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Side effects when increasing Synthroid dose

I am starting my third week of Synthroid increase from 175 mcg to 200 mcg.  Is it normal to still feel exhausted but also have a little chest pressure and muscle aches.  Should I give it another week to settle down?  My labs prior to increase were:
Tsh 3.33 (.27-4.2)
Ft4 1.4 (.9-1.7)
Ft3 2.6 (2.0-4.4)
Rt3 38 (10-24)
My rt3 was high but I was battling flu and bronchitis. Endo increased and will re check everything in a month... but I'm so miserable with these symptoms. However if I just need to ride them out than I will.  
16 Responses
Avatar universal
I would say that any hypo type symptoms you have are not side effects of the dose increase, but are due to inadequate level of Free T3, compounded by excessive Reverse T3.  Many of us have found that we needed Free T4 to be at least mid-range, and Free T3 to be in the upper part of its range, and adjusted from there as needed to relieve symptoms.  Your Free T4 is adequate, at 62% of its range, but your body is not converting the T4 med to T3 adequately, as evidenced by your Free T3 being at only 25% of its range.   In addition your RT3 is way over range.  Combined with your low Free T3 this means your ratio of Free T3 to Reverse T3 is only .7 (2.6 times 10 divided by 38).  The general  recommendation is that the ratio should be at least 1.8, so your ratio is way too low.  

I am very skeptical that the high RT3 is solely due to flu/bronchitis.  If you look at Recommendation 9, starting on page 12 of the following link you will find some useful info on RT3, including some potential causes for excess levels.  You will also note that "Successful treatment usually entails first correcting any identifiable cause and then symptomatically reducing T4 excess and gradually increasing T3 levels until RT3 approaches the middle of its range and Free T3 the upper part of its range."


http://www.thyroiduk.org.uk/tuk/TUK_PDFs/diagnosis_and_treatment_of_hypothyroidism_issue_1.pdf

For you I think you need to reduce your relatively high dose of T4 med and add a source of T3.  That would help in two ways:   Less T4 is available for conversion to RT3 and the added T3 will increase your Free T3 level.  If it were me I would ask the Doctor to reduce your T4 by 50 mcg and add 20 mcg of T3.  Note that if you do so, it should be done in two steps about 2 weeks apart, since T3 affects you much faster than T4.

In addition, hypothyroid patients are frequently deficient in Vitamin D, B12 and ferritin.  So if not tested for those, I highly recommend doing so and then supplementing as needed to optimize.  D should be at least 50, B12 in the upper end of its range, and ferritin should be at least 100.  Note also that ferritin levels have a significant effect on conversion of T4 to T3.  

Do you think your doctor would be agreeable to this?  
11 Comments
Thanks for all your insight.  I agree my t4 med needs reduced and some cytomel added in.... however I have not been able to convince my endo of this.  This is the first time he has even checked my rt3. I have been begging him for past 4 years.. lol. I really think he checked it to shut me up, and surprise I was right!!!  He wants me to wait a full month on this increase and retest, but I'm so tired of this game. He is normally pretty open minded with most of his patients. Not sure why he is being so stubborn with me. I guess I will try to hang in there another week then redo labs... ugh. I wish doctors had to have this disease before they could treat us.  Thanks again!!
You might consider giving the doctor a copy of the link I gave you, and ask him to review the material and consider making the recommended changes.  All the info in the link is supported with extensive scientific evidence, so it is hard to refute, even though it is different than how doctors usually diagnose and treat hypothyroidism, based mostly on TSH, and T4 med only.  
Yes, that is a great idea!  Do you think by him increasing the synthroid, the rt3 would have gone up higher?  It's strange, some things seem better: sleep is so deep, legs hurt less but I keep getting this yucky chest feeling.  
Yes, if the conditions exist for T4 to be converted to excess RT3, then the additional T4 will result in additional RT3.  Hard to diagnose a "yucky chest feeling"  LOL  However, I have no doubt that you will feel much better when you get your relatively low Free T3 and your high RT3 optimized.

