reducing T3 and adding more synthroid

[burgundy123]

I am hopeing someone can help me.  I have had hoshimotos desiese for 30 years and was on synthroid alone for 28 of those years.  While I felt good physicall,Ialways suffered from depression and took prozac for years. I also had my thyroid removed about 10 years ago due to thyroid cancer. About 2 years ago i began taking sustained release t3 along with synthroid and stopped the prozac, began taking vitamin d, fish oil, etc.  Depression was much better and mostly non existent.    Then I switched to armour for about 7 months and felt great emotionally but just did not feel right physically.  Hair falling out, I couldnt find the right dose, extreme appetite.  I have always been thin (5'6" and 128lbs) and i gained 10 pounds while on armour.  In april I switched back to synthroid 150mcg (1xper day) and 7.5 mcg of sustained release t3(3xper day). This was the sam dose i was taking pre-armour.    Initially i felt better but had heart palpitations.  The heart palpitaions mostly went away but i began to feel nervouse all of the time, irritated, low stree threshhold, insatiable appetite, etc.. i had labwork done at this point.  Free T4 - 1.06  range(.82 - 1.77)   Free T3 3.0 range (2.0 - 4.4) and TSH .008  range(.45 - 4.5)  All of the iron tests were in range. 3 weeks ago i cut back on 1 of the t3's and immideately felt less anxiety and nervousness and appetite returned to normal.  I also upped the synthroid to 150mcg 8 times per week.  Now I am absolutely exhausted for most of the day, have very little appetite but I'm gaining weight, dry eyes, depression.  The question is does it sound like upping the synthroid to 150mcg 8 x per week as opposed to the previous 7xper week was enough to offset the lowered dose of sustained release t3? or should i add more?  has anyone else had similiar side effects to taking cytomel/t3 meds?  I have a doctor who prescribes my thyroid meds but allows me to make decisions as well.  I'm waiting to see a new endocrinologist in December but do not want to wait that long to adjust my medicine.  Any comments on labs, etc would be great.  Thanks!
   In addition to this I have a strange cyclical swelling problem with my knee that seems to be agravated when my thyroid hormones are off.  every other week my knee swells to the point that i can barely walk and then unswells for a week.  No dr, reumatologist, orthopeidist has been able to figure it out.  but this is another reason that i am in a rush to get my thyroid hormones under control
    

[burgundy123]

Thank you very much for all of your time:)

[gimel]

Your ferritin level is way too low.  For women it is recommended to be 70 - 80.  I'm sure it hasn't changed for the better since January, so I think you should consider supplementing with ferrous fumerate, or ferrous gluconate, which are the best forms to take.  I'd start with about 25 mg per day, along with Vitamin C, to prevent possible constipation.  Then after a couple of weeks to become accustomed to it, you could increase another  25 mg.  

I think that only leaves B12 as an open question.  I'd get that tested as well at next opportunity.

[burgundy123]

I came across ferratin lab results from last january.  

ferratin 19  (range 13-150)  ng/dl

[gimel]

There are several different approaches, dependent on whether it is due to excess Reverse T3, or low Free T3, or a combination of both.  But let's not worry about that right now, we really need to find out about your ferritin level, and respond appropriately.  Also, need to give your med changes a chance to have full effect, and then it would be good to re-test Free T3, Free T4, and Reverse T3 at that time and see where that leads.  

[burgundy123]

What can be done to possibly affect the reverse t3 ratio?


Thank you so much for all of this information and your time.

[gimel]

Your ratio of Free T3 to Reverse T3 is 3.5 divided by 23 times 100, which is 1.52.  Two different sources, recommended a ratio of 1.8 and 2.0 or above, so your ratio is not terrible, but something to keep in mind.  After making the changes you are considering on thyroid med dosage, and giving some time to allow full effect, if you continue to have lingering hypo symptoms, you may have to consider action to try and reduce the Reverse T3 level.  But that can be handled later.  

Low ferritin, if that is the case, is one of the possible contributors to higher levels of Reverse T3.  That is why I'd like to see a ferritin test result.  I would also like to see a B12 test result, since most hypo patients find that they feel best with B12 in the upper part of its range.

[burgundy123]

No I didn't take meds in the morning.

[gimel]

In answer to your question, no the 150 per week (approx. 21 per day) increase is less than the 7.5 mcg of T3.  That is one of the reasons I suggested you consider adding back a portion of the 7.5 mcg of T3.  I also do think you need to give some time for both changes to have full effect, not only on serum levels, but also symptoms.  

When you were tested in April, while still on Armour Thyroid, did you take your med in the morning before the blood draw for tests?  

[burgundy123]

Thank you so much for all of that information.
I will have ferritin levels checked. I posted reverse t3 above and I think the ratio was normal
   I had my thyroid completely removed 10 years ago due to thyroid cancer.

