Thyroid Disorders Community
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Avatar universal

Combination therapy and beating a dead horse.

Hey Folks,

I need some more input if you are willing. I've now been hypo for about 3-4 years. I started of sub-clinical (tsh between 5-10) and there was debate if I needed therapy or not. Regardless of that,  I had what seemed to be hypo symptoms.

The main ones for me were, and continue to be fatigue, joint and muscle weakness. I am 36 m. I used to be able to run a marathon after a heavy night of drinking no problems, now I can barely function. I don't know if my symptoms have gotten worse of I am just more aware of my disposition.

I think I have found a good thyroid doctor and I feel like there is trust there.
When my most recent blood work came back, MY tsh was 4 and I didn't even bother asking about the t4. She asked if I had been talking my meds regularly to which I said not really, I had given up being consistent because my symptoms have not really eased away. I've had a HORRID time being stable, and never really have been stable, even when taking meds religiously, I see-saw between hypo and hyper. I've had both my t4-t3 ranges close to the upper limit and not sure I really felt any better.. I know I have had moments when it felt great, but by they I mean moments, like a day when everything aligned just perfect, but I don't know what my numbers were.

I love to work out, that is my happy pill, but these days I can't do it without pulling a muslce, tearning a meniscus and basically just feeling like mr.glass.
More over my gf is extremely outgoing and active, and I like doing all these things but it always feels like to her that I don't like doing these things. The best way I can summarize to her how I feel is that imagine you are out of shape completely and you decide to go for a run, now in about 3mins of running your body just wants you to to stop running and that's all you can think of, stop running. That's how I basically feel, can I just stop running, except for me it might be that we are at dinner or going to a pub or hanging out with friends. I just want stop.

I guess this has turned out to be a long winded rant and basically what I am saying is that I just don't know anymore.
I like the idea of being on NDT but there is a bunch of debate on weather this is effective and have read reports that over-medication can be a bad thing too which is why most docs stay away from combination meds, and that moreover  it's never been proven that combination is more effective than mono therapy.
Even though I just read a study where (if I read correctly) rats reached a truer state of euthyroidism on combination than mono (t4 only.)
So for me it's not a question of natural vs synthetic. I believe they make synthetic to be ( I may be mistaken) close to the same thing the body makes, and in my case I have had t4-t3 above mid normal but I don't think I have ever been stable or have had significant and consistent improvement in my symptoms.

I've been on Armour since last Thursday, and I maybe having a time adjusting. I've had rapid heartbeats and have been up all night last night just wired so now am trying half and half, though with the 30mg grain it's hard to break. And yeah chewing it tastes like burnt flesh.. yuck. I think, after I take it in the morning I do feel good, almost like a high. But then again it maybe just my concept of the t3. I am hoping I settle into this.

Here are my more recent TSH Ranges:
june 2012
T4 Free 1.36 ng/dL 0.76-1.46
T3 Free 4.43 pg/mL 2.77-5.27
TSH 0.371 mIU/L 0.358-3.74

aug 2012
T4 Free 1.58 (H) ng/dL 0.76-1.46
TSH 0.056 (L) mIU/L 0.358-3.74

oct 2012
T4 Free 1.28 ng/dL 0.76-1.46
TSH 2.230 mIU/L 0.358-3.74

mar 2013
T4 Free 1.51 (H) ng/dL 0.76-1.46
TSH 1.720 mIU/L 0.358-3.74

I didn't bother asking for t3 ( I know it's a mantra here) after june since, it looks like I convert ok, even though it seems I need to be on the lower end of tsh to get proper amounts of  t4.. so maybe I do need some t3 therapy. Maybe when feel great, I can run in and get blood work so I know what my levels were that day? I do know the theory is that most people feel good when tsh is about 1 and t4.3 are above mid range, but for people like me who are extremely sensitive to meds and constantly fluctuate am I asking for too much here?

