloods!! You deserve to feel great!! :) best of luck! Also...make sure they test your cortisol with a 24-hour cortisol saliva test to rule out any adrenal/ HPA-axis dysfunction as you will need to have the right amounts of cortisol at the right times of day to support both thyroid and adrenal glands working together to get you healed.
I am so sorry to hear that these doctors took you off of Cytomel (T3) hormone and put you on a T4-only drug given your symptoms and lower-than-optimal T3(active hormone) levels. It seems to me that you may have been suffering from high reverse t3 issues (where the ratio of free t3-reverse might have been less than 20) while in t4 drugs. NDT or t3-only drugs will be a better option for lowering reverse t3 levels, and they should have checked those levels on you!! You shouldn’t have to live in depression that comes with being in what is clearly a hypo state. Please fire any doctor and find a new one when they do or order a full thyroid panel that includes free t4, free t3, Rt3, and antibodies for Hashimoto’s or Graves!! And if they ignore symptoms and sinlply only go by bloods!! You deserve to feel great!! :) best of luck! Also...make sure they test your cortisol with a 24-hour cortisol saliva test to rule out any adrenal/ HPA-axis dysfunction as you will need to have the right amounts of cortisol at the right times of day to support both thyroid and adrenal glands working together to get you healed.
I agree that all signs point to hypothyroidism until overdosed on T3. I would only add that it would be a good idea to test for Vitamin D, B12, and ferritin. It is important for hypo patients to have all three of those well up in their ranges. Also, might be a good idea to broach with your doctor the idea of a 4 sample (24 hour) saliva cortisol test.
depression and anxiety are associated with low (hypo) thyroid.
But Barb is right. Cytomel is not an antidepressant. But many people who are depressed because of low thyroid, getting your thyroid levels optimized can minimize or eliminate depression. but that is no gurantee, but at least a possibility.
The fact that your depression lessens when on a thyroid medicine (T3 cytomel) would lead you to believe getting your thyroid levels optimized may have a positive effect for you.
I too agree with Barb. 25 mcg of Cytomel is HUGE dose. And many people here have reported that they need to have a pretty narrow balance between Free T4 and Free T3. And yours are definately askew with FT4 very low and FT3 higher.
When you removed Cytomel and increased and went on T4 only meicine I think your FT3 level was about the same if not slightly higher. What that tells me is that you appear to be converting OK. So it makes complete sense to me to try to slowly work up your T4 dosage by as Barb says with a smaller T3 cytomel dosage taken twice a day.
This process will be slow. The more "traditional" of maybe common process for thyroid is to go the exact opposite route. It is to start out on a T4 only medicine and work up the dosage until you either feel well or you get to 50% of the range. At that point the addition of cytomel (T3) is added SLOWLY.
But Barb is right. Cytomel is not an antidepressant. But many people who are depressed because of low thyroid, getting your thyroid levels optimized can minimize or eliminate depression. but that is no gurantee, but at least a possibility.
The fact that your depression lessens when on a thyroid medicine (T3 cytomel) would lead you to believe getting your thyroid levels optimized may have a positive effect for you.
I too agree with Barb. 25 mcg of Cytomel is HUGE dose. And many people here have reported that they need to have a pretty narrow balance between Free T4 and Free T3. And yours are definately askew with FT4 very low and FT3 higher.
When you removed Cytomel and increased and went on T4 only meicine I think your FT3 level was about the same if not slightly higher. What that tells me is that you appear to be converting OK. So it makes complete sense to me to try to slowly work up your T4 dosage by as Barb says with a smaller T3 cytomel dosage taken twice a day.
This process will be slow. The more "traditional" of maybe common process for thyroid is to go the exact opposite route. It is to start out on a T4 only medicine and work up the dosage until you either feel well or you get to 50% of the range. At that point the addition of cytomel (T3) is added SLOWLY.
In a very large study, they found over 95% of healthy people (aka no signs or symptoms of thyroid disease) had a TSH under 2.5mU/L. When my existing hypothyroid symptoms (cellular hypothyroidism with NO labs to show it) worsened, I requested a full work up and found my TSH (1.4 or 1.5mU/L for decades) was now in the mid 2's and I had elevated thyroid antibodies. Hashimoto's thyroiditis had shown up! Grrrr
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It's really too bad that your psychiatrist didn't check your levels prior to putting you on the cytomel in the first place. That was pretty irresponsible, since cytomel should never be given without close monitoring.
When everything is working like it should, when thyroid levels get low, the pituitary gland produces TSH to stimulate the thyroid. The thyroid then responds by producing the hormones T4 and T3, but mostly T4. Of the T4 produced, a large portion of it is bound by protein and unavailable for use. The remainder of the T4 (unbound portion) is the Free T4, which is then converted to T3. Again, of the T3 in your body, a large portion of it is bound by protein and unavailable for use; the remainder (unbound portion) is the Free T3 and is the hormone that's actually used by the individual cells in the body.
