high Rt3, ratio, and out of range labs

[froggykar]

Brand new to site and new to detailed Thyroid info. labs out of range/ratio. Very confused. Help please!

History: diagnosed LADA (T1 diabetes) 3 years ago. On insulin and metformin. Started thyroid meds about same time.
Currently on Tirosint 88 and have been on this amt for over 1 yr.
Recent past FT3 labs (two separate testings over the last month or so) came back:
2.2 L        (Range 2.3-4.2) with
TSH .875  (Range: .350-5.500)

Dr. prescribed 5 cytomel without much more info. Started some reading re thyroid. Did not start cytomel as I wanted additional testing. So...


Redid FT3 test again with additional tests last week. These most recent labs came back as follows:

TSH: 0.337 L (Range .350-5.500)
FT4:  1.65     (Range: .89-1.76)
FT3:  2.4       (Range:  2.3-4.2)

Anti-TG  <20  (Range <41)
TPO       33    (Range <61)
Thyroglobulin (TG)  2.4  (Range: <55)

RT3:    443 H   (Range: 90-350)

Iron Serum: 67 (Range:30-170)
TIBC: 284        (Range: 250-450)
Ferritin: 48       (Range: 10-291)

Vit B12:  1219 H  (Range: 211-911)
Vit D 25:  50.5     (Range: 30-100)

What does all this mean--the very high RT3 and Vit B!2, especially? My Dr. keeps saying I have Hashi's, but do the labs indicate this? interpretation and some direction would be so appreciated!!

Thank you!

[froggykar]

thank you for the response. My hope was to wean off ALL thyroid meds since i have never tested positive for antibodies or hashi's. I take it opinions in this community are that my labs are suggestive that at this point losing meds may not be the correct course for me????

[des900]

with the above thyroid result you can see

you have a normal free t4 so no point in increasing levothyroxine. so stay on current levothyroxine dose.

also your reverse t3 went down so your current t4 dosage is current one.

your free t3 is on lower side so adding some t3 alone medication like cytomel will help regarding it, so consult your doctor and choose an appropriate cytomel dose.

never take any vitamin b12, iron or other supplements without testing the actually levels as not everyone will respond same to those. though vitamin b12 excess get excreted but if have some liver, kidney problems it might not work smooth and excess can remain in system for long and can experience strange symptoms.

[froggykar]

thanks for comment to repost on original thread! didn't realize. And thanks in advance for any guidance out there!

[froggykar]

recent labs update after decreasing from Tirosint 88 to Tirosint 75 for one month. My goal was to see if I could gradually wean off of all thyroid meds by slowly decreasing dosage. Numbers still don't look optimal. Looking for advice on what to do next.

Labs:

Recent                          
                                                            Compare one month ago (same rr)
TSH    1.585       rr .350-5.00                   .337 (L)
T4F     1.24         rr  .89-1.76                    1.65
T3F     2.5           rr  2.3-4.2                      2.4
RT3     87  (L)      rr 90-350                       443 (H)

All of this is so very confusing to me. I would appreciate any help!
Thank you!

[froggykar]

that's what I thought. Thank you for the confirmation. You have been very helpful.

[gimel]

No, that made no sense to me either.  Maybe the doctor thought that would increase your Free T3 level; however, it is far better to just add T3 med for that.  Free T4 is fine at the middle of its range, or slightly higher.  

[froggykar]

ok, that makes sense.  thank you.
on the other front, WHY would my Dr. up my T4 meds (1) given my recent lab results, and (2) while adding T3?
Now that I've begun reading more about the thyroid, this action seems wrong. Is he crazy, or am I unable to appropriately digest the info?

[gimel]

Always is a pretty difficult requirement.  LOL  I can't even find info that defines the probability of it being conclusive. Just for perspective, per the ATA, "About 5 % of patients with a diagnosis of Hashimoto’s thyroiditis based on clinical grounds or by ultrasound appearance have no measurable thyroid antibodies."  You have reported only the symptom of being tired, which can obviously be associated with other causes, plus your tests for antibodies were positive, but within the reference ranges, and your TSH has not been elevated.  Nothing clearly definitive there, so our thinking is to do the ultrasound as another attempt to rule Hashi's out or in.      

