Is Generic T4 the cause of my symptoms

[Flotti]

Total thyroidectomy in Feb 2011 due to rare Hurthle cell found during biopsy in one of the countless nodules on my thyroid. In the 3 years since surgery I have only felt really well for 7 months at the longest. Otherwise, it's been a roller coaster and lots of med adjustments. The last year has been spent reducing my meds as my TSH was consistently hovering at .5.  I take 100 mcg of T4 and 9 mg of compounded thyroid extract. I had been taking Tirosint for my T4 med since 2012. The price increased in the fall of 2013 and my doc changed my T4 to a generic brand Sandoz at the end of Nov 2013. My last labs we're taken 3/7/14 TSH 1.27 and Free t4 1.42. I have had significant lower back pain for two months. I had an X-ray last wk and it showed significant inflammation in both SI joints with possible autoimmune as the cause. My eyes are so dry that as of a month ago I can no longer wear contacts. Bloodwork in Feb showed low iron levels and I am experiencing hypoglycemia and fatigue. I have already emailed my endocrinologist to check my labs again and possibly change me back to Tirosint. My question is could these symptoms all be because of the generic T4? When one experiences joint pain with thyroid issues is there visible inflammation on an X-ray? Is it possible to have great labs but be symptomatic just because the brand of medication doesn't agree with your body?

I will post new labs this wk when I get them.
Thank u!
Tara

[Flotti]

I saw the new doc, who ran a full thyroid panel, and also had my primary run the auto-immune testing.  I have the following results:

All auto-immune testing related to sacroiliitis was negative (Sed rate, ANA and HLA-B27).  

B12 - normal 720 pg/mL    Range: 200-1100
Ferritin was not taken
In additional to formerly posted low iron results I tested low in some minerals:
Zinc   60 ug/dL            Range  62-104
Copper 63 ug/dL         Range 53 - 166

Thyroid Panel:
Total T3   73 ng/dL      Range: 76-181    
Reverse T3  26 ng/dL Range: 8-25
TSH  2.04 mIu/L         Range: .4 - 4.5
Free T3  3 pg/mL       Range: 2.3 - 4.2
Free T4  1.3 ng/dL      Range: .8-1.8

I also tested high on the allergy scale for peanuts and gluten.  I also tested high in IgG Candida antibodies: 1.9 (any value greater than 1 is positive).

I would appreciate any feedback on these results.  I have started on a probiotic, iron supplement and mineral supplement.  I have taken peanuts and gluten out of my diet.  I typically take 4000 IU's of vitamin D per day and have continued to do so.

I saw an ophthalmologist and my eyes are in great health.  Dryness due to long, cold winter in Northeast.

Chief complaints currently: afternoon fatigue, mood swings/anxiety.   GI symptoms resolving (perhaps due to new diet).  SI Joint inflammation improving with PT.  

This is a wonderful forum.  Thank you.

[Barb135]

In my opinion, any doctor who prescribes a T3 med, without running a Free T3 is bordering on malpractice.  Why would anyone prescribe, based on a calculation when they can run the actual test which is far more accurate?  Makes no sense. :-(

Okay, that's off my chest... lol   Rule of thumb is for FT4 to be about mid range; yours is at 63%, which is a bit higher than it really needs to be.  Rule of thumb for FT3 is upper half to upper third of the range (50+%).  You have no FT3 test so we don't know where you are.  I'm guessing that possibly, your FT3 is too low, which is leaving you with symptoms.  Just because you're at the "right ratio" with the numbers, doesn't mean that's right for you; your doctor is treating numbers only. You might find that you could possibly drop back to about 88 mcg T4 and bump up the T3 med by a few mcg.  Since FT3 levels correlate best with symptoms, that might be enough to alleviate yours.

Totally agree that your iron level is low enough to warrant supplementation.  Did you have a ferritin test?  Ferritin is the iron storage hormone.

Blood sugar levels are always something that we need to keep an eye on, whether we have hypothyroidism or not.  Unfortunately, fatigue is one of those symptoms that's shared by any number of conditions, including hypoglycemia, hypothyroidism and hyperthyroidism, along with many others.  One thing that does come to mind is vitamin B12.  Have you had that tested?  B12 deficiency can cause fatigue or total exhaustion.  You might ask your new doctor to test that, as well.  

[Flotti]

Reference range for Free T4 is .93 - 1.7 and my result again was 1.42. My doctor does not believe in getting a Free T3 level.  I am in the process of changing doctors and see the new one on Thursday.  I will ask her to run that test and then post result.

I do not have a full iron panel (again doc on Thursday will probably run more labs) but it's my saturation level that's low at 11% with a reference range of 15-50.  My total iron was 44 mcg/dl in a range of 40-175 so not terrible but enough to warrant an iron supplement and indicate to me that something is potentially off with my thyroid meds as this has happened before.

I eat very healthily; gluten free, low sugar, small meals throughout the day.  I find the hypoglycemia is an issue when the thyroid meds are not at a therapeutic level (high or low).  It's a symptom rather than a regular medical problem for me, which is why I mentioned it.  Is this something that I should always pay more attention to as a thyroid patient though?  In reference to fatigue, I have experienced it whether hyper or hypo though worse when hypo.  

I appreciate your feedback and the general message is...check T3.  My doc prescribes the T3 based on a ratio/calculation to the T4 dose and I am, supposedly, at the right ratio but I don't feel well, which is why I posted.  I will check in with the new doc on Thursday re: T3, iron and initial autoimmune testing.  

[Barb135]

What's the reference range for the Free T4 result?  Ranges vary lab to lab and have to come from your own report.  Do you also have a Free T3 result that you could post, with reference range?  Free T3 is the hormone that correlates with symptoms, while TSH and FT4 do not.

Just to set the record straight, for others who might read this, Sandoz is a manufacturer of generic levothyroxine, rather than a brand name.  If you switched from the hypoallergenic Tirosint to a generic, it's possible that you're reacting to fillers/binders in the pills, but I'd say it's unlikely.

What was your actual iron level?  Iron is necessary for the synthesis of thyroid hormones.

Your fatigue could be coming from the hypoglycemia (low blood sugar).  Are you making sure that you eat at regular intervals to keep your blood sugar levels up?  You should also be eating low glycemic foods to keep your levels stable, not sugary foods that all them to spike, then fall quickly.

Fatigue can also be caused by hypothyroidism, which could still be an issue if your FT3 levels aren't high enough.

Autoimmune issues can show up as inflammation in the body; you might want to ask your doctor to test you for RA and other autoimmune issues.

It's very possible to have good labs and still be symptomatic, though it's not likely to be the different medication.  Because Tirosint is a gelcap, it's dissolved and absorbed better than pill type meds, so it's possible that you'll need a higher dose of the pill than you needed of Tirosint. It's also possibly that you're not converting Free T4 to the usable Free T3, which is causing you to have hypo symptoms.  You need Free T3 test to determine this.