On a side note and I did see a post about hypo and celiac. Incidentaly I have stopped wheat. I never felt good on it and would get the WORST heartburn after taking wheat and I do believe that it can be a cause of may illnesses especially if you take into account that a lot of is now genetically altered. And recently seen a show about how there is a protein in it that our bodies can't digest blah blah blah. Anyways I do thinK I feel better without wheat.
My first app with a functional medicine doc is in oct. IT will cost 600. He don't take insurance but I heard that a lot of docs send their patients to him when they can't figure out what's run. He apparently ran the NASA medical team for 10years etc and they do tests that people never heard of. Hopefully something will come of this.

Any feedback advice support is greatly appreciated.
43 Responses
Avatar universal
My Lab work from last week is

T4 Free 1.19 ng/dL 0.76-1.46
TSH 4.440 (H) mIU/L 0.358-3.74
Vitamin D(1,25 Dihydroxy) 37 (NA) pg/mL 18-64
1756321 tn?1547098925
There is a Danish study showing addition of T3 to T4 significantly improved patients' quality of life (QOL) and depression.

A total of 59 patients (55 women); median age 46 years. When comparing scores of QOL and depression on T(4) monotherapy versus T(4)/T(3) combination therapy, significant differences were seen in 7 out of 11 scores, indicating a positive effect related to the combination therapy. Forty-nine percent preferred the combination and 15% monotherapy (P=0.002). Serum TSH remained unaltered between the groups as intended.

In a study design, where morning TSH levels were unaltered between groups combination therapy, (treated with T(3) 20 microg once daily) was superior to monotherapy by evaluating several QOL, depression and anxiety rating scales as well as patients own preference."

Nygaard, B et al. "Effect of combination therapy with thyroxine (T4) and 3,5,3'-triiodothyronine versus T4 monotherapy in patients with hypothyroidism, a double-blind, randomised cross-over study." Eur J Endocrinol. 2009 Dec;161(6):895-902. doi: 10.1530/EJE-09-0542.


You might Hashitoxicosis (Graves and Hashimoto's combined). Treating this condition is block and replace therapy. Block with anti thyroid medication and replace with T4 or combination T4/T3.  What thyroid antibodies have been tested?

Avatar universal
Thanks for the feedback!
I think TPO or something of that nature and I was borderline Hashis and the doc told me that I pretty much have it. so .

All those results that I posted while ON Synthroid Medication. So I am not sure it is graves too is it?
798555 tn?1292791151
I was like you. Synthroid, no matter what the level, did nothing for my symptoms, just labs. I dont mean to bash it since it does work for most people.

Natural thyroid made my life better. Per labs when I was on synthroid only, I really didnt need much more T3. Tried combo with cytomel anyway, it was not so good for me.

NDT was what I needed, even with all that extr T3.. Armour pre 09 was great for me, then it changed. So i went on Erfa, NP thyroid (USA)should be similar. Not all symptoms are gone though, so additionally I'm looking into other things.

Starting anything with T3 *****. Its harsh for many people till one month out. Start low and work up if you feel better that way.
Avatar universal
Thanks LazyMoose.

I've cut back to 1/2 pill monring and then gonna do half tonight. I heard the same about NP thryoid and it is interchangeable at my pharmacy. I was looking at the tablets of Armour as I heard about the hardness etc. Mine were soft, thought I don't know soft compared to pre-09. I will try NP Thyroid next month once I get blood work. The doc wants to do this for a month and see how I do. It's just so odd to me that the Identical ones don't do well for alot of people too and that NDT does, even though it's not identical.. I guess we are what we eat.  

1756321 tn?1547098925
You might Hashimoto's...geez i really need to proof read my work sometime lol. Hashitoxicosis is a reason for not stabling on thyroid medication.  The antibody under suspicion is TSI (thyroid stimulating immunoglobulins) antibodies (also known as TSH receptor antibodies - TRAb).
1756321 tn?1547098925
Umm i didn't proof read my last answer either haha.
Avatar universal
lol... I got it. Thanks Red_Star.

Am hoping NDT does for me what it has done for many that don't do well on Synthetic.
Avatar universal
For 1 thing it is not  hugely uncommon for someone with Hashi's to swing between Hyper and Hypo especially during the earlyl stages of the disease.  Once the thyroid has been beaten down by Hashi's after a while it usually stabalizes into strictly hypo.