[froggykar]

thank you. I will see if I can get the ultrasound done and go from there. Is an ultrasound result always conclusive of hashi's/no hashi's?

[gimel]

Understand that we are operating in a gray zone here.  There are no hard and fast rules to follow because of the unusual circumstances.  So after some discussion with another member, Barb, I suggest that the first thing that you might do would be to get an ultrasound of your thyroid gland.  Even though your tests for the antibodies of Hashi's were within the reference range, and had not changed in 3 years, it might be best to confirm/rule out Hashi's with an ultrasound before proceeding with anything else.  .

If the ultrasound were to show Hashi's then consideration would be to modify your med dosage and also add some T3 to increase your Free T3 level.  Other actions would also be needed to address your high Reverse T3 level.  

If the ultrasound did not confirm Hashi's, then I would continue with the recommendation to wean off the thyroid med in three equal steps, but maybe extend the interval to 6 weeks before going back for re-test.  That would provide additional time for the change to show in serum levels and also for symptoms to manifest..

Obviously this is just our opinion, based on personal experience and from years of Forum participation.  Assuming you are successful at getting the ultrasound test done,  depending on the results, you should discuss all this with your doctor and reach agreement on the plan.  Please keep us informed of your progress.

[froggykar]

Thank you gimel. Your response is very confirming. This is what I needed to hear & where I was headed--slowly lessening the Tirosint over time to see if my thyroid can rebound and function independently without meds.

I have decided to find a new endo, and am kicking myself for not doing more research when he first prescribed thyroid meds. In hindsight, I guess I just accepted his advice, thinking that because of my autoimmunity diabetes I probably had autoimmune hashi's as well.

Today REALLY confirmed the need for me to lose him as my Dr.! Here's the story:  I had recently sent him a message informing him that I had (on my own) lowered my dose of Tirosint from 88 to 75 given my recent results. As I said in an earlier post, he wrote back: "take the cytomel". Then today, I got a call from his office nurse that he had called me in a prescription for and wants me to take the cytomel 5 and Tirosint 112! What??!! Why would he UP my T4 med to 112??
Needless to say, I will not be following this advice..

I'm so thankful for this community, as I was feeling so confused about direction.

Are you familiar with best protocol for attempting to wean off of thyroid meds? Would love your opinion as to:
1. How long to stay on current Tirosint 75 (decreased from 88) before making another decrease; and
2. Amount by which to decrease per each adjustment

I do realize that I may not feel great during the adjustment periods, but am at least willing to give my natural thyroid a shot and just react according to how it (labs + feeling) plays out.

Thank you again, and any help on weaning protocol would be very appreciated!

[gimel]

I am a bit puzzled by why the doctor chose to react to your original tests for the antibodies of Hashi's.  Your results did not exceed the reference ranges for either test, yet your doctor diagnosed Hashi's and started you on thyroid meds.  Most of the time Hashi's patients have to fight tooth and nail to get doctors to start them on thyroid med before their TSH exceeds 10 or when TSH is > 4.3, but their Free T4 level is still within range.  Exceptions to that usually are related to the patient having severe hypo symptoms and aggressively pushing for thyroid meds.  

So here you are 3 years later taking thyroid meds.  Your Free T4 is unnecessarily high from the T4 med dosage.  Your Free T3 is lower than optimal for many people and your Reverse T3 is above the range limit.  Your ferritin and Vitamin D are a bit lower than optimal.  I am surprised that you don't have more hypo symptoms.  Your TPo ab and TG ab levels haven't increased in 3 years, which further throws into question the presence of Hashi's.  

