Can anyone interpret labs? Is my TSH dangerous?

[sagesparrow]

Hi!  I started feeling sick in February, and here are the corresponding labs.

First labs run, in April:
T3 Free: 1.7 [range 2.2-4.0]
FT4: 0.77 [range 0.93-1.70]
TSH: 1.15 [range 0.27-4.20]

I was sent to an endocrinologist and they started me on 100 mcg Synthroid, and 25 mcg Cytomel. In 6 weeks, we ran labs again.

TSH: 0.020 [range 0.35-4.50]
T4, FREE: 0.91 [range 0.89-1.76]
T3, FREE: 3.1 [range 2.1-4.2]
Anti-Thyroid Peroxidase: <28 (reference range <60)
Anti-Thyroglobulin: 20 (reference range <60)
TSI: <89 (baseline <140%)
Thyrotropin-binding INHIB Immunoglo: 20 (H) (reference range <17)

So now, after 6 more weeks on 100 mcg Synthroid and anywhere from 5-15mcg a day on Cytomel, here are my latest labs:
TSH 0.033 (range 0.35-4.5)
FT3 2.4 (range 2.3-4.2)
FT4 1.18 (range 0.89-1.76)

Is that very, very suppressed TSH a problem??  I'm freaking out about it.  I have had palpitations at night, especially after eating.  I also have a fine tremor.  Temp is low (97), BP is very low (80/40).  Otherwise feeling a bit sluggish but ok.

Thanks!

[goolarra]

I'm confused...I thought you were taking 5 mcg Cytomel in the morning and another 5 mcg early afternoon.  

Only you know how you feel; I can only look at your labs and say that it doesn't look like you should be lowering either.  

What's your resting HR?

I have what I call "TSH guilt".  I told you that my TSH stays around 20.0, and I KNOW I have to ignore it, but it still bugs me!  LOL

Do you have a link to the articles you found?  I'd love to read them.

[sagesparrow]

Hi! So then, palps about 4 hours after last dose of 1.25 mcg... And ONLY after eating (so frustrating), from the Cytomel? Should I lower my dose? Or maybe lower my Synthroid dose?

And also, HR of 130ish while walking (again, brisk, uphill mostly), not safe?  

So confused. :(

I found some articles today re: TBII and TSH suppression. I guess I just have to trust that TSH is useless on me huh? Or should I be 'listening' to these symptoms and lowering dose? It's hard to say, since I'm still feeling hypo most of the time.

[goolarra]

I don't thin it's just the contrast from your previously very low HR to your current HR that you're feeling.  Yes, sometimes people who have had very low HR FEEL like their HR is fast when it gets back to normal, but yours really IS high at 130.  It shouldn't be that high, and it is not normal for Cytomel.

There are other issues besides pituitary tumors.  I have pituitary resistance to thyroid hormone, which keeps my TSH around 20.0...obviously NOT suppressed!  Trauma (blood loss) can exacerbate autoimmune response.  Thyroid antibodies can be "somewhat elevated" (a term never defined) if you have another autoimmune disease.  So, lupus could explain your "in range", but "somewhat elevated" results.

TBII blocks TSH from binding to receptors, inhibiting thyroid hormone production and causing hypothyroidism.

Palps are tricky because they can be symptoms of both hypo and hyper.  So, the question is are the palps due to the Cytomel, per se, or to the drop in FT3 levels that occurs several hours after taking it?  Technically, if they happen within the first 3-4 hours after taking it, I'd be more likely to attribute it to the Cytomel, itself.  If later, it might have more to do with the drop in FT3 once the T3 is neutralized???

[sagesparrow]

Hi again, goolara!  Thank you!

My doctor has seen the antibodies results.  At first he said normal, then he said TBII was blocking TSH receptors, then he said Hashi's.  I honestly got the impression that he was just grasping at straws, since I am a weird case.  However, I DID read TBII can falsely lower TSH reading.  Is this possibly what is happening in my case?

Anyhow, doctor called again today and said to lower Synthroid to 75mcg.  I outright refused.  I said not until we run more tests, as I feel that my TSH is falsely low.  I'm waiting for yet another call back now (sigh).

Also, my pharmacist said essentially the same about T3… it's like a "multivitamin", as your body makes/needs it anyway, and you're just supplementing what your body is not producing anymore.  

So, my other question is... after about 5-6 hours or so… any palpitations I feel are NOT from Cytomel?

