Meds before testing

[AquaClara]

Hello...new to the forum.  I've been hypothyroid for about fifteen years.  The best I have ever felt was when I was taking 180 mg Armour Thyroid.  Weight stable...good energy, digestive system good, blood serum levels for cholesterol were very much improved - dr was ecstatic with that!  While having my cholesterol tested, also had blood drawn for thyroid  - since it hadn't been tested in a while.  Of course had to fast for the cholesterol test, and had taken my thyroid medication that morning.  My doctor almost had a coronary when he saw thyroid results.
TSH:  0.008.  (Range 0.350-4.500)
Free T4:  1.80 (range 0.80-1.80)
Free T3: 9.9 (range 2.3-4.2)
Immediately took me off the 180 and decreased it to 150 mg. and it has been downhill since.  Follow up test, blood was drawn in the afternoon after medication was taken in the morning.
Results:
TSH:  0.008 (range 0.350-4.500. -  ranges listed again for convenience)
Free T4:  1.42 (range 0.80-1.80)
Free T3:  4.6 (2.3-4.2)
Would not prescribe Armour again but prescribed a new synthetic called Tirosint, 137 mcg.  
Have gained 10 lbs, muscle and joint aches, digestive issues, bloating, swelling, tired....feeling horrible!
I have an appointment with an Endocrinologist this Friday.  My question is should medication be taken on the day of testing?  Also, is T3 being really high that bad?  I felt really good...no heart palpitations, racing heart, slept well.  Another question...I've heard people are getting better results from taking their medication at night?  Has anybody had any luck with that?  I kind of feel that it is too close to dinner, but digestion is different when sleeping.  I really appreciate any comments.  

[AquaClara]

Hi Barb135,

I really try to watch what I read.  I thought this was through Mary Shoman's website but possibly could have been redirected to another portal.  That article also listed a lot of references at the end.  But have to say it was that article that finally put me over the edge.

I called the drs office for the ranges used, which brings another question to mind.  How can a person be properly diagnosed hypo, euthyroid, or hyper if ranges vary from lab to lab?  That's crazy.  When I first started reading, I thought all drs went by the range set forth by the American Thyroid Assoc or such other medical society.

Anyway...  Here are my results again along with the ranges used.

TSH  -  0.0200. -  (.3000 - 5.000)
Free T3. -  2.790  -  (2.300 - 4.2)
Free T4. - 0.750. -  (.500 - 1.400)

Thanks so much for taking the time to answer my concerns.
Aqua Clara

[Barb135]

Different labs use different measures and different ranges?  Yes, they do, so we need to know the reference ranges from your report, as we always have to compare your results to the ranges on your report.  If the ranges are similar to what we, typically, see, your levels are very low in the ranges, indicating that you need an increase in med.

The TSH of 0.02 indicates, basically, nothing, because TSH is a pituitary hormone and is often suppressed when one is on a T3 med, such as Armour.  It only means you're over medicated if you have symptoms of hyperthyroidism.

I have no idea why the person who wrote the article you read would say that TSH, FT3 and FT4 are unreliable for gauging dosage for someone with Hashimoto's... that's just plain silly.  While TSH is irrelevant, FT3 and FT4 are the gauges we go by, along with symptoms.  FT3 had been found to correlate best with symptoms.  

Even if you've never had thyroid antibodies tested, I wouldn't be the least surprised if you have Hashimoto's, as it's the number 1 cause of hypothyroidism in the developed world.  Many doctors just assume that anyone who is hypo has Hashimoto's.  

One has to be very careful when reading on the internet.  While there's a wealth of information to be found, a lot of it has to be taken with a grain of salt.  If something doesn't make sense try to find other articles or studies that back it up.

[AquaClara]

Hello!  My thyroid saga continues…    Spent a wretched amount of time on 150 mgs. Armour...long enough to have labs done correctly this time.  However, the results returned are still confusing and I’m worried the doctor will still view my results as I am being over-medicated

TSH – 0.0200            
Free T3 – 2.790        
Free T4 – 0.750        

I am completely confused.  The more I read, the more confused I get.  Different labs use different measures and different ranges?  Articles on interpreting lab results are different from article to article.  I just finished one article saying that 0.02 with normal being from 0.5 to 5.5 was an indication of being under-medicated  (http://www.thyroid-info.com/articles/woliner.htm).   I thought 0.02 was an indication of pituitary hormone suppression and suppression meant over-medicated.   The same article stated that for a person with Hashimoto’s these tests are unreliable for gauging dosage.   (I’ve been hypothyroid for about 15-20 years and have been told by three different doctors that I have Hashimoto’s although no tests have been performed to prove this.  However, I have seen my thyroid on an ultrasound while it was compared to a healthy gland and mine looks atrophied.)