Where to go from here?  If there is a good chance that your body can work well without supplemental thyroid meds, think if it were me I would seriously question the doctor about the need for thyroid med, with no evidence of Hashi's and your only symptom being tiredness, which can be related to other things as well.  If the doctor cannot convince you of the need to continue on thyroid med, then you could very gradually reduce your T4 med over a span of say 3 months and note how you are feeling.  I say gradually so that you allow time for your body to acclimate. As this progresses, you may have some hypo symptoms you notice along the way, but they should subside as your body readjusts.  If symptoms should become intolerable, I would go in and test everything at that time.  If everything goes okay, then in about 4 weeks with no thyroid med, it would be good to re-test everything and determine your new levels.  

[froggykar]

Results from 1012 were:

TSH:   2.441 (rR .350-5.500)
FT4:    1.27   (rR: .89-1.76)
TPO:   37      (rR; <61)
Anti-TG: <20  (rR: <41)
C3 complement: 86.2 L  (rR: 90.0-170.0)

FT3 was not done at the time.

Thank you, gimel.

[gimel]

If you still have lab test results from 2012 please post them, along with reference ranges.  I'd like to see what the doctor used to diagnose Hashi's at that time and start you on thyroid med.  

[froggykar]

gimel: current symptoms would be tiredness only.

[froggykar]

gimel: Thank you for staying with me here.  I thought the reason for the high RT3 was oversupply of T4 from Tirosint, hence the reduction in my Tirosint dose. No?
My endo sent me an email ( in response to my latest labs) which said: "take the Cytomel". There was no further instruction. I'm not comfortable with that. And at this point I'm now questioning whether I need any thyroid med at all. The labs from 2012 and most recent do NOT show elevated hashimotos antibodies.

Red Star and Barb135: Thank you both for responses and for the info and sources. (I will look for that video.)
My experience with T1 and low carbing does allow me to take a lesser amount of insulin, particularly meal time bolus. I feel safer operating this way, as I have found it difficult to consistently correctly cover meal time carbs. Even with the identical meal on two different days, and the identical amount of insulin, I can have pretty different results, depending on factors i do know about--such as exercise, and factors only my body knows about!

[Barb135]

LCHF is not for everyone and does not guarantee that all diabetics will be able to reduce to one insulin shot/day... My son was diagnosed Type I diabetic at the age of 10 (he's now 43), eats LCHF and still needs multiple shots/day... You have to follow your body.

[Red_Star]

Okay well too much B12 then.  That was easy. :)  A video that is worth checking out: Troy Stapleton - I Manage My Type 1 Diabetes By Eating LCHF.  LCHF stands for low carb high fat.  I don't think he mentions how many carbs he eats on the video but I found online he eats under 50 grams a day of carbohydrate. This is a poll of those who have hypothyroidism eating LCHF...

"Question:

Are you on thyroid medication for hypothyroidism? Have you started an LCHF diet after being diagnosed? What happened?


After I started an LCHF diet I...

...had to increase the hormone dose a lot.  8.67%  (28 votes)


...had to increase the dose a bit  11.46%  (37 votes)


...need the same dose.  41.18%  (133 votes)


...could decrease the dose a bit.  14.55%  (47 votes)


...could decrease the dose a lot.  11.76%  (38 votes)


...could stop taking thyroid hormone.  12.38%  (40 votes)


Total Votes: 323"

Now if you have to increase the thyroid dosage then consider the bonus of 1 injection of insulin a day. I think this is a no brainer for me as I hate injections. :)


Diet Doctor: One Year on an LCHF Diet with Type 1 Diabetes...

"How does an LCHF diet work with type 1 diabetes? Here’s a one-year update:

Today I celebrate 1 year with LCHF, or I could say that I celebrate 1 year in good health! I can certainly endorse the LCHF diet as being good for type 1 diabetics.

Besides a more stable blood sugar and a more easily managed diabetes, I’ve gotten rid of pain in my legs, headaches, GI problems, and constant throat infections. Previously, I had recurring yeast infections, but during this past year I haven’t had a single one!

I only need one injection daily, instead of the previous 5-9. I eat delicious food, and I don’t miss anything. I have more energy and I’m happier than ever before! During the past year I’ve also gotten to know, and come in contact with, a lot of great people through Instagram and my blog!