[sagesparrow]

Hi flyingfool, thank you for the advice!

I usually split my Cyto dose in two… 5 mcg at 8-9AM, 5 mcg at 1 or so.  My anxiety has been getting the best of me, which is probably from the Cytomel (and all the bad doctoring lol), but I am getting better at managing it and recognizing the Cytomel is helping a lot.  The only thing I will say is that my pulse shoots way up when I even go for a light walk (like 130bpm).  Normal for Cytomel?  Or maybe I was just so used to having a pulse of 35-40 for so long, before treatment!!  

I actually had been the one who suggested a possible pituitary problem, but the doctor said it was unlikely.  He ended up running the prolactin and some other sex hormones, which were suppressed -- but he said normal, due to me being on birth control pills.  Are there other pituitary issues besides a tumor?  Could the blood loss of surgery have damaged things?  I also have been previously diagnosed with lupus.  Could this be attributing?  In general, the doctors think I have an auto immune response.  I am not sure where my doctor is getting Hashimotos…

But The TBII antibodies did come back high.  What are those?

Thanks!!

[goolarra]

You had all three of the tests for antibodies, and they were all negative.  So, it doesn't look like autoimmune thyroid disease to me (not a doctor, of course).  Had your doctor seen these results when he said that?

This happens to a lot of people.  TSH is suppressed by meds, and then their doctors want them to reduce dosage, which makes them feel sick again.  Your FT3 and FT4 are both on the low side.  TSH is NOT (for whatever reason) accurately reflecting your FT3 and FT4 levels.  You don't have hyper symptoms.  Don't let him reduce your meds!  (Easier said than done, I realize.)

Cytomel goes to work as soon as it gets into your bloodstream, depending on your metabolism, probably in less than half an hour.  It peaks at about 3 hours and is mostly gone a few hours after that.  It all depends on your metabolism, but it doesn't hang around long.

T3 is more potent than T4, and it's faster acting, but it's not really a "drug" at all.  It's an exact chemical replica of the hormone your body would be converting if it were able to.  It's a little trickier to use than T4 because of its fast nature...

FT4 should have stabilized at 4-6 weeks.  Sometimes, though, FT3 will continue to rise for a while afterwards as conversion ramps back up.

[sagesparrow]

Oh also -- if I have been on Synthroid for about 12 weeks or so now, at 100mcg, will my FT4 continue to rise?  Or has it "stabilized" now?

[sagesparrow]

Hi!  Thank you for your very informative, and stress-reducing, answer!  lol

My doctor said he looked at pituitary, and thinks it is NOT that.  Though we have never done any imaging or anything.  He basically ran a prolactin and did some other tests that he said "rule it out".  Though I did have surgery before I started getting sick, and I lost blood during surgery.  I wonder if that didn't damage something.

But anyway, he thinks it is auto-immune in nature.  From what I have read, TSH can also be falsely reflected by antibodies?

However, he wants to lower my dosage in 6 weeks if TSH doesn't come up.  I'm not sure how I will feel about that.  :(  I feel sick when I lower dosage.  I tried coming off Cytomel and did not feel well at all.

I do split my Cytomel dose.  I have been taking 5mcg at 8AM, and then 2.5 or another 5 (depending on how I feel) around 1PM.  Do you know how quickly Cytomel works, btw?  I have heard conflicting answers and I am trying to get my head on straight about it.

If I take 5 mcg of Cytomel at say, 8AM… by what time is it actually working in my body, and by what time is it completely depleted?

Also, is it a dangerous drug??

Thanks a bunch!

[goolarra]

NO!  The very suppressed TSH is not a problem.  TSH is nothing but a messenger from your pituitary to your thyroid to tell it to produce more thyroid hormone.  TSH, per se, causes NO symptoms.

Your FT4 is still on the low side, at 33% of range.  50% is the guideline for FT4, based on where many of us found symptom relief.  FT3 is right on the floor of the range, very low of the 50+% guideline for FT3.  According to those guidelines, you could use an increase in meds.

Do you split your T3 into more than one partial dose?

I would guess that you might have a pituitary issue going on (perhaps secondary hypothyroidism).  Looking at your April labs, your TSH is very "normal", while your FT3 and FT4 are both below range.  Your TSH should have been much higher.  This is another reason that TSH should not be a concern for you.

Secondary hypo is actually a pituitary problem.  Your pituitary doesn't produce enough TSH to stimulate your thyroid to produce enough hormone.