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Are we supposed to decrease T4 dose when adding T3?

In my previous post, I explained that my doctor added 5 mcg of T3 (generic liothyronine) to my daily medication dose.  So, I currently take 100 mcg of Tirosint + 1/2 grain of Armour (19 mcg of T4 + 4.5 mcg of T3) + 10 mcg of liothyronine = 119 mcg T4 + 14.5 T3 daily.  With the extra 5 mcg of T3 that was added, was my doctor supposed to lower T4 and if so, by how much?  Thank you!
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649848 tn?1534633700
COMMUNITY LEADER
It's typical to decrease T4 dosage by ~25 mcg for every 5 mcg T3 added, but that's not always necessary.  It depends on what your labs look like -whether Free T4 is too high and Free T3 too low, etc.  If you can post your actual lab results, we can be more specific.
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Thank you for responding!  My last labs (and ranges) are as follows:

FT4 1.3 (0.8-1.8)
Total T4 7.9 (4.8-10.4)
FT3 2.8 (2.3-4.2)
Total T3 72 (76-181)

I am working on raising my very low ferritin levels (6, range 16-232) and total iron (27, range 40-190).  I was just trying to figure out what might be causing this weird hip pain I am experiencing 1 hr after taking the T3 (which in the past happened when I went hyper).    Thanks for any insights!
Most of us feel best with Free T4 about mid range, which right where yours is.  Free T3, typically, needs to be in the upper half to upper third of its range.  Because your Free T4 is right in the middle of the range, I wouldn't think it necessary to reduce your T4 dosage, but would recommend you test regularly to make sure your Free T3 increases enough to alleviate your symptoms, but your Free T4 doesn't get too high.

Ferritin is the iron storage hormone and iron is necessary for the proper conversion of Free T4 to Free T3.  Are you taking an iron supplement to bring your level up or trying to bring it up with diet?

Have you had vitamin B-12 and vitamin D tested?  Both of those are also necessary for proper thyroid hormone metabolism.
Hi again, yes I am taking iron supplement.  I have been trying different ones over the past years. I was really hoping that liquid one would work because it did not cause constipation.  But, it didn;t work.  I tried Vitron C, it caused constipation.  as of a week ago, I am now on iron bisglycinate - 50 g of elemental iron every other day (dr says it absorbs better that way).  I am having constipation, but it is so hard to tell if it is iron pills or thyroid levels - symptoms seem to overlap.

I also take 50,000 IUs of Vitamin D weekly.  Vitamin D was last tested at 56 (range 18-72).  Last B12 is 539 (range 200-1100).

Could raising my iron and eventually having it in normal range possibly result in needing to lower my thyroid dose, due to better absorption?  
I believe gimel can direct you to the best iron supplements but I know that taking vitamin C with your iron will help it absorb better.  

I assume you're taking such a high dose of Vitamin D on your doctor's orders?   Vitamin D levels are best between 50 and 60.

Your B-12 is on the low side, even though it's "in range".  Most of us find that keeping vitamin B-12 at/near the upper level of its range works best to alleviate symptoms.  Lower levels of vitamin B-12 can cause debilitating fatigue/exhaustion, depression, brain fog, etc.  If not treated, low B-12 can cause nerve damage that may be irreversible.  Although your level isn't low enough to cause extreme symptoms, it is low enough to contribute to symptoms of fatigue, depression or brain fog, etc.  

"Could raising my iron and eventually having it in normal range possibly result in needing to lower my thyroid dose, due to better absorption?"  Being a gelcap, Tirosint is said to be absorbed at a much higher rate than pill-type medications.  It isn't always the absorption that makes the difference.  It's the body's ability to convert Free T4 to Free T3, since Free T3 is the hormone that's actually used by individual cells, whereas Free T4 is a "storage hormone" and must be converted in order to be used.  Iron, along with zinc and selenium helps with that conversion process.  