Do you think increasing synthroid by 1 pill (150mcg) per week is enough
To offset the decrease of 7.5 mcg t3 (once the medicine has time to take the full effect)?

Thanks

[gimel]

When I try to put all that dosage info together it looks like this.  

                                   T4        T3      Equivalent T4*            Symptoms

two years ago  150      22.5               240 - 280 mcg      hypt/hyper/hypo

switched to :              
  2 gr. Armour    78       18                 150 - 186  mcg     hair loss, wt. gain

  then 3 grains  108      27                 225 - 279 mcg    palps, nervous, stress

3 wks ago         171     15                 231 - 261  mcg  fatigue, wt.,depression


After 30 years, and with TPO ab at 12, and TG ab at <20, it appears that your thyroid gland is basically destroyed by the Hashi's.  Although I guess that does not preclude nodules from possibly contributing to your hypo hyper swings 2 years ago.  We really don't know the state of the gland at that time.  Nodules sometimes form with Hashi's and leak thyroid hormone at times, causing swings from hypo to hyper and back.  

Next thing is that from the test results and symptoms, it seems that you do not tolerate T3 doses that exceed about 20 mcg.  Also, your switch to 171/15 T4/T3 3 weeks ago helped with the palps, you are now feeling fatigued, gaining weight, dry eyes, and depression.  That may be due to the significant reduction of T3 and that you may not have had time to fully feel the effect of the concurrent increase in T4.   So your T3 dosage may need to be increased the T3 just a small amount, and then allow time to get the full effect of the changes.  Remember, symptom relief tends to lag changes in levels of thyroid hormone.  So patience is important.

The only other things that comes to mind are iron/ferritin.  Your labs above look good; however, it would be good to know the level of ferritin also.  Ferritin levels that are too low can cause a lot of variability in the metabolism of thyroid hormone.  If not checked previously I recommend doing it.

Another thing that can cause seemingly strange results is your Reverse T3 level.   Reverse T3 is a normal component of thyroid hormone, but it is a mirror image molecule of T3, and biologically inactive.  There is a long list of things that can contribute to excessive conversion of T4 to Reverse T3.  If the ratio of Free T3 to Reverse T3 is inadequate, hypo symptoms can occur even if Free T3 level looks to be adequate.  I also recommend testing for Reverse T3, just to rule it in or out as a contributor.  

Please correct me if I have misunderstood and listed anything incorrectly above and I'll have another look.
  

[burgundy123]

I thought I would add that my compliment c3 is low and my
Rheumatoid factor is high( in the past 4 years it has ranged from 16 - 80).
I have had low white blood cell count since I was 18 ( 20 years ago).
My anti-ds DNA is out of range( or positive). Ana negative. Negative anti-to antibodies. Lupus and rheumatoid arthritis have been ruled out.

[burgundy123]

Thank you  

I have been tested for all of these.  I currently take 10,000 ius of vitamin d3 and have it monitored every few months.  It used to be low several years ago but is now in the upper 1/2 of the range.  I dont have the test results with me though.

I have had my B12 levels checked in the past and they were always in range but i also dont have those tests with me.

labs in april just before i switched off of armour thyroid:
Reverse T3   23   (range 8- 25)ng/dl
Free T3  3.5  (range 2.3 - 4.2  pg/ml)
Thyroid peroxidase AB   12   (range <35 iu.ml)
free t4 1.3   (range 0.8 -1.8 ng/dl)
thyroglobulin AB   <20  (range <20 iu/ml)

Iron and TIBC (I had just finished taking supplemental iron at the time of these labs in July)
Iron Bind.Cap.(TIBC)  356  ug/dl  (range350-450)
UIBC 204   ug/dl(range150-375)
Iron, Serum 152   ug/dl(range 35 -155)
Iron Saturation 43 %(range 15-55)

Thank you so much for your feedback:)

[gimel]

Need to do lots of thinking about all this, but have to leave right now.  Will follow up later in the day.  In the interim, I need to know if you have been tested for Vitamin D, B12, ferritin, and Reverse T3?  If so for any of those, please post results and reference ranges shown on the lab report.  

[burgundy123]

Yes 7.5 mcg t3 3xper day for a total of 22.5mcg per day
I switched to armour because I could not regulate my thyroid. One day I would feel hypo and the next week hyper on the same dose.
I now feel that it might be that I don't do well with the t3 meds.
I started with 2 grains of armour and went up to 3.
I had heart palpitations and cut back to 2.5 and added in some synthetic t4.
I can't remember exact dosages of armour and t4.

[gimel]

So, two years ago you were taking 150 mcg of Synthroid and 7.5 mcg of T3  (3 times each day), right?  Or did you mean 7.5 mcg of T3 split into 3 doses each day?   Then you switched to Armour Thyroid.  Why did you decide to switch?  What was the Armour dose?  I ask this to understand if the doses were roughly equivalent or if that had some effect on the symptoms you experienced afterward.