Avatar universal

High FT3, Low FT4, suppressed TSH (as per usual tsh)- test result question

Hi guys! It's been awhile! I got a lot of help here years ago. I've been on the same dose of NP Thyroid for the last several years, I hadn't tested in a long time. I have been under-weight for a few years, but that had seemed to happen in cycles in my life and the previous test to this a couple of years ago was all good.....

Thing that has changed: I had been prescribed Propranolol 30 years ago to prevent migraines. the thing ALL my doctors seemed to miss, as did i- was the effect the drug has on not only testing but RT3. It seems that if you're on thyroid med and take Propranolol also, there can be issues. little did I know that propranolol would actually mask hyper symptoms.....having said that, I discontinued taking Propranolol (slowly) and have been completely off of it for a over a month.

Here's where it gets weird. I have finally started to put on a little weight the past month or so (about 7-9 lbs) sleep well, get constipated etc...BUT when something stressful, big or small happens my hands start to shake. Pretty much during stress---big or small it all hits hard. I decided to get tested after a decent amount of time going off the drug passed. I assumed going off of it would help with any RT3 (I've had high RT3 in the past (probably from that drug) but I regret to have not had the RT3 test this time, I didn't think it would be needed and getting tested isn't easy or cheap where I am.

My TSH has been suppressed for as long as I've been on med, about 13 years. I currently take 180mg (or 3 grains) of NP Thyroid, Here are latest results.

TSH           .01      - 0.40-4.50

T4, FREE  1.1      -  0.8-1.8 ng/dL

T3, FREE  4.8      -  2.3-4.2 pg/mL

Any thoughts on this are appreciated. It's great to see you all still here and helping people! Thanks!
12 Responses
1756321 tn?1547095325
I've read Propranolol can mask  symptoms of hypoglycemia (low blood sugar) as well. A drop in blood sugar can occur in response to stress. I have only had low blood sugar once (after a glucose tolerance test) and my hands shook like crazy. I ate a chocolate chip muffin and the tremors went away.
Thanks! Good to know. My glucose level has always been normal to normal-high. I think i've gone a bit hyper, I just find it weird that my FT4 isn't high too. In the past, when I've had my FT3 too high, the FT4 was as well. For awhile I also thought that since my adrenals got hit hard years back, that they are just shot to this day.
Avatar universal
Here is my take on your situation.
Your 180 mg NP Thyroid dose is a little on the high side, containing 114 mcg T4 and 27 mcg T3. (For comparison, I am a full grown guy and my FT4 and FT3 labs are at midpoint taking 94 mcg T4 and 15 mcg T3.)

However you may have been in a good place with your 180 mg dose due to the effect of the Propranolol - it slows the conversion of T4 to T3, so lowers your Ft3, and it also slows the elimination of RT3, so raises RT3. Lower FT3 and higher RT3 may have kept you from feeling on the hyper side with your high-ish dose of NP.

Now that you have stopped using the Propranolol, you are getting the full effect of the 180 mg NP Thyroid, that is high FT3. And you may be having hyperthyroid symptoms. (I agree that your FT4 is oddly low).

If it has only been one to two months since you stopped the Propranolol, your thyroid hormones may not have fully adjusted yet. You may find if you get labs again in a month that your FT3 is back in the reference range. I have seen where people taking too much T4+T3 initially have high Ft3 but then their body's defence mechanism kicks in and starts converting more T4 to RT3 rather than T3 to protect you from being hyperthyroid. So your FT3 may look OK, but your RT3 may be high. But high RT3 is not desirable, so the solution would be to reduce the NP dose.
Thanks so much for really thinking on that! Once
i calmed down and woke up, I thought it through and came to the same conclusion. For whatever reason I never realized what propranolol was actually doing in the mix- but the doctors should have. The ones who would look at my TSH (when my other levels were good) but I was experiencing hypo symptoms and really high RT3. Many doctors over the years never even connected those things, even a "world renowned" Endo. I always figured if i was taking too much, I'd "feel it".