Your Free T4 is about where it should be but your Free T3 is much too low, indicating that your conversion is off.  Whether you're simply not converting or whether you're converting too much Free T4 to Reverse T3 (rT3), which is a mirror image of Free T3, but rT3 is inert and prevents FT3 from being absorbed into the the cells.   Have you ever had a rT3 test done?  Most conventional doctors do not routinely order rT3, but it should be done at the same time as Free T4 and Free T3.  
I was taking VitronC and it was giving me GI issues.  I do not do well with medications that have many fillers or colors, so I stopped VitronC and tried liquid iron.  However, it was not raising my iron fast enough.  So now, I found iron bisglycinate chelate which was said to be "gentle" and doesn't have that many fillers and no colors.  Dr was the one who said to take 50 g every other day.  

As for Vitamin B12...When I was taking it, besides making my face break out in cystic acne, it made me super irritable.  When I stopped, the aggravation stopped and the face got better.  I did that several times - same results.  Have you heard of these side effects before?  

I did rT3 test several times before.  95% of the time, it was over the range.  The last time was in April of this year and it was 26 (range 8-25).  At that time, my dose was 100 mcg Tirosint + 1/4 grain NP Thyroid (prior to recall for subpotency) = 109.5 mcg T4 + 2.25 T3.  I was having hip pain then too and heavy, heavy, heavy periods.  Since then my doctor did not order rT3 as he believes it is not an accurate or valuable test.  

So let's say I am converting too much Free T4 into rT3, how can that be addressed?

Also, given the need for all these vitamins - is there one pill that can address all or most of them?  Or are we supposed to pop the pills pretty much all day.  I am already taking 3 doses daily plus iron plus vitamin D3, making sure everything is spaced out properly and taken before 7 pm so it does not cause GERD.  I am running out of hours in a day :)  Thank you!

Is the iron you're currently using helping to bring you level up, not causing constipation, etc?   Try taking vitamin C with it and see if it works better.

I've never heard of Vitamin B-12 causing those symptoms, but of course, everyone is different and things affect us all in various ways.  I would wonder what type of B-12 you were taking.  Because B-12 is necessary for proper metabolism of thyroid hormones, it's important to keep levels high enough.  The best type of B-12 is methylcobalamin, which is "body ready".  The other type of B-12 is cyanocobalamin and must be converted to methylcobalamin in order for the body to use it properly.  If you weren't taking the right type, it's always possible that it could cause adverse effects.  It's also possible that there's a filler/binder that doesn't agree with you.  You might try a liquid methylcobalamin and take it sublingually.

If rT3 is too high, the protocol is, typically, to reduce T4 dosage and increase T3 dosage.  Many doctors don't believe in rT3 and refuse to order it.  My doctors also refuse to order it because they say it's not a valuable test.  However, since we know that rT3 blocks FT3 from entering the cells, it's baffling that doctors have decided it's useless.

As for the supplements - I get it when you say you're running out of hours in the day to take them. Sometimes I feel like all I do is pop pills and I find myself in the same situation, especially with things like calcium, magnesium, etc that have to be separated from thyroid medication by at least 4 hrs.  I, too, have to be careful about eating anything late in the day because of GERD, but it's important to note that GERD/acid reflux is a common symptom of hypothyroidism.  When I'm not hypo, my GERD, typically goes away.  If you get to a point at which you're no longer hypo, it could be safe to think your GERD might ease up, as well.

That said, things like B-12 and vitamin C don't necessarily have to separated from the thyroid medication by so many hours... I'm on B-12 injections, but when I was taking it in pill form, I took it with/shortly after my thyroid medication without adverse effects.  Also, assuming that you're taking all your thyroid medications before mid-afternoon, you can take other vitamins with dinner, in the evening or at bedtime. since vitamins/minerals don't typically contribute to GERD.  If they do, make sure you take them before that 7:00 pm cut-off.  

Your original post said you're taking 100 mcg Tirosint, 1/2 grain (30 mg) Armour and 10 mcg Liothyronine (T3).  I'm not sure the small amount of Armour is doing that much good.  If your doctor would eliminate that and add another 5 mcg (to start with intent to increase further) of T3, you could take your Tirosint and part of the T3 in the morning and the rest of the T3 later in the day... noon or early afternoon.  That way you'd leave some time in between to take some of the other supplements.  
The iron I am currently taking is causing constipation, even though it says it is "gentle" on the stomach.  I bought some chewable Vitamin C pills to take with it.  I just started it about 10 days ago, so I am giving it a bit of time to hopefully work.  Dr also said Miralax helps.

I checked on the B-12 and it is cyancobalamin.  I shall try the liquid methylcobalamin then.  Thank you for teaching me something new.  If you have a good brand to recommend, please do, I am all ears as I have a cabinet full of supplement duds.

In terms of reducing T4 by eliminating Armour - this would certainly be doable.  Would that lower my FT4 below mid-point though?  I worked really hard and long to get it to mid point :)  Or would my body somehow still maintain mid level of FT4, while also increasing FT3?

Also, I read a few NIH studies that advocate figuring out the "right" T4 medication dose based on your weight.  I've been steadily gaining weight and based on that I am already below the "recommended" T4 dose.  Would lowering T4 further make me gain even more weight?  Or would my body figure out how to keep my FT4 levels in mid range and actually work with me to drop these stubborn 15-20 lbs I've gained "just because I am in my mid 40s" (as my doctor explains and it drives me up the wall!) :)  

Thank you very much, Barb135!
Avatar universal
Another thing to consider is that there is no biochemical test(s) that can reliably determine your thyroid status.   A good thyroid doctor will diagnose and treat based on a full medical history, an evaluation for signs/symptoms typical of hypothyroidism, and expanded testing to include FT4, FT3, cortisol, Vitamin D, B12 and ferritin.  TSH is useful  as a diagnostic only when at extreme levels typical of primary hypothyroidism.   Upon diagnosis as hypothyroidism, the good doctor will test and adjust FT4 and FT3 levels as needed to relieve symptoms, without going so far as to create hyper symptoms.   So symptoms are more important than FT4 and FT3 3tests.   Which, if any, of the following symptoms do you have?


Fatigue
Increased sensitivity to cold
Constipation
Dry skin
Weight gain
Puffy face
Hoarseness
Muscle weakness
Elevated blood cholesterol level
Muscle aches, tenderness and stiffness
Pain, stiffness or swelling in your joints
Heavier than normal or irregular menstrual periods
Thinning hair
Slowed heart rate
Depression
Impaired memory
Enlarged thyroid gland (goiter)
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Thanks for responding!  I had the following:

Fatigue
Increased sensitivity to cold
Constipation
Weight gain
Swelling in my ankles
Heavier than normal or irregular menstrual periods (that's how it all started 4 months ago)
Depression (mainly in a form of low energy and lack of interest in activities)

My last tests were:
FT4 1.3 (0.8-1.8)
Total T4 7.9 (4.8-10.4)
FT3 2.8 (2.3-4.2)
Total T3 72 (76-181)

I am working on raising my very low ferritin levels (6, range 16-232) and total iron (27, range 40-190), % Sat (7, range 16-45%), TIBC (400, range 250-450).   I also take 50,000 IUs of Vitamin D weekly.  Vitamin D was last tested at 56 (range 18-72).  Last B12 is 539 (range 200-1100).

It also seems that every medication dose "tweak" adds another couple of lbs.  For example, this last add of 5 mcg of T3 added 2 lbs overnight and now they are set it regardless of diet or exercise.  