My original doctor has agreed to revisit my situation with new lab results.  He is who I have the best rapport.  I want to be as knowledgeable and informed as I possible.

I am very interested in hearing your comments.

Thank you,
Aqua Clara

[Red_Star]

"T3 containing medications (such as desiccated thyroid or Cytomel) cause a peak in Free T3 levels a few hours after ingestion (42% within the first 4 hours), and then a decline until the next dose. [1]  Even T4 medications like Synthroid or levothyroxine cause a small bump in thyroid levels a few hours after a dose (16% rise in Free T4 with no change in free T3)."

- Tired Thryoid - Thyroid Lab Results are Affected by the Time of Your Last Dose.

***

"Results: Sixty-five patients completed the study. The mean thyrotropin concentration was 1.06 ± 1.23 mIU/liter when levothyroxine was administered in the fasting state. When levothyroxine was taken with breakfast, the serum thyrotropin concentration was significantly higher (2.93 ± 3.29 mIU/liter). When levothyroxine was taken at bedtime, the serum TSH concentration was also significantly higher (2.19 ± 2.66 mIU/liter).

Conclusion: Nonfasting regimens of levothyroxine administration are associated with higher and more variable serum TSH concentrations. If a specific serum TSH goal is desired, thereby avoiding iatrogenic subclinical thyroid disease, then fasting ingestion of levothyroxine ensures that TSH concentrations remain within the narrowest target range."

Timing of Levothyroxine Administration Affects Serum Thyrotropin Concentration  J Clin Endocrinol Metab. Oct 2009; 94(10): 3905–3912.

[Barb135]

No, I don't agree that TSH wouldn't be affected, because there are so many variables that can affect TSH.  It can vary by as much as 75% over the course of a day.  Free T3 is really the only thing that would be affected, because the Free T4 in your system, today is actually what you took a couple of weeks ago.

Since you had taken your med prior to having the blood draw, it's reasonable to wait a few weeks to let everything stabilize then retest, without taking your med first.  The problem with waiting is your symptoms that will only worsen.  

I'd start looking for another doctor right away; maybe you'll find one who can get you in sooner and is willing to retest right away.

[AquaClara]

Hi Barb,  thanks for your comments.  I think I will start to find another doctor.  My old dr. forwarded the results from the past few blood tests that had been drawn under his orders.  This new doctor made his decisions based on those tests knowing that I had taken my medication prior to both of them.  He said it would affect the free T3 and free T4 but not the TSH.  (Clarification:  The last test, blood was drawn around 3 pm, but had taken med that same morning; then the test before that one was the one where I took med about an hour prior to blood being drawn).  Do you think that is correct that the TSH would not be affected?  New dr. wants to wait 6 weeks before doing another test.
Thank you again for your comments.  Best regards...AC

[Barb135]

Of course, you need a doctor who is willing to work with you as far as symptoms and not just relying on TSH.  

"The doctor I just saw said of course I was going to feel better with that much Armour"... I can poke a hole in that comment real easy... not everyone would feel better on that much Armour; some of us would be having very dangerous symptoms of over medication and since you didn't, he should be able to see that you actually "need" that much Armour.

Actually, if you are in the U.S. you can interview a doctor.  Find one you think might sound promising, then call the office and ask to speak to either the doctor or her/his main nurse or NP.  The following questions:

1)  What tests are routinely done?  Answer should be FT3/FT4 and TSH.
2)  Whether the doctor places as much importance on FT3/FT4 and symptoms as s/he does on TSH?  Answer should be yes.
3)  If the doctor is open to prescribing whatever medication makes the patient feel best at therapeutic levels, including synthetic T3 only meds AND desiccated hormones.  Answer should be yes.

You can ask other questions if you like, but those are the most important ones.  Sometimes, you might have to speak with an office manager or something, but if they don't seem to know what you're asking or what they're talking about don't bother with them.  

[AquaClara]

Good morning Barb135,  what you are saying makes so much sense.  Although I don't want to go doctor shopping, I would like to find one who is on the same page with me.  One who is considerate of my symptoms.  The doctor I just saw said of course I was going to feel better with that much Armour, but it sounded like feeling better was a bad thing. I am not opposed to being monitored for bone loss, heart rate, etc, but would like for them to work with me according to symptoms and not numbers.  It's not like I can interview a doctor to find out what practice policies they follow, so other than word of mouth, how do you find the right doctor for what you need?  

Thank you so much for you comments.

[Barb135]

Many doctors think that suppressed TSH causes osteoporosis and all kinds of other "ills".   That's just simply not true.  TSH is a messenger hormone, produced by the pituitary to stimulate the thyroid.  It neither causes nor alleviates symptoms.  Once the thyroid has been destroyed, TSH becomes irrelevant, because no amount of TSH is going to make it produce hormones.