So you might be one of those people who are swinging between hypo and hyper.  Sure sort of sounds like it.

#2) your Vitamin D is also low.  I think most say you want the Vit D3 to be about 60 which is towards the top of the range.

#3) have you ever had your Vit B-12 checked?  Low B-12 can cause very high levels of fatigue.  Also there is an autoimmune disorder called pernecious anemia which causes severe low B-12.  Many people need even to have monthly or even weekly shots of B-12.

Hashi's is autoimmune, and when you have one autoimmune condition you are more likely to have other autoimmune issues. So I would recommend you get checked for Vit B-12, and while you are at it you may as well get your iron and ferritin levels checked.  Again both of these are also related to fatigue.

The B-12 range typically is a VERY wide range, and many people do not feel well until they are well above mid range if not towards the very upper end of the range. So again do not let a Dr. tell you that you are "fine" or "normal" if your level simply falls within the hugely wide range.  Sublingual B-12 absorbs better than swallowing the pill.

#4) I think since you are so sensitive, you may be very sensative to the T3 that you are getting. You  report feeling a slight "high" after taking the Armour.  Well what you are feeling is the T3.  ANd that gets used up and then you sag in the afternoon.  But with NDT medicines since you can not control independently the FT4 and FT3 levels you may be out of balance.  Several people here have reported that when they get thier FT3 levels where it would "seem" to be perfect but their FT4 levels remain very low, they still feel terrible. But when taking NDT and getting their FT4 levels higher there FT3 levels go too high and they feel terrible.

So you may want to try switching to a combination of two separate synthetic drugs, or you could also try reducing your NDT and simply adding more synthetic T4.

But really you cannot make these types of determinations without having BOTH the FT4 and FT3 levels done.  And you cannot really gauge any sort of value on how you convert if you don't have a solid record of having both FT4 and FT3 to see how each dosage change causes a change in each of the individual levels.

You report that you are now splitting your dose.  Remember not to take this last dose of the day too late.  Or the T3 will often cause people to have trouble sleeping or getting to sleep.  Many people can't take this 2nd dose past about 2 or 3PM.  Others it doesn't seem to bother.

#5) Any Dr who treats a patient with T3 and does not take a FT3 level in my opinion borders on malpractice/negligence.  It makes no sense.

Finally, you say that you've had your levels both above the mid point of the range. But do you know if that occurred at the same time?  You may be one of the people where BOTH of the FT4 and the FT3 levels need to be in a pretty specific level.  And regardless how "perfect" one or the other looks, if you do  not have the right combination, you won't feel well.  And if you are not consistently getting both FT4 and FT3 levels tested every time you'll never be able to know that.  Likewise if this is true, then it is nearly impossible without pure luck to be able to achieve this very specific dosage with NDT since you cannot control each hormone individually.

These are just my opinions for you to consider with your Dr.
Avatar universal
thanks Flyingfool, that make alot of sense. I have the blood work coming up in a month and will ask for all those tests.

I guess what I was saying overall was that I don't feel like I have done well on the synthetics and still have the fatigue. At least with the t3 I was feeling good till I was getting those fast heartbeats. I like that high feeling.. ;) ha, better than feeling like crap and tired.

I never new that about vit d, I was told that 37 is a good range so I will up my dose. Right now I am doing about 2000ui a day. Do you have a recommendation of dose?
Avatar universal
Also, this is the first month that I am starting t/3. So if she does not have them I will request them. I suppose I liked the idea of taking t3, but then how do you determine if you need it? I mean I never done well on synthetic. So would trial and error do? Or, looking at my t3 from last time, I was at an optimal level on t4 and t3 so but I am not really sure I felt great at that time.
Avatar universal
Just reading through this thread quickly I didn't see any mention of ferritin level.  Have you been tested for ferritin?  If not, you should make that a priority.  It is important for ferritin to not be in the bottom of the range when taking thyroid meds.  
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