I could go on about more positive things, but now I’m off to make dinner. A fatty, smoked rainbow trout to honor the day!"

[gimel]

Looking back I don't see any information on current symptoms.  Please tell us about those.  

I don't think it is the sole contributor to excess conversion of T4 to T3, but you should supplement your ferritin with some form of iron, to optimize.  Ferritin should be 70 minimum.

[gimel]

Not sure how you came up with a diagnosis of hyperthyroidism.  I suppose it is because of the low TSH level.  Are you aware that the TSH frequently becomes suppressed when taking significant dosage of thyroid med?  There are several scientific studies that have shown this.  So a suppressed TSH  does not indicate hyperthyroidism, unless there are accompanying hyper symptoms due to excessive levels of Free T4 and Free T3, which is not the case here.  Free T4 is within range, and Free T3 is much too low, since it is only at about 5% of the range.  Taking into account the high RT3, no wonder there would be hypothyroid symptoms.  So there is a need for T3 med, not a reduction in med.  

[froggykar]

thank you. I dropped back my Tirosint to 75 (as I had some on hand) until I talk w/ my Dr. I'm glad I didn't take the cytomel 5 he prescribed, adding it to the Tirosint 88 I was already taking, without doing further tests!
I will look into the folate RBC. thank you.

[jsycz]

Immediate concerns are High B12 and Hyperthyroidism

I would have them drop back your thyroid hormone just a little bit and Have them run a Folate RBC.

[froggykar]

Thank you for your reply, Red Star.
You are very helpful and kind to take so much time to provide info. Honestly It's so much information. I'm wondering what my next steps should be. I would love some guidance.

More info that might be helpful:

1. Was supplementing with a multi B and B 12 vitamin. Have cut that back since high B12 result;
2.. Have an appt with an integrative Dr (instead of my regular endo), to address thyroid, as I'm concerned over endo's handling of thyroid. Since last result, cut my Tirosint to 75 (since I had some left over from before Dr. increased me to 88 a long time ago);
3. Diet/lifestyle is healthy: exercise, don't drink, eat real unprocessed foods, and due to T1 diabetes--low carb. (I did read that low carbing can cause lower T3, but not sure of extent.) Prior to T! diagnosis, was a bit underweight (5'5" at 104lb). With insulin I've climbed to 112.

Thank you!

[Red_Star]

Your doctor would suspect Hashimoto's thyroiditis even with negative antibody levels as you have type 1 diabetes. And since you have high vitamin B12 serum another suspect is autoimmune pernicious anaemia (see study below on this*). This may nor may not be the case but it is something to consider since these autoimmune diseases are genetically linked. I found an article on causes of reverse T3 and insulin dependant diabetes is a listed cause of elevated RT3.

***

"Most patients with Hashimoto’s thyroiditis have measurable antibodies in the blood, with ~90% of patients having positive TPO antibodies and ~50% of patients having positive thyroglobulin antibodies. About 5 % of patients with a diagnosis of Hashimoto’s thyroiditis based on clinical grounds or by ultrasound appearance have no measurable thyroid antibodies." - Patients with Hashimoto’s thyroiditis and negative thyroid antibodies have a milder form of the disease - Clinical Thyroidology for the Public > Vol 7 Issue 9 > Vol 7 Issue 9 p.10-11

***

"Other causes of reverse T3 dominance include: leptin resistance, inflammation (NF kappa-B), dieting, nutrient difficiencies such as low iron, selenium, zinc, chromium, Vit B6 and B12, Vit D and iodine, Low testosterone, low human growth hormone, Insulin dependent Diabetes, Pain, Stress, environmental toxins, Free radical load, Hemorrhagic shock, Liver disease, Kidney disease, Severe or systemic illness, severe injury, Surgery, Toxic metal exposure." - Custom Medicine - Reverse T3 Dominance

***

The following info is from the book "The Everything Guide To Thyroid Disease" by Theodore C. