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Please help with symptoms and dosing
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Please help with symptoms and dosing

I'm worried that I'm too much medication because I've had diarrhea for over two weeks now. I have a few nutritional deficiencies and don't want to get more due to this. I also have low, but in range cortisol.

I am on Tirosint 100 and Cytomel 10 (divided dose) for a little over 8 weeks. Before that I was on Levoxyl 100 only (and constipated).

November 5th results at 4 weeks of Tirosint 100 at 7am and Cytomel 5 at 8am and again at 2pm.
I didn't take any T4 or T3 before the blood work at 9:30.

test   result   range  
TSH 0.06     0.40-4.00
FT4  1.0       0.6-1.6
FT3   3.4      2.4-4.2

Since adding Cytomel my T4 has gone down a little. Is this normal?

I still have these hypo symptoms. Some of these have improved, but are still present. I had many more (not listed) that are no longer symptoms. Those that persist are
No sex drive
Exhaustion after minimal effort or exercise
Weight gain
Blurred/worsened vision
High cholesterol
Problems staying asleep through the night (fall asleep easily/instantly)
Cold hands and feet
Feeling cold when others are not (except for when I fist take Cytomel)
Cold in the hands and feet
Irritability, anxiety and depression
Difficulty concentrating/forgetfulness
Tired, low energy
Bloating

My doctor is proposing reducing Tirosint to 88 and leaving Cytomel at 10. Please can I have your opinion? I'm at a loss.

Thanks
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Avatar_m_tn
Just my opinion, but after looking at that long list of hypo symptoms,and your test results, I don't think the problem is just excessive medication, and I wouldn't let the doctor change your dosage.  Ultimately, you need to increase your Free T3 level to relieve those symptoms.  As for your current problem,  it may be that you should have started on half that T3 dosage and increased to the 5 +5 dose after a few weeks, in order to allow your body to accommodate.

At this point, maybe the best approach is to take an Immodium pill after an incidence of diahrrea.  After a few days of that, it might allow your system to return to normal.    Another alternative is that you could back off on your dosage for a short time to allow your body to adjust to the Cytomel, then increase very slowly.  JMHO  

Another thing that came to mind is that I seem to remember that you had an indication of being low in iron.  Is that correct?
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Avatar_f_tn
Hi Gimel,

Thank you for your reply.

I'm sorry, I wasn't clear about dosing. I Started out on only Levoxyl for almost two years. Often my T3 was below range. Then in mid September Cytomel was added (2.5) gradually increased. By October 6th I was on (started) Cytomel 10 and by October 8th I was on Tirosint 100. Before that I was on Tirosint 88 for a week. I didn't have any bloodwork done between going from Levoxyl 100 only to Tirosint/Cytomel combo.

Yes, I'm low iron and copper and supplementing those. My B12 is low, but in range and my D which use to be low is now in range, but I'm still supplementing that and B12.

Here are my iron results which I don't understand.
Test                result      range
Ferritin           7             11-307
Serum Iron    79            28-170
TIBC              404          261-478
%Saturation   19.6         24.0-44.0

Cortisol (8:57am)     8.4           am range 7.7-22.6

I wondered if it's taking Cytomel at 8am and having coffee between 8:30 and 9am that's doing it. Today I had coffee at 8am and Cytomel at 10 pm and no diarrhea.

The doctor thinks that my symptoms are not due to thyroid at this point. He'll lower something and proposed lowering to Tirosint 88 and keeping Cytomel the same.

I had blood work done yesterday and am curious to know how my FT3 and FT4 have changed since November 5th. At that time (four weeks on Tirosint 100 and Cytomel 10) I was constipated and had been for a long time.
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Avatar_f_tn
Is it normal for FT4 to go down when you add T3?

Thanks
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Avatar_m_tn
Have a look at this chart of iron tests and diagnoses.  Based on your test results, it appears that you could have iron deficiency anemia.  Are you a vegetarian?

http://www.irondisorders.org/Websites/idi/files/Content/854256/FActsAnemia.pdf

I am also sending a link by PM.  It is a good discussion of the importance of iron.