If levels of FT3 get too high, the increased metabolism can contribute to osteoporosis, heart issues, etc.  People who have hyper symptoms often have rapid heart rate, palpitations, which lead to heart issues, if not treated.  

You have no evidence of any of these things happening.  My TSH has been at < 0.01 - 0.01 for the past 6 yrs and I've never been hyper or had hyper symptoms.  My endo does request that I do a bone density scan periodically, but the one, time before last, showed that I'd actually rebuilt bone, with a program of exercise and calcium supplements and the last one showed that I'm maintaining that.

Your symptoms - joint pain are those of not having enough hormones.  Hopefully, back on the Armour, you will do better.  

Just remember not to take any medication with T3 in it, prior to blood work.  You might also think about splitting your Armour dose into multiple doses through the day, as that will help keep levels stable throughout the day.

As to whether your doctor is making sense - yes and no... Yes, because he put you back on the Armour and if things stabilize he'll keep you there .. No, because of his knee jerk reaction to your low TSH and his thoughts about it causing osteoporosis and heart issues.  I, personally, might give another chance, but I'd probably be on the look out for another doctor in case he continues to be fixated on the TSH.

[AquaClara]

Have been traveling on business so couldn't post earlier, but I did go to my apt with the endocrinologist.  He didn't order a blood test but had been sent my previous test results from the previous doctor.  Long story short was he wasn't concerned about the free T3 or free T4 but that the TSH was suppressed to 0.008.  He did say that prescribing the 137 mg of Tirosint was way below to the equivalent of Armour that I should be taking and prescribed 150 mg of Armour and told to have labs done in 6 weeks to see if an adjustment is needed.  Wants to see the TSH levels come up.  Said of course I would feel better with the extreme levels but it wasn't healthy.  And that in spite of not having hyperthyroid symptoms, studies show that people with suppressed TSH levels were more likely to suffer osteoporosis, kidney (or was it liver?) problems, or heart failure.  He did take a look at my thyroid through a sonogram and confirmed definite  Hashimotos.  I'm not sure he noticed, but when taking the 180 and the 150 Armour, both times the labs came back as the same 0.008 TSH.  I feel okay in my head, but joints...neck, shoulder, elbow, hip, knee...all are sore.  Digestive issues even with probiotics, yogurt... And the lovely weight gain and water retention.  I guess my question is does it sound like the dr is making sense or should I carry on to find another?  Thanks to all...I really appreciate your comments.

[Red_Star]

I posted the wrong name. :)

[Red_Star]

Translation: don't take thyroid medication prior to testing to avoid higher than normal lab results which may lead to unnecessary drop in thyroid medication.

[jacrjacr]

I agree with barb, doesn't sound like you were overmedicated to me. I never take my meds before blood test.
Always take blood test first thing in the morning.
this way you will have most accurate results without recent meds spiking your test results falsely. I am shocked your dr didn't ask about this but on the other hand < I am more shocked doctors know so little bout common sense things about being hypothyroid and medication.
I also take first thing my meds in the morning, and don't eat for 30-60minutes and take my meds with water.

[AquaClara]

Hello Barb135,

I did miss your post at first.  Sorry...I'm new at this.  Yours was easy to understand but I was at work and could only type small segments at a time, so my response may sound choppy, but nonetheless appreciated.  I feel so much better hearing from everybody.  I didn't think or feel like I was over medicated but what do I know?  Well, now I do know better!  Thanks again!

[AquaClara]

Hello Barb135,  thanks for your comments.  Very interesting...and going forward will not take meds prior to testing and will plan to have blood drawn first thing in the morning.  Sounds like you have it worked out pretty well.  I was very stable when taking the 180 Armour...always took it first thing after rising and really didn't have anything else for about an hour.  My husband also takes thyroid meds - Synthroid - but doesn't have half the symptoms I have and his dr. told him to take it at night.  Plus I had read something saying it was advisable, so hence the reason for my question.

No, didn't feel hypothyroid.  Felt a good normal.  Digestion issues were a thing of the past and I've struggled with that issue for years.  

I'll talk to the endocrinologist on Friday.  Thanks for your response.

[Barb135]

Not sure if you missed my post between sblythe and Red_Star or not, but it might be a bit easier to understand.

Your Armour was doing what it should have been doing; just that your timing for taking your med and getting the blood work was off.

[AquaClara]

Ah ha...so, if I'm reading this correctly, the Armour Thyroid was doing exactly what it should be doing?  Or, it seems that the levels are gauged on a different scale?  Sorry...not sure I understand.  Translation for a layperson, please?  Thanks for responding to my question.

