Thyroid Disorders Community
26k Members
Avatar universal

Trouble finding correct dosage (tirosint)


I am a lurker - have been stumbling upon this site for years as I  reasearched my hashi's situation.  Finally breaking down and registering so I can ask for insight :)

I have Hashis and still have my thyroid.   I was origionally put on armour, then armour plus cytomel and did this for 2 years never feeling well.  i suffered adverse affects from armour right from the get go but got to a level that wasnt optimal but at least wasnt horrible...then I crashed and we finally made a switch to synthroid with a little cytomel.  This was about 2 months ago.  Very quickly after starting synthroid, I started breaking out so we switched to tirosint as it is a bit more  "pure".  That at least solved the breaking out but I am still determining the right dose.

I seem to feel better initially after an increase in T4 (sometimes I might be foggy for a day or two until it settles), but then about 2 weeks later I seem to crash.   I'm now on 125 tirosint plus 10 cytomel.  My origional armour dose was 90 mcg armour (1.5 grains) plus the 10 mcg cytomel.

I might be due for an increase or not.  I guess I am afraid that the trend will continue - feel better for a few weeks, then worse again.  Has anyone run into this and have any idea why this might be and what I shoud do?

I am at a loss.  My doc wont test my thyroid levels for another couple of weeks and even suggested reducing my tirosint to 100 (not sure why other than he said he likes FT4 levels less than 1, which is odd, bc i thought FT4 levels were supposed to be closer to 70% of the range).

These are the latest test results (taken when I was on 125 synthroid and 10 mcg cytomel - I was only about 3 weeks in however.  I did not have my RT3 tests at the time but it came in recently at 22 (she didnt give me the range however).  Unfortunately I do not know what the latest is which is a shame since I think it would be more accurate as  Ihave been on tirosint 125 for a while

TSH .019 (.350-3.00)
FT4 1.41 (.89-1.80)
FT3 3.50 (2.3-4.2)
T3 total 99 (60-181)
44 Responses
649848 tn?1534637300
I'm happy to hear that your doctor isn't a TSH person.  Most of them tend to have a knee jerk reaction, whenever they see a low TSH, even when actual hormone levels are good, or even low in their ranges.

TSH is often suppressed when on a replacement thyroid hormone, particularly one with a T3 component, such as cytomel, but that doesn't have to do with whether or not your thyroid is still producing.  It has to do with whether the pituitary gland thinks there's enough hormones (no matter where they come from) or not; apparently, your pituitary is a happy camper.  When the pituitary senses adequate (or too much) hormones, it will stop asking the thyroid to produce more, which is what TSH does. Sometimes, the pituitary has plenty of hormones, but the rest of the body doesn't, which could leave you with peripheral hypothyroidism - I suspect this to be part of my own problem.

Yes, some people do crash after a couple weeks on a new med. As I noted above, it's not unusual for symptoms to get worse, or for new ones to appear, when you change doses/meds.  Also as both myself and flyingfool noted, your body has to have time to "get well" after the meds reach potential.  Each time you're changing the dosage/med, your body has to start all over again.

I know that crash is no fun, but sometimes you just have to ride it out for a bit to see if things get better. I, too, would be interested in your symptoms, when you experience this crash.

By the way - since it takes 4-6 weeks for med to reach full potential in your blood, taking labs at only 3 weeks into a dosage would not give you a full picture of the situation, because the med would not have had time to reach full potential/stabilize in your blood; given an actual 4-6 week time frame, your levels might, actually, be even higher.  I will be interested in the next ones, as well as symptoms.
649848 tn?1534637300
Rule of thumb is that FT4 should be about mid range, with FT3 to be mid range to upper 1/3  of its range.  Your levels are actually very good; your FT4 is 56% of the range and FT3 is 63% of its range, though you do still have room to increase the cytomel.

Are you sure your doctor wasn't reacting to your TSH, which is lower than the reference range?  It's not unusual for TSH to be low/suppressed when taking a T3 med.