I wouldn't expect FT4 to go down due to adding T3 meds.  How much did your FT4 go down?  
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Avatar_f_tn
Hi Gimel,

Thank you for the link and pdf. I'll read them today.

I am a vegetarian. I'm now mindful of not having iron rich foods with dairy and am adding a vitamin C source when eating iron rich to increase absorption.

I'm also supplementing with 18 mg chelated Iron gluconate. I was taking one a day at 7pm, but will start taking it at 12 pm also. It's okay to take near Cytomel, but four hours from Tirosint right?

I also take it away from Copper and have now started supplementing with Zinc to keep my Copper/Zinc ratio in balance.

Here are some previous labs.

I was likely alternating Levoxyl 100 with 112 here (many hypo symptoms, but former doctor convince me I was hyper. I have a different doctor now who prescribes Cytomel). After these labs my former doctor reduced my Levoxyl to 100 (again).
May 7, 2011
Test Name   Result Normal  
TSH  0.21    0.40-4.00
FT4  1.3       0.6-1.6
FT3  2.6       2.4-4.2

On Levoxyl 100 from October 16, 2010 until this blood test (many more hypo symptoms)
December 30, 2010
Test Name   Result Normal
TSH            1.19 0.40-4.00
Free T4        1.1 0.6-1.6
Free T3        L 190 210-440
T3 Total (RIA)         82 76-181
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Avatar_m_tn
I wouldn't worry about the drop in FT4.  Test variability could be part of it.  Also, since you have been taking some supplements, it could be that you were converting some of the T4 a bit better.

Sorry if I'm covering some things previously discussed, but I also wondered if you have gotten your Vitamin D and B12 levels into the upper part of their ranges.
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Avatar_f_tn
Hi,

Don't apologize, even if it was covered I wouldn't mind going over it again. You help dozens of people daily and I wouldn't expect you or anyone to remember my details. I don't remember my details!

May 7, 2011
test     result      range
D        30           30-80

Nov 5, 2011
D         51          30-80
B12     284         180-914
Copper 65          80-155

I am supplementing all of these still. My Zinc is in range (but low in the range). However, my Zinc to Copper ratio is good and I've read that that's important so I'm now supplementing with Zinc too.

I can't believe I told my doctor I've been having diarrhea for two weeks and today I didn't. It might be taking Cytomel at the same time as coffee or it's something else. But, he will change my medicine since he wanted to do that because of my low TSH and I begged him not to until he read articles I brought him. I also had list of my symptoms... what's improved, what hasn't etc. and he looked at it carefully. But, he wanted me to be retested and if my TSH stayed the same then, he'd change something. I hope my body is converting better and that correcting these deficiencies (that I know about) will help with continued symptoms and converting.

If he HAS to change something then should it be reducing my Tirosint from 100 to 88 or Cytomel from 10 to 7.5. I think he's also be willing to reduce Tirosint to 88 and add an additional Cytomel 5 since that's what he said at my last visit. But, I think Cytomel 15 would be too much for me.

I wish I hadn't told him, but having diarrhea for over two weeks worried me and I have been so easily stressed and so worried about having other autoimmune conditions (diabetes 1 since I'm afraid of needles) it's such a production to even go and do blood work.
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Avatar_f_tn
Because of "Exhaustion after minimal effort or exercise" symptom he also orderd cpk and aldolase.

At the last visit, he said that he doesn't think my symptoms are do to thyroid at this point. I know he said that because of my TSH
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Avatar_m_tn
I'm glad to see that your Vitamin D is much better now.  I do think your B12 is way too low.  From what I've read the upper third of the range would be much better for you.  

As for the TSH, many patients find their TSH suppressed when taking thyroid meds.  I don't know if I have mentioned it previously to you but my TSH has been about .05 or less for well over 25 years without ever having hyper symptoms.  In fact I was taking 200 mcg of Synthroid and still had hypo symptoms.  After finding out about the importance of Free T3 on the Forum, mine was tested and found low in the range.  My meds were changed to Armour and after some tweaking, my Free T3 is 3.9 (range of 2.3 - 4.2) and I feel best ever.  