What it came down to in the end is till that pesky low FT4...I've lowered my dose the past 2 weeks and testing again in 4 weeks and this time I'll have the RT3 test also. Thanks to this site, I knew all of this but in my panic, I reached out, so thank you!
Avatar universal
Just to make sure, did you take your morning dose of NP Thyroid before the blood draw?  If so, how much NP Thyroid and how long before the blood draw for those tests?
Hi Gimel! I was taught well, so no meds were taken before draw. I usually would test about 24 hours since last dose, but this time it was at about 17 hours.
Avatar universal
What is your new dosage of NDT med?  Have you been tested for some other important variables: cortisol, Vitamin D, B12 and ferritin?
My dose is a little unstable. I took about a third less for a few days, maybe more- then knocked about 15mg per day off of dose. I'm a lot less shaky under stress now and fine when not stressed. I didn't want to cut too much too fast, I'll test again in 3-4 weeks.

My Vit D was low-ish a few months ago at 49 (30-100) My B12 could come up a bit as well, but not as low as it's been in the past. I haven't had ferritin tested in quite awhile. I started taking D and Magnesium but then got horrid achy joints, either my hip or wrists and realized that had happened before. The last time I took some, I got a migraine- weird.....

When I test again I'll have a ferritin test as well as RT3 and hopefully it'll sort itself out. I have some good B12 and I need to get back into that- with split dose thyroid meds, it's always been hard to fit the vitamins in.

Thanks for your input!
PS. Cortisol. I had thought about that but wasn't sure which test to order and felt overwhelmed at the time as well as the fact I don't have a good thyroid doc, let alone to find anyone who deals with adrenals! ugh, the struggle is real, and continues on....
Avatar universal
Cortisol that is either too high or too low can have a big impact on the body's response to thyroid.   For a cortisol test doctors usually will only order a  morning serum cortisol test (total cortisol), which is not nearly as useful as  saliva cortisol tests (free cortisol).  There are labs from which you can order a kit for collecting 4 samples of saliva at 4 times of day, and then send to lab.  Cost is about $145.  Another approach is to try and get your doctor to order a morning and evening saliva cortisol test.

It is also very important to have Vitamin D at least 50 ng/mL.  If you cannot tolerate D supplements ask the doctor about injections.  

When you test for RT3 , it is best to also test for FT3, to enable calculation of the  ratio of FT3 to RT3, from the same blood draw.
Thanks, great advice! I just meant that this time I'll get the FT3 in addition to the other usual tests. I really wish I had gotten that the last time. I only see this doctor twice a year but I will ask about the injections. I had an instance today in a store that was very stressful and got very shaky, I'd even skipped my 2nd dose of thyroid med yesterday. I am wondering what my brain and body have been going through under the surface of the Propranolol all these years. Crazy. Thanks, and I will update when I test!
Avatar universal
Here's an update, although not much of one. Back in 2012, myself and another here started NP Thyroid at the same time and I followed his lead in how much to tweak at a time, so as not to have dramatic rises in levels as we found our sweet spot. After getting so shaky from stress etc last fall, I was on 120mg per day as opposed to the 180mg per day I had been taking forever. I did that for quite awhile but then decided to knock 15mg per day off of my original dose and then test in 6 weeks, it ended up being 8 weeks, but the results are barely different than my original post on this. I am starting to question the lab....I used to use the one that started with an "L" and used the "Q" one the last 2 times. I did get a RT3 but no cortisol or ferritin. I eat a lot of red meat, if that makes a difference. I do have some labs from last August where my D was pretty low. Here's the latest:

TSH   .01    (.40 - 4.50) same
Ft3    4.8    (2.3 - 4.2) same as last time
Ft4   1.3     ( .8 - 1.8) only slightly up from 1.1
RT3   33     (8- 25)

Last August-

Vit D  38  (20-100)
B12    485  (193-986)
Folate  6.5  (3-17)