It's very uncommon to take a T3 med, only. Since you were on the T3, only, med, it kept your TSH level down, so your thyroid stopped producing T4.
As you can see, your FT4 level is actually below the lowest portion of the range, meaning it's WAY too low. Rule of thumb is to have FT4 at about mid range, so you can see that yours has a long way to go. Looking at all your labs, I'd agree with your primary doctor, that you really are hypo and do need medication.
When one is put on thyroid medication, it's typical to be put on a T4 med and bring FT4 levels up, then if one is not converting adequately, T3 med (cytomel) is added.
25 mcg of T3 is a huge dose. Add that to 50 mcg synthroid and it's no wonder you had hyper symptoms. If you took it all at once, I'm sure you got quite a jolt. A starting dose of T3 is, typically, 5 mcg, increased as needed by about 2.5 mcg at a time. If you want to take the cytomel, talk to your doctor about starting low and increasing in very small increments; it's very unlikely that you need a full 25 mcg/day.
Additionally, it's best to split the dose into multiples throughout the day... for instance, I'm on 10 mcg T3, with 88 mcg T4. I take my T4 med first thing in the morning, on an empty stomach with water. About 30 minutes later, I take 5 mcg T3. About noon, I take the other 5 mcg of T3.
T3 is faster acting than T4 and only stays in the system for a few hours; by splitting the dose you keep the levels steady throughout the day, rather than getting one huge jolt, then running out before the day is over.
Whenever you have blood work done, don't take the T3 med until after the draw, or it can show falsely high levels.
It might not hurt to get off all the thyroid med for a couple weeks to get it out of your system, have labs again to see where you are, then you can start the meds again. Talk to your doctor about this.
Be aware that cytomel is not an anti-depressant; your psychiatrist was definitely using to "off label". Cytomel is very powerful and can be dangerous if not administered and monitored by someone who knows proper testing and dosage.
Whenever you have labs, always be sure they do, both the Free T3 and Free T4, along with TSH.
When everything is working like it should, when thyroid levels get low, the pituitary gland produces TSH to stimulate the thyroid. The thyroid then responds by producing the hormones T4 and T3, but mostly T4. Of the T4 produced, a large portion of it is bound by protein and unavailable for use. The remainder of the T4 (unbound portion) is the Free T4, which is then converted to T3. Again, of the T3 in your body, a large portion of it is bound by protein and unavailable for use; the remainder (unbound portion) is the Free T3 and is the hormone that's actually used by the individual cells in the body.
It's very uncommon to take a T3 med, only. Since you were on the T3, only, med, it kept your TSH level down, so your thyroid stopped producing T4.
As you can see, your FT4 level is actually below the lowest portion of the range, meaning it's WAY too low. Rule of thumb is to have FT4 at about mid range, so you can see that yours has a long way to go. Looking at all your labs, I'd agree with your primary doctor, that you really are hypo and do need medication.
When one is put on thyroid medication, it's typical to be put on a T4 med and bring FT4 levels up, then if one is not converting adequately, T3 med (cytomel) is added.
25 mcg of T3 is a huge dose. Add that to 50 mcg synthroid and it's no wonder you had hyper symptoms. If you took it all at once, I'm sure you got quite a jolt. A starting dose of T3 is, typically, 5 mcg, increased as needed by about 2.5 mcg at a time. If you want to take the cytomel, talk to your doctor about starting low and increasing in very small increments; it's very unlikely that you need a full 25 mcg/day.
Additionally, it's best to split the dose into multiples throughout the day... for instance, I'm on 10 mcg T3, with 88 mcg T4. I take my T4 med first thing in the morning, on an empty stomach with water. About 30 minutes later, I take 5 mcg T3. About noon, I take the other 5 mcg of T3.
T3 is faster acting than T4 and only stays in the system for a few hours; by splitting the dose you keep the levels steady throughout the day, rather than getting one huge jolt, then running out before the day is over.
Whenever you have blood work done, don't take the T3 med until after the draw, or it can show falsely high levels.
It might not hurt to get off all the thyroid med for a couple weeks to get it out of your system, have labs again to see where you are, then you can start the meds again. Talk to your doctor about this.
Be aware that cytomel is not an anti-depressant; your psychiatrist was definitely using to "off label". Cytomel is very powerful and can be dangerous if not administered and monitored by someone who knows proper testing and dosage.
Whenever you have labs, always be sure they do, both the Free T3 and Free T4, along with TSH.
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