I have some good links about TSH suppression not being a concern.  I'll track them down and post later.  They might be of use for you with your doctor.  
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Avatar_m_tn
This link would be a good place for your doctor to start to understand that TSH suppression is not necessarily a problem.

http://www.altsupportthyroid.org/tsh.php

And then this page from the same source.

http://www.altsupportthyroid.org/tsh/tshmedrefs5.php

Here's another written by a doctor.

http://www.drlowe.com/frf/t4replacement/critique2.htm

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Avatar_f_tn
Hi Gimel,

I found links of yours on a post to LazyMoose when he had low/below range TSH and doctor wanted to lower his meds. I also found a bunch from the link you just PM'd me and some on pubmed. I brought these and many other articles to my doctor. He took them, but I don't know if he read them.

But, I've been having diarrhea (which I'm concerned about) and now he know this and he will reduce my meds since he wanted to do that anyway. If the diarrhea goes away then I'll fight him on this, but It's just a matter of time until I see him again (January 3rd unless he has a cancellation) and he reduces my meds. I haven't had any weight loss with this so that's good I guess? I'm almost overweight now where as before going hypo I wasn't.

I didn't take any T3 or T4 the morning of the test so my FT3 might be higher than what the test shows right? Since my last dose of T3 was at 2pm and the test was at 9am? In the event that he does lower one of the two then which should it be?

I know no one wants to see me hypo and being under-medicated/not properly medicated is a big concern for us, but maybe lowering my T4 or T3 might still be okay? I don't know though and don't know which one if there HAS to be one.

He didn't lower my T4 meds at all when he added T3.

Thanks again for your help.
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Avatar_f_tn
I was writing my (long winded) reply as you sent you message - sorry about that.
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Avatar_m_tn
In view of your symptoms, and your FT3 and FT4 levels, there is no reason to lower your meds.  The doctor is only thinking of doing it because of the suppressed TSH level.  You might ask him what he thinks is the supposed jeopardy.  If it is heart related, then that is easy to respond to.  If it occurs, then you just reduce your Cytomel.  If it is osteoporosis concerns, tell him that thyroid hormone does not cause bone formation or loss.  Higher levels of thyroid hormone, and higher metabolism, will only speed up whatever condition exists for either bone formation or loss.  

Here is another link to a letter written by a good thyroid doctor.  I'm sure you've seen it because  I use it so often.  It has some great info about TSH suppression.

http://hormonerestoration.com/files/ThyroidPMD.pdf
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1202943_tn?1347844252
Have you ever tried cutting gluten from your diet?  It might be a little hard since you a vegetarian. For some people gluten can cause constipation or diarrhea. It can also cause some deficiencies.  I feel much better when I don't eat gluten.  Just a though!
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Avatar_f_tn
I see your point. My only (possibly) hyper symptoms is diarrhea and I still have a lot of hypo symptoms.

In reading a bit more about Copper and Iron in the last few days I've found that iron and copper work together and that a deficiency in either causes anemia.

It's possible that my low copper or my unusually heavy periods these last few years is contributing to low iron . My periods are lighter since adding T3.

I'm wondering if copper is low not because of my diet, but because of a problem in absorption? Maybe too little stomach acid, but I don't understand it all enough to know.

To little stomach acid might be contributing to diarrhea also, but I don't understand it enough to know. Before adding cytomel I have been mostly constipated for almost two years except when on Levoxyl 125, a dose that was too high according to TSH results, but my FT3 and FT4 weren't tested.

When someone's T3 is in the upper 1/3 of the range - is it like that most of the day or does it depend on when their blood work was done?
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Avatar_f_tn
Hi Ericamegan,

I've never tried gluten free for any meaningful amount of time, but I've been tested for celiac and all tests came out negative. I guess I can still be sensitive to gluten though. Right?

I went through a period where I ate more glutenous products. Coincidently it coincides with my going hypo. There was a time where my husband thought I didn't like bread. Then our living situation changed and I was suddenly eating a lot of bread and sweets, but there were so many other changes at that point in my life including a lot of stress.

I think I should give it a try. Did you go gluten free or cut back. How long before you saw benefits? Did you have nutritional deficiencies that improved?