[AquaClara]

Thank you so much for your comments!  No...definitely not on the thin side.  Would be pleased as punch to lose about 35 lbs.  I will definitely discuss this with the endocrinologist and hope he is willing to work with me.  Do you know when thyroid meds should be taken prior to testing?  I think that's why my first test was showing free T3 as being so high.  I had taken my medication on an empty stomach about 1-2 hours earlier.

[Red_Star]

Thyroid Manager - Adult Hypothyroidism...

"9.8.1 PHARMACOLOGY OF THYROID HORMONE REPLACEMENT PREPARATIONS

Levothyroxine.

"Serum T4 concentrations peak 2 to 4 hours after an oral dose and remain above normal for approximately 6 hours in patients receiving daily replacement therapy 5,6 . The gradual conversion of T4 into T3 in various tissues increases serum T3 concentrations so slowly after thyroxine absorption that with daily levothyroxine administration, no significant changes in circulating free T3 are detectable."

***

"Before the first dose of T3, serum T3 levels were 153 +/- 43 mg/100 ml; after T3 the levels increased promptly reaching after 4 h a peak of 264 +/- 90 ng/100 ml. Afterwards T3 levels showed a similar peak after each dose: 262 +/- 77 and 266 +/- 78 ng/100 ml, slightly decreasing in the intervals between the doses: 227 +/- 63 and 255 +/- 69 ng/100 ml. After the last peak T3 levels showed a slow decline during the night."

- Twenty-four hour variations of triiodothyronine (T3) levels in patients who had thyroid ablation for thyroid cancer, receiving T3 as suppressive treatment. J Endocrinol Invest. 1980 Oct-Dec;3(4):353-6.

[Barb135]

In a word - no - one should not take medication containing T3 prior to a blood test because it causes false high readings.  T3 has a very short half life and it peaks within 3-4 hours of taking it then leaves your body, if not used.  Had you not taken the med prior to the blood draw, your level would most likely have been in the normal range and your doctor would have been happy.  I take a generic synthetic T3 med and when I have blood drawn, I go ahead and take my T4 med, but wait with the T3 until after the draw.  Since I always do my labs first thing in the morning, my schedule is not upset.

Just because your TSH was suppressed and your FT3 over range, does not mean you were hyperthyroid.  Lab numbers don't make you hyper; you're only hyper if you have hyper symptoms and you weren't; therefore you weren't hyperthyroid.  

Tirosint is a relatively new gelcap. Because it's a gelcap, its dissolved more fully than pill type meds and it's absorbed better.  Because of the increased absorption, many people find they have to start at a lower dose.  I've been on it since it came out in May 2009 and I love it, but I do have to add a T3 med with it, because I don't convert well. Also take into consideration that it does take 4-6 weeks for any dosage/med change to take full effect.

Had you been taking your entire dose of Armour all at once, in the morning?  Most of us on a T3 med find that splitting it into multiple doses throughout the day, keeps T3 levels more stable, since T3 med peaks within a few hours, then is gone.

I have to disagree, somewhat, about it not being necessary to take med on an empty stomach.  First off, the manufacturers wouldn't put those instructions on the med if there weren't a reason for it.  Secondly, if the meds are absorbed better and more consistently on an empty stomach, why would one not want to do that in order to get the most benefit from their med?  Personally, I, typically take my Tirosint when I first get up, then  it's usually about 15 minutes before my coffee is done and I do go ahead and drink coffee, but I don't eat anything.  Consistence is the most important thing -- if you routinely eat 15 min after med, you might actually require an increase in med in order to make up for the lost absorption.  Since my TSH lives in the basement, my doctor, for sure, would not increase my med just because I refuse to take it on an empty stomach as directed.

[sblythe]

Yours is a very difficult question to answer. A lot of physicians don't like the Armour Thyroid, but lots of patients feel better on it than on the synthetics, which for the most part just provide the T4. Then there is the issue of your levels. Obviously you were hyperthyroid. But the "normal range" for thyroid levels is extremely wide, and although you were outside the normal range on the high side, you were not (from what you say) having hyperthyroid symptoms. Now that you are normal you are gaining weight, etc. If you were extremely thin on the previous dose, then I would agree with your physicians that this is better, but if your BMI (body mass index) was normal, your heart rate was always normal, etc, it is a hard decision to change the dose just because of the blood tests when you feel good on it. Discuss all this with the endocrinologist.  Lately there has been a lot of emphasis on taking thyroid supplements on an empty stomach, but this is silly. The supplements may be absorbed better and more consistently on an empty stomach - but for the most part it doesn't make a huge difference and I have patients who have been on a stable dose for 20 years based on how they feel and normal blood levels that are now being told that they are taking their medication wrong!