What causes this continuous and rapid weight gain and what do I need to focus on to shed these pounds?  I appreciate all your thoughts!
Avatar universal
Before further discussion, I wanted to ask what time of day do you take your thyroid med?   And what time of day was the blood draw for those tests?
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I take 100 mcg of Tirosint and 1/2 grain of Armour (so, 119 mcg T4 + 4.5 mcg T3) at 7 am daily.  I was taking 5 mcg of liothyronine at 1 pm daily.  On the day of the blood draw, I waited to take my morning dose until after the blood draw was completed at 8:30 am.  Thank you!
Avatar universal
I agree with Barb about the Armour.  I see no benefit from taking that small amount.  I suggest that you just stop the Armour and increase your  Tirosint to compensate as well as increasing your T3 to 10 mcg to compensate for the Armour and also add the 5 mcg back.  You have a number of symptoms which can be related to being hypothyroid still, along with extremely low iron which can also cause symptoms.  With your ferritin/iron as low as it is you might consider asking the doctor for iron infusions to get your level optimal.  Ferritin needs to be at least 100 and that would take a lot of supplementing, which you have trouble with.  

Everyone is different in the FT4 and FT3 levels adequate for them to feel well.   Except when TSH is at extreme levels, there is no lab test(s) that reliably determines an individual's thyroid status.   So a good thyroid doctor will treat a hypo patient by increasing FT4 and fT3 levels as needed to relieve symptoms, without being influenced by resultant TSH levels.   Symptom relief is the only criterion for success.  

It makes no sense that you would gain weight overnight by taking that small amount of T3 med.    Weight is mainly a result of our Resting Metabolic Rate (RMR) and our diet and exercise habits.    RMR is largely associated with our thyroid status.  Hypothyroidism causes  RMR to drop.   If diet and exercise are constant,  for women every drop of 100 calories in RMR results in about 23 pounds of weight gain, over an extended period.  This is because every pound ladies gain increases RMR by 4.3 calories per day, so you would have to gain 43 pounds to get your metabolism back to where you were no longer gaining weight.
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I asked about iron infusion, dr said that would be the very last resort due to potential side effects.  He also said that it takes months to raise iron levels and then even longer for ferritin to reflect increased stores.  So it seems this will take a while.

As I type this, my left hip and thigh hurt.  This dull pain is awful and I just want it to stop.  The problem is that, in the past, I felt the same pain when I had too much as well as too little thyroid hormone. So I have no idea what to do.  

All I know is that the pain gets worse about 45 min to 1 hr after taking liothyronine at noon and 5 pm.  
However, the pain is not there after I take Armour at 7 am (along with Tirosint) that supposedly has 4.5 mcg of T3 in it.  

I hope to figure out this soon as my doctor (of internal medicine) will likely try to refer me to a "specialist" - an endocrinologist I ran away from many years ago.  Ugh.  Thank you for your insights.
Avatar universal
As I mentioned I can think of no reason why 5 mcg of T3 would cause tht pain within one hour.  Only one thought.  T3 does have an effect on cortisol and vice versa.   Have you ever had a cortisol test done?  IF not, the best is a 4 panel saliva cortisol test for Free Cortisol.  Doctors usually only order a morning serum cortisol, which is total cortisol and not nearly as revealing as Free Cortisol.  
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Interesting thought, thank you!  Are you suspecting adrenal fatigue?  It is another condition that many doctors seem to disregard. In the past I had serum cortisol done and you are right, it revealed nothing.  Where can I get the 4 panel test you are recommending?  And since I take my meds at 7 am, noon and 5 pm, at what times would you recommend I do the saliva testing for accurate results - before or after meds?

Report from this morning - went to bed with hip pain, but it thankfully subsided over night.  Took my morning Tirosint + Armour and so far, no pain.  My 5 mcg of lio is due at noon, and then another at 5 pm (also tried 10 am and 3 pm, same pain).  So it is somehow definitely related to liothyronine increase from 5 mcg to 10 mcg.  Also, for the first 7 days after the increase, I felt so much better - my energy was back, my sleep was better.  On day 8 is when the hip pain started like I described.  Thanks again!
Avatar universal
There is a good site I, and several friends have used with great satisfaction.  The test you want is diurnal saliva cortisol: 4 tests.  It costs $135.  I will send you a PM with info.  To access, just click on your name and then from your personal page click on messages.
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