These days I'm not eating a lot of gluten, but it's admittedly harder around the holidays.
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Avatar_m_tn
I have seen a study that showed that Free T3 followed the Circadian rhythm exhibited by TSH.   The swing in levels of FT3 was much lower than the swing in TSH level from its high around 9 pm and low around 9 am.  So, FT3 hit its peak around 11 PM, apparently in preparation for getting the body up and moving in the morning.  

Obviously, this does not work the same when you are taking T3 med.  With T3 meds,  the effect grows gradually and then dissipates, over about an 8 hour period I think I remember.  That is why it is recommended to split a T3 dose in half and take in the morning and early afternoon.  Also why many members don't take their T3 med until after blood draw for thyroid tests.  
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Avatar_f_tn
I took mine after my blood draw. I've started taking Cytomel later in the day at 11am and 2pm instead of 8am and two pm, but nothing's changed with my BM. I'm still having diarrhea in the morning (before Cytomel).

I'm going to give up coffee (again) for a few days and see what happens.

It's just odd that it's happening even with the addition of iron which is suppose to be constipating.
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Avatar_m_tn
First off I'd hate to see the Dr. change your medication levels.  Your FT3 & FT4 levels many of the people here would kill to have. Not saying they are perfected for you. But in general the results are pretty darned close to what people generally start to feel well.

I agree with gimel that the ONLY reason why the Dr. wants to change dosage is because of the TSH.  This is further proved by his statement that he doesn't think the symptoms you are having is Thyroid related.  If he REALLY believes that, why the heck would he want to change the dosage?

Sometimes Hypo symptoms lag behind your lab results.  I personally would be tempted to do nothing with the medications and just try to relax and be patient.   If he HAS to lower something to make him feel well.  I would recommend only the T4 med.  I think based on your history it appears you have some conversion problems so that reducing your T4 may not have a big effect of dropping your FT3 levels.  So it it makes your Dr happy then all the better.  Likely what will happen is your TSH will almost be unchanged next time because the T3 med and your FT3 levels won't be much changed. And thus your Pituitary won't really sense a need to change the TSH level.  So they you may have "proof" that TSH is not a problem.  Or if you do go Hypo more with the reduction you will have "proof" that TSH is unreliable indicator for you.  So you may have proof either way that TSH is virtually worthless.  And that may finally convince your Dr.  (or maybe not!!!!)

I could never be vegetarian so I give you a ton of credit.  But being a veggie you have to also make sure that you are getting sufficient protein.  Also you may be getting huge amounts of fiber depending upon what your diet is made up of.  That could cause loose stools.

Iron is very difficult to absorb from what I understand.  So to raise it a person typically has to take very large doses as so little actually gets absorbed into the body. Same with B-12 from what I understand.  Some people need to get weekly injections of B-12 in order to actually get enough.

If you have regular coffee with Caffeine then you may want to wean yourself off or you may end up with headaches from the withdrawl (withdrawal) symptoms.

If you are used to having caffeine in the morning it can take awhile to get used to not having it.  Trust me I know.  I eliminated caffeine because I was having PVC's (pre ventricular contractions) which is a fluttering of the heart.  One I stopped caffeine these went away.  But I had to wean myself off the caffeine over a couple weeks.  I started by going with a 50/50 or half caf coffee.  Then over to full decaf.

Now if I get tired and have a cup of coffee or soda with caffeine, MAN does it work!  I seem to be able to have caffeine for a couple days in a row before I notice the heart contraction thing again.  So I have the option of a quick pick me up when I "need" it.
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Avatar_f_tn
Hi Flyingfool,

Thank you for your input/experience.

He wanted to to lower my dose based on TSH after my last labs in November, but I convinced him to wait and retest hoping he'd read the articles I left.

I'm concerned about the diarrhea and now he knows about it too. I've been thinking about lowering T3 to 7.5 and taking it three times a day, but they are hard to divide evenly and have made a positive difference. My doctor said to lower T4, but I don't have an appointment with him until January 3rd so nothing is going to change until then although I'm also tempted to lower something.

My diet hasn't changed much if at all in the last few months, but I went from being constipated with sometimes no BM for several days to this.