I'm stymied. Maybe when trying to go UP to hit the sweet spot you have to go slower, but you'd think that even with the small change of 15mg per day that SOMETHING would have changed. Also, old doc retired, had to see a new one who wanted me to go on Synthroid....I guess I am going down another 15mg per day and/or switching labs...it's weird that it is basically the same. Thanks!!!
PS....I no longer get shaky, even under stress.
Avatar universal
Hi Jackie, a couple of quick questions for you.
1. Most importantly how do you feel?? Pretty good? Any problems??
2. could you confirm the these labs represent 8 weeks on 165 mg NP Thyroid.
3. confirm you are still not taking Propranolol
4. going way back, did you have Hashimotos, radioactive drink to kill thyroid, or surgery for thyroid removal.
Hi, and thanks for response!
1. I feel alright, just got done moving, so that can make a person a bit tired and adjusting to change, but pretty good, I'd say!
2. These labs represent probably over 8 weeks on 165mg NP Thyroid per day (had not taken dose since day before)
3. Have been off of Propranolol for 4 months, at least.
4. I was told I have a "hashis" thyroid from ultrasound and exam by endo at a very reliable clinic (but I still question even my diagnosis back in '05 now) and no RA and no removal.
Avatar universal
I think the key factor here is that you feel pretty good. Based on that I wouldn't change anything. 165 mg NP Thyroid gives you 105 mcg T4 plus 25 mcg T3. I think that is a pretty reasonable dose. You previously indicated that you were on 180 mg NP Thyroid for quite a long period without major league problems, so just this little change may be all that you need.  As long as you continue to feel good, I would carry on and get new tests in a couple of months. Personally I would add Total T4 and Total T3 to the tests that you get.

Your lab results may not be what you expected. But there are a number of factors affecting them, such as what time you take the meds, what time you get the test done, and the precision of the lab test itself. For example I have been at a constant dose for quite a while and I have eight FT4 readings which vary from 1.1 to 1.4, so you kinda have to take an average.

However I will put a big caveat on what I have said here. Jackie - from your posts it appears that you are somewhat "self directing" your thyroid meds. I think you need to be very careful and be aware that it is possible that some other factor could kick in to affect your thyroid. For example occasionally Hashi turns to Graves disease which could give you bouts of being hyperthyroid. So if you get any bouts of shakiness again it could be an indication of being hyperthyroid. You could go and get labs to see what's going on. If the labs were wildly different, you'd know something was wrong. So you need to be aware that something else could affect your thyroid labs besides the meds you take. If this happens you absolutely must refer to your doctor.
Thank you for your comprehensive thoughts on this. Discontinuing propranolol has exposed something that they all missed all these years....I did happen to have a total T4 and total T3 as well. Thank you so much for your input. I have to decide where to go from here, but I must get my dose down in a safe way as soon as I can. Thanks again.
Avatar universal
Something else to take into account is that with you getting blood drawn before taking your thyroid med in the morning, that means your test results represent about the lowest level (trough) you will see with that med and dosage.  Due to the different half-life of T4 and T3,  after you take your med you will have a significantly higher peak  for FT3, and a somewhat higher peak for FT4.   The average for the day will also be higher than the trough levels..   With  your FT3 being over range and your FT4 being at mid-range, at their  troughs, it suggests over-dosing.   Of course, the purpose of thyroid medication is to relieve any signs/symptoms of hypothyroidism without creating any signs/symptoms of over-treatment.  
Gimel! As I said above, I have been lead astray...propranolol and thyroid med? REALLY? For a "hypo" person? Not one doctor ever put it together, especially the one who diagnosed me as hypo. If memory serves, my TSH was barely over range (over 5 less than 6) at the time. I complained of feeling "burnt", achy eyes and a bit tired, but my weight was fine and those were my only complaints and not even why I had the appointment. Next thing i know, I'm taking med. I'll work this out, but I have to go lower, and soon. Thanks for your input, so much!
Avatar universal
Hey Jackie,
If I read between the lines, it sounds like you are questioning your need to be taking thyroid hormones and you're thinking of backing off the NP Thyroid and seeing if your thyroid will pump out the hormones??  I guess we don't need to tell you that you oughta discuss that with a doctor. Anyway, it would not be a good idea to cold turkey stop all NP because it takes a few weeks for the T4 that you taken to wear off and let TSH rise, in the meantime you would be major league hypo. Also it would not be a good idea to simply taper off the NP, because down to about 1.5 grains or 90 mg NP your TSH would still be extremely low and hence not stimulating your thyroid to do its job. But 90 mg NP only has 57 mcg T4 plus 13.5 mcg T3 and so you would definitely be hypo even before that point. You have to have a way to get your TSH up while tapering off taking thyroid hormones. The only way I can think of would be to switch from NP to synthroid (or other T4 only) because synthroid does not drive your TSH nearly as low as NP. So if you switched over to a kinda normal dose of 100 - 125 mcg synthoid, your TSH might come up to 1 - 3, then you could think about tapering down the synthroid slowly and getting frequent labs to see what is happening. Good luck
Thank you so much for all of your input on this! I hadn't planned to go cold turkey, I was just really concerned by all of my my levels and thinking about how long it's probably been this way and I'd have never felt it while on propranolol. I AM happy to be off of that! I will figure it out, I promise to take it slow and test. You and Gimel have given me important info to consider. Thank you so much!! As always, this board is invaluable!
Avatar universal
I feel like I've been trusting the labs who draw blood, and they aren't doing their part....possibly. I first posted about high labs in Nov '18 and then posted again in Feb. Although I had adjusted my dose of NP Thyroid, both tests were almost exactly the same even though there was an adjustmeent of med. I found that suspicious. It was from the Q lab, so i used the L lab this time (hadn't used them since 2014) I have adjust med DOWN twice since first recent test and have tested 3 times now.