In prep for giving the doctor a copy of the paper, it would also be a good idea for you to read at least the first two pages, and more if you want to get into the discussion and scientific evidence.  That would better prepare you to discuss with the doctor of what needs to be done for you.  If that fails, and you need to find a good thyroid let us know.  We have access to some lists of doctors that have been recommended by other thyroid patients.
Thanks gimel!!  I had a terrible night waking in panic every hour. My chest pounding and feeling lightheaded. I think this 25 mcg jump is too much for me.  
Yes, a recommendation for good dr would be great. The current one I'm dealing with is semi retired, so I will need to look elsewhere soon anyways.  Thank you for all your time you dedicate to all of us.  
Where are you located?
Duh, that might help...lol!  I totally can't think this past few weeks!!  I'm in rehoboth beach, Delaware. We don't have many to choose from, so my guess is I will have to travel. Thanks again.
Just sent you a PM with info.  To access, just click on your name and then from your personal page, click on messages.  
Had my labs done yesterday afternoon per dr.  Everything stayed exactly the same EXCEPT the ft3 dropped from 2.6 to 2.4. I honestly think it has to be the rt3 issue.  Have appt Monday to discuss this all. Fingers crossed.  
When you see the doctor I suggest that you emphasize having symptoms and feeling bad still and that your FT3 is now only at 16% of its range while FT4 is at 62% of its range, and your RT3 is way over range.  All that is a clear indication that conversion of T4 is out of whack.  Suggest that from the paper the best approach would be to reduce your T4 dose by 50 mcg and add about 20-25 mcg of T3.  If you can push him to do that then make the change in two steps as described above.  

Also try to get the Vitamin D, B12 and ferritin tests done.
So I just talked to nurse from endo.  He said rt3 is not important unless it's low. Wants me to go back to 175 6 days a week and nothing on day 7 and recheck in 4 weeks.  I'm so very frustrated and guess I need to just move on to a new doctor at this point.
Avatar universal
I have no idea where an Endo would come up with that idea.  He needs to read Recommendation no. 9 starting on page 12 of the link above, and the supporting scientific evidence.  

I agree that you should not waste any more time with that doctor.  You need a good thyroid doctor that will treat clinically, as previously described.  

Please keep in touch and let us know how you are doing.

I just had an idea.  Is there a compounding pharmacy in your nearby area?
2 Comments
Yes we do have a couple compounding pharmacies... why?
Sending you a PM with info.  To access, just click on your name and then from your personal page click on messages.
Avatar universal
Gimel
I had an unexpected call from my endos nurse asking me to come in this afternoon.  I am praying we can have a intelligent discussion on this rt3 topic and he will change my meds. He is a brilliant doctor and I originally went to him bc he was so willing to try different things with some of his patients I know.  If I can't convince him of cytomel/synthroid combo, do you think armour would help with this issue. I know he prescribes and prefers armour.
Avatar universal
Btw by his increasing my synthroid 3 weeks ago, my rt3 climbed higher and my ft3 fell.  
1 Comments
If that is the only option he will consider, then yes Armour would be okay.  Keep in mind that the equivalent of 200 mcg of T4 is 3 grains of Armour.  This is covered in Rec. no. 6 in the link I gave you.  I mention this because most doctors follow the erroneous conversion table that shows one grain of NDT is equal to 100 mcg of T4.  That conversion would give you too little Armour.  

If the doctor does make a change to Armour, he might only reduce some of your T4 and add the equivalent Armour.  Make sure that the change is consistent with one grain of Armour for every 66 mcg of T4 med.  

I think it would also be a good idea to take a copy of the link and give it to the doctor, if he needs to be persuaded on anything.  
Avatar universal
So I left endo with a script for cytomel and he would like me to go back down to 175 mcg synthroid. Praise God he was with me on this!!  Now he said take 10 mcg cytomel in a.m. And 5 mcg in afternoon.  I am thinking of starting slower, what do you think??  He feels I am very hypo, thus all the crazy symptoms returning.
Avatar universal
The 10  + 5 = 15 mcg of Cytomel is the equivalent of 45 mcg of T4.   Plus the half life of T3 is less than a day, while the half life of T4 is about a week.  So if you just reduce your Synthroid by 25 mcg, you won't get the full effect of that on serum levels for 4-5 weeks.  Meantime you will get the full effect of the Cytomel dose in 4-5 days.  

Seems to me that  the 15 mcg of T3 (equivalent to 45 mcg of T4) should be offset with a comparable reduction in T4.    And yes, you should phase in the Cytomel, maybe 5 mcg a week.  