The symptoms that I still have are not as severe as they were before Cytomel. Only the top five have no improvement. I'm also not losing weight despite my BM.

At this point I really want to eat meat and fish. I've been trying and have eaten some crab cakes, less than an ounce of sole etc. I think eating red meat and liver would be especially difficult, but I've been considering fresh made broth and blocking my nose. I'm not a "typical" vegetarian in many ways as it's mostly psychological at this point - I've been this way since I was a child, but I feel it's working against me health wise. My BUN (lab) is low, but in range.

I've gotten B12 injections many years ago and then did nothing for a long while. Now I'm supplementing with tablets (16,000% the daily value), but haven't been retested since I started. The iron is only 100% daily value so today I took three, but I have only been taking one which seems like it won't be enough. My doctor seemed hesitant to suggest I take iron and I'm not sure why. The only deficiency he seemed motivated to do something about was B12. He mentioned shots. I'm afraid of needles so told him I'd supplement. He was iffy about everything else and wants me to go to another lab when we test copper again because it's not commonly tested and the problem could be with the analysis. He said he doesn't know much about copper deficiency, but I trust he'll read up on it.

I get massive Caffeine headaches. I've gone from 3 cups regular to 1 cup regular and 1 cup decaf.

That's great that you found the connection with PVC's and coffee and that you were able to quite a regular coffee habit - it's hard to do.

Maybe my FT3 would still be good at with 7.5 Cytomel instead of 10 since I had the blood test 19 hours after my last dose?
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Avatar_f_tn
The pdf about iron you sent is excellent and helped me understand what hours of reading didn't.

I've not been supplementing with enough iron. I have been taking only 18mg. Yesterday I took three tablet and today I was constipated.

I'm also leaning towards keeping my dose the same - thanks for all your's, flyingfool's and Ericamegan's input. It might be a fight with my doctor, but I'm going to see how things go until then.

It could be one of the supplements that's causing it for all I know.

Until recently, I've been under-medicated from the beginning of treatment. That may have well contributed to some the nutritional deficiencies and other problems I'm having now especially with iron (heavy periods).

Thank you guys again
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649848_tn?1357751184
Meat, eggs and dairy products are major sources of both iron and Vitamin B12, and deficiency in either can cause some pretty tough symptoms.

Do be aware that too much iron, can be just as bad as not enough.

If you had vitamin B12 shots before, you many need to have them again.  Although I have to do my B12 shots weekly, this is not the norm.  B12 is typically administered weekly for 3-4 weeks, then reduced to once/month.  The needles are quite small and really not painful at all; I administer my own shots.
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649848_tn?1357751184
Are you supplementing with selenium to help with conversion?
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Avatar_f_tn
Hi Barb,

Now, I have eggs, yogurt and milk regularly. My B12 was fine last year, but I may have been supplementing then? Having blood work/needles cause me such a massive amount of stress that I really rather supplement with tablets. Not sure why I had the injections instead of tablets way back when (about 15 years ago now), but I must have been very low.

When I triple the 18mg iron tablets it's still less than the ones they prescribe for anemia, but are over the counter.

Here are my iron results.
Test                result      range
Ferritin           7             11-307
Serum Iron    79            28-170
TIBC              404          261-478
%Saturation   19.6         24.0-44.0

I triples iron for two days in a row now, but today I wasn't constipated (yesterday I was) so I don't really know what's going on with my body.

I've read that copper helps iron get where it needs to be, but I don't have enough copper still. I'm trying to figure out where the problem starts? In my stomach, intestines or something else?

I eat bazil nuts for the selenium. I haven't had them in ages, but have started again. I have been well over the range for selenium when I was eating them regularly in the past.

I have also added a probiotic which I'll take at night before bed, but so far I've only taken it once a few days ago and then forgot.

I haven't changed anything with my medicine, but do go back and forth about weather or not I should.
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Avatar_f_tn
I have read your threads and unless you are a licenced doctor  experienced with endocrinology, i would not diagnose anyone with this serious problem.

I too have this and am finding a holistic practitioner who specializes in this the natural way.

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