What symptoms do you have? It takes 4-6 weeks for a T4 med to reach full potential in your blood and it's not unusual to feel worse for a while before feeling better.  Even once the med reaches full potential it takes time for your body to "get well".  
Avatar universal
Thank you for your response.

No, my doc isnt a TSH person.  He isnt concerned bc he realizes it will be depressed.  Although is there such a thing as having a too surpressed TSH?  sometimes I worry

I was able to get my other dr to write me a script for labwork - so I did that first thing this morning.  I am sure I will not know what the numbers are until next week

I guess I am wondering - is it normal to feel better initially then crash?  Is that a sign I'm not on enough?  I just hate that that seems to keep happening...adjust: feel foggy for a day or two, then feel better, then crash....

When I took the labs above it was about 3 weeks into my dose.   I will be curious to see what this latest test shows
Avatar universal
i have read that there is a bio feeback loop that takes about 2 weeks.  So what you report seems to be consistent with that theory.  not sure what to do about it.

As stated above you levels by the numbers seem OK. But the true test is how you feel.

You call it a "crash" and feel worse.  What is it that you are feeling exactly?  What symptoms are you having?

After being hypo for an extended period of time, it takes a while for the body to heal once it gets hormones again. So you may be best served by not making any changes for a few more weeks and see what happens.  You may stabilize and even feel better once your body has a chance to settle out.  if you keep "shocking" your body with changes in dosages etc, it has to react to each of those changes.  So I advise slow and steady.

Having TSH be very low is no problem.  It would indicate that your actual thyroid gland probably is producing little or nothing in the way of hormone, and thus you are completely reliant upon your medication. Which for most people with Hashi's is where they end up eventually anyhow.  So I would not worry about a very low TSH.

Just my opinion.
Avatar universal
Thank you guys!  My symptons for crashing are mainly extreme fatigue.  Is almost like I did intense physical activity the day before.  It's extremly difficult to wake up am get out of bed for work.  Coffee doesn't real,y get me going. My limbs feel heavy my eyelids are heavy. I move slow I feel as though I could sleep all day and just have low energy. Sitting makes it worse so I try to walks around the neighborhood

This newest blood test should show a snapshot of about 6 weeks or more on the same dose. I agree with you in saying I may want to ride this out to see if it improves instead of adjusting doses all the time.   I am wondering about the biofeedback loop as well   I will post my results as soon as I get them.

It will be interesting to see the results. Perhaps you are right and my levels are even higher - potentially too high (although I certainly do not feel hyper!)
649848 tn?1534637300
Unfortunately, the fatigue you describe is one of those symptoms that can "cross over" and apply to either hyper or hypo, so it's hard to say just by that, that you are one or the other.

Please do be sure to post your new blood work, so we can see where you are with everything and maybe will be able to advise further.

Have you had vitamin B12 tested?  Deficiency in B12 can also cause the fatigue you're describing; that was much worse for me than thyroid related fatigue.  I might suggest that you get your B12 levels tested.
Avatar universal
Thank you! I take a B12 supp but I have not had my levels checked in quite a while. I try and stay on top of that and Vit D and get adequate iron in my diet.   Just covering y basis as much as possible ;)

I've thought about the cross over stuff- its what makes tihs so tricky. I could be feeling more fatigued bc I'm on too much for sure.  Or not...ha.  

I am super interestedin my results as well and will def be looking here for feedback suggestions.  Often times I like to get my results prior to going into the Dr so that I understand what the results are and am able to have a good discussion with my Doc about next steps/adjustmens etc.  Thanks in advance for any help!!!  
649848 tn?1534637300
Taking a B12 supplement doesn't insure that your levels are adequate.  Some of us don't properly absorb B12, so you should have your levels tested to be sure. Same with vitamin D.