No difference in first two tests when going from 180mg NP to 165mg NP per day

Now, after 6 weeks of 150mg per day, I get test back from the L lab and it looks almost exactly like the last one I got from them in 2014!! So, I'm not sure what to think seeing as how the three tests should have shown the progression down in numbers rather than just a big drop....the other odd thing was that my ft4 had been running low and it is a tad higher.

FEB TEST at 165mg per day NP (same as at 180mg per day, almost anyway) - Q lab

TSH   .01    (.40 - 4.50) same
Ft3    4.8    (2.3 - 4.2) same as last time
Ft4   1.3     ( .8 - 1.8) only slightly up from 1.1
RT3   33     (8- 25)

April test (now) at 150mg per day - L lab

TSH   .006    (.450-4.500)- (their go-to for my TSH)
FT3    4.2           (2.0-4.4)    (Seems to be their go-to #)
FT4   1.41         (0.82-1.77)
RT3   31.7           (9.2-24.1)

All of this to say, that 2nd test in Feb was a waste of money. Rather than the numbers tapering over 3 tests, they just drop off. Also the L lab test result looks suspiciously just like the last test I got from them 4 years ago. I'm throwing this out there for anyone who uses these labs to order their own tests, as I know many do.

I have some appts next week and will try to get these ordered again and see how the hospitals numbers line up with these recent ones. Maybe I am just paranoid, but I'd had these same numbers on MORE med in the past and haven't been on a dose as low as 150mg in 8 years. I am definitely feeling better than I did 4 months ago though. Thanks again to all who have shared their thoughts on all of this!
maybe you should decrease to 2 grains and see how you feel, I know when my FT3 is high my RT3 is high as well.
Avatar universal
Hi Jackie, I'm glad to hear that you are feeling better. I think you are on the right track. I don't agree with you that the labs could be screwing around with the numbers - there's a lot of factors affecting the results, so a person has to be very careful making decisions based on the results of just one test.

I think on 150 mg NDT ( 95 mcg T4 + 22.5 mcg T3) you could be pretty darn close to optimum. Really the lab to focus on most is FT3, and yours is good at high normal. If FT3 is good it doesn't matter if FT4 looks a bit low. Do you split your daily dose into two? That might make the RT3 come down a bit. I think because your thyroid meds have not been right for a very long time that it could take several months for your body to recover fully when you are on the best dose. So if I was you I would stay at 150 NDT for another couple of months and see how you feel.
Thanks Dany, and thanks Telus! I was being paranoid about the labs, but I do the testing the exact same way every time, the only difference being is that for the past 2 months, I've been taking my dose all at once, rather than split doses as I'd been doing for years. I would tend to forget the 2nd dose or it interfered with being able to take vitamins etc.

Thank you for your thoughts on all of this, Telus. It seems the Propranolol I had taken, for no good reason, really did a number on my ability to "feel" that I was on too high a dose, and I suppose the dose that gave me good numbers 5 years ago is not necessarily the dose that is right for me now.

I'm SO glad that the shakes are over with, but I am still quite under-weight, which could be for any number of reasons. This board and community was and is invaluable with all of your support and insight and very much appreciated!
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