So now the Endo thinks you are hypothyroid because of symptoms, in spite of taking a large dose of T4.  Took a long time for him to get there.  What did he have to say about your Reverse T3 level and its effect on your symptoms?
Avatar universal
Well, I could just take the 175 mcg tablets six days a week, thus equaling 150mcg. Maybe I will try that. I'm not sure what changed his mind other than maybe my prayers!! Lol!! I went in with all this info and prepared a speech in my head, and he said let's try cytomel.  About fell off the table!!!  I do remember trying to add cytomel in my dose of 150 mcg a couple years ago. I got such terrible headaches.  It that common at first?? I was trying 5 mcg a day back then, split in two doses.
1 Comments
So he had no comment about the RT3?

Sounds like a plan.  I think I do recall some people having headaches on T3 when first starting on it.  If you get a reaction to T3 it would be a good idea to test for cortisol.  Also, don't forget the importance of testing for Vitamin D, B12 and ferritin and then supplementing as needed to optimize.
Avatar universal
Thanks...I will keep you posted. I do currently take vit D and B12.  Ferritin has been good. Thanks for all your help/info. And no, he didn't bring up rt3 and neither did I since I got what I wanted..lol
Avatar universal
So I started the cytomel yesterday. I decided to start slow. I took 2.5 mcg first thing in morning and was incredibly dizzy and almost "drunk" feeling. Very spacey. So at afternoon dose, I only took a quarter or 1.25 mcg. Tolerated it better but still felt a little off. So this morning I took 1.25 at 5:30 upon waking and tried the other 1.25 in 5 hours.   Omg, about an hour later I was so dizzy I could barely stand and heart was racing.  I am super sensitive to meds.  Should I just start with the 1.25 mcg for a bit, push through, or could it be that t3 won't work. I did try a few years back and I think I started with a quarter pill then.  I don't want to give up and really want this cytomel to work.  Advice?!?
Avatar universal
Have you ever been tested for cortisol?
1 Comments
Yes, results were normal :(....frustrated with my body.
Avatar universal
The range is very broad.  What was the result and the range shown on the lab report?
1 Comments
I'm sorry, I don't have results anymore. I had test done twice. Once by my primary and once at john Hopkins. I am super sensitive to any meds though. A quarter of a xanax knocks me out for a full day. Same with a beta blocker we tried once.  Smallest dose almost killed me.
Avatar universal
I have to wonder if the reaction to the small dose of T3 was related to cortisol.  You say you are super sensitive, yet you are taking a large dose of T4 med.  Did you have any reactions when starting on that?
2 Comments
Oh yes!!!  I had to creep up from 12.5 mcg. Took me over 3 years to get to 175mcg.
I'd start with the lowest dose and increase slowly to get up to where you need to be.
Avatar universal
Help please!!!  Started with 1.25 mcg of the cytomel in morning and again at 3. I keep getting a racy heart and dizzy when I stand. Then as soon as the dose wears off I get hit with swelling/pain and exhaustion. It is normal to feel this way for a week or so??  Will it calm down?  I really need this to work!!
Avatar universal
Only two things I can think of.  One is to try only 1.25 per day and give it a few days to see how that works.  The other is a question:  can you get tested for cortisol and ferritin?
2 Comments
I could get tested again on my own. I'm pretty sure my endo will not do it.  I am ready to give up!!  I know I need more med bc I have such terrible hypo symptoms. This happened a couple years ago every time I would increase. Had to increase synthroid at like 3 mcg at a time. I have tried to take iron in past just in case, but it makes me so sick to the point of vomiting. Even tried the children's iron.
I really think it would be worthwhile to get a diurnal saliva cortisol test panel done.  If interested I will send you a PM with info for a good source for the tests.   I also think you should find out your ferritin level.  Very important for a hypothyroid patient.  If you need iron you could always get iron infusions, to avoid the problems you mention.  
Avatar universal
Thanks Gimel.  I will work on getting some labs. In the meantime, maybe I'll just lick the cytomel...hahaha
1 Comments
One lick or two?
Avatar universal
Well I have completely stopped the cytomel. Nurse told me to just stay at 175 mcg.  I am going to slowly work up to 200 mcg. I am so swollen and sore but hopefully everything will some how even out... and now my children have shared a nasty head/sinus virus with me. My choice is swollen, fat and tired or racing heart and psychotic.... guess I'll be swollen.. lol
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