New Dr- lab results and starting new dose of Tirosint

[Rue6]

My old Dr. retired and new Dr. feels I was on far too much medicine. Old Dr. had me on 50mcg Tirosint and 25 mcg Cytomel am and 25 Cytomel pm. The Cytomel was adjusted from 5 and 5, to 20 and 5, to 25 and 5 to 25 and 25 over the course of 3 years. I really felt better with a pm dose, but still not great. My last Free T3 with old Dr. was 3.7 and she wanted me above 4. Then she retired.  New Dr. looked at year old blood work and the doses and proclaimed I was on way too much, but my labs were not bad, so maybe a malabsorbption issue and set me up with a Gastro. (next week).  I had blood work that day and just saw her again to go over the results. My Free T3 had skyrocketed higher than ever before. She was alarmed.
Free T4 - 0.9 (0.8-1.8)
Free T3 - 7.2 (2.3-4.2)
TSH-  <0.01 (0.4-4.5)

The new Endo took me off Cytomel completely and raised my Tirosint from 50 to 150. I'm to be on it 6 weeks, get new blood work at 7 weeks and see her again in Feb.

She didn't say anything about possible side effects. I had not had any with the prior 50mcg. I came here to read up on anything close to my issue. Any thoughts?

[gimel]

Even the AACE/ATA Guidelines for Hypothyroidism recommend deferring the morning dose of thyroid med until after the blood draw, in order to avoid false high results. But since the blood draw was late in the afternoon, the effect would have been minimized.  

I agree that your labs are not optimal.  Your Free T4 is only at 10% of its range, when it should be mid-range, at least.  Your Free T3 is way above range, and it should be in the upper half of its range, adjusted as needed to relieve hypo symptoms.  The doctor probably was also concerned about your TSH level, but suppression frequently occurs when taking adequate doses of thyroid med.  That does not mean hyperthyroidism unless there are accompanying hyper symptoms due to excessive levels of Free T4 and Free T3.  In addition you need to get your Vitamin D to at least 50, and some say 60.  Your B12 at 952 is adequate.  You also need to know your ferritin level.  It should be at least 70, and some say 100.

If you were ever on T4 med only, and you have several sets of old test results from that time, perhaps we can determine  if your body was adequately converting T4 to T3.  That could point out if T4 only is likely to work for you.  

About the Gastro.  How would malabsorption account for any your test results?  Your Free T4 is relatively low due to taking only 50 mcg of T4.  Your Free T3 was very high due to taking 50 mcg of T3.  Where is the absorption problem, other than possibly your previously low Vitamin D and B12, and I expect ferritin also.  That is quite normal due to inadequate stomach acid with hypothyroidism.

[gimel]

First question is whether you took your morning dose of Cytomel prior to the blood draw for those tests?  Also, what time of day was the blood draw?

I don't really understand why your doctor had you on only 50 mcg of T4, to go with the 50 mcg of T3.  That 1:1 ratio is far too much T3 for many people.  The result is that your Free T4 is barely in range, at only 10% while your Free T3 is much higher.  Can't really comment on just how high until you answer about the timing of your morning dose and the blood draw.  For info, many of us here have found that we needed Free T4 at least at mid-range, and Free T3 in the upper half of its range, and adjusted from there as needed to relieve symptoms.  Symptom relief should be all important, not just test results.  In addition, you need to test and supplement as needed to optimize Vitamin D, B12 and ferritin.  D should be at least 50, B12 in the upper end of its range, and ferritin should be at least 70.

I am also concerned about deleting T3 from your med.  I suspect that your old doctor had you on T4 plus T3 due to inadequate conversion of T4 to T3, thus requiring some T3 med.  By switching your dose to T4 only, I expect that you will have a problem from inadequate Free T3 levels.  In addition, the old dose of 50 T4 and 50 T3 was the equivalent of 200 mcg of T4.  So the new dose of 150 mcg of T4 is much less, and is another potential problem for you.  

[Rue6]

Great points, thank you. Morning Cytomel taken at 6:30 am. Blood draw was 3:30pm.

Inadequate conversion of T4 to T3 was definitely an issue old Dr. considered. She also found Reverse T3 to be high. New Dr does not test, nor believe in reverse T3 being an issue. She said she's concerned about the very high Free T3 and wants to see if T4 alone will bring Free T3 into range. I'm concerned about how I'll be feeling for the next 6 weeks of trying the 150 T4 only.  Had not thought about old T3/T4 meds having equaled 200 T4. More to think about.

Have been supplementing B12 and D for years. New Dr. did not test those levels though. Last draw from old Dr. had B at 952 and D at 36 (had been as low as 12). I take 10,000 iu D and a B complex daily. Tested iron over a year ago, and I don't have those lab results, but Dr. notes saying "iron was great and not of concern." New Dr. is having me see a Gastro. in 3 days to look for malabsorbption issues.