Will look forward to seeing your new labs and providing feedback.
Avatar universal

I'm back :)

Here are my latest results as promised, ranges are in parenthesis:

TSH:        .015 (.350-3.0)
Free T4:  1.55 (.90-1.80)
T3 Total:  93 (60-181)
Total T4:  9.3  (4.5 - 10.9)
Freet T3 :  3.20 (2.3 - 4.2)
Reverse T3: 16.4  (9.2-24.1)  <--- want to note that my last results above didnt have the RT3 included as they didn thave the results at the time,  but I got them and it was 22 so it appears to have gone down)

Im unsure what to do - based on the labs I'm inclined to think adding perhaps another 5mcg of cytomel might be in order since my T3 is not in the upper end of the range - perhaps that explains the fatigue?  

My T4 is higher though which I THINK is good?  seem to get varying info on where FT4 should be. My doc is happy if its close to 1, whereas I read it should be about 60-70% of the range...my RT3 went down

However, if my FT4 went up, shouldnt my FT3 go up as well? esp as it looks like my RT3 went down a bit?   I'm very confused.

I'm holding off on making any changes until I speak to the Dr of course.  I also battled a nasty bug/cold since last talking to you so its hard to seperate fatigue from sickness (which honeslty could have contributed to my fatigue earlier  - maybe my system was busy fighting a bug in its early stages) from fatigue from meds.

If they do add cytomel, wouldnt I expect my FT4 to then drop?  

Looking for advise and opinions - thank you!

Avatar universal
"How do you sleep?" Was a question my doctor asked when I kept going back for what I thought was thyroid issues.  I said fine.

I still was exhausted, some headaches, and some muscle cramps.  She did a pulse ox recorder while I slept and found that my oxygen drops really low at night. Needless to say I was excited that my doctor didn't either 1.  Blame everything on thyroid and 2. Say everything is fine and send me away.

"It's extremely difficult to wake up am get out of bed for work.  Coffee doesn't really get me going" When I read that I thought of my own battle with apnea.  And you don't have to be overweight to suffer from any type of sleep apnea or hypopnea.
Avatar universal
Thank you - that is interesting and something I will consider.  I usually sleep quite well though and the times I've had trouble waking up where times when my thyroid dosage was off.  

Barbara - do you have any insight as well? Thank you!
649848 tn?1534637300
Sorry, I was offline all day yesterday, so just now saw your new labs.

Just to clarify your question on where the labs should be -- you're backwards on the FT4....... as I noted farther up in the thread, rule of thumb is to have FT4 at approximately mid range and many find that FT3 has to be mid range to upper third of the range.  That means FT3 should be  higher in its range (around 67%), than FT4 in its range (50%).  

Your FT4 is 72% of the range, which is very high.  Your FT3, on the other hand is only 47% of its range.

If everything is working right, it's true that when FT4 goes up, FT3 should go up; however, if one doesn't convert adequately, that won't happen.

Are you still on the 125 mcg Tirosint and 10 mcg cytomel?

It's customary to decrease T4 med by 20-25 mcg whenever adding/increasing a T3 med.  You could talk to your doctor about dropping the Tirosint back to 100 mcg, which should bring your FT4 down to something reasonable.  

Are you taking the cytomel all in one dose or are you splitting it into multiple doses?  Typically, those of us on a T3 med find it best to split it into at least 2 doses/day.  For instance, I take 5 mcg in the morning, 5 mcg around noon....... that keeps the FT3 more stable throughout the day and I don't usually crash in the afternoon.

Have you had vitamin B12 tested, as suggested above?  That could be a major factor in your fatigue and if not properly addressed, you're not going to feel good no matter how perfect your thyroid levels get.  Same goes for vitamin D.
Have an Answer?
Top Thyroid Answerers
649848 tn?1534637300
Avatar universal
1756321 tn?1547098925
Queensland, Australia
Learn About Top Answerers
Didn't find the answer you were looking for?
Ask a question
Popular Resources
We tapped the CDC for information on what you need to know about radiation exposure
Endocrinologist Mark Lupo, MD, answers 10 questions about thyroid disorders and how to treat them
A list of national and international resources and hotlines to help connect you to needed health and medical services.
Here’s how your baby’s growing in your body each week.
These common ADD/ADHD myths could already be hurting your child
This article will tell you more about strength training at home, giving you some options that require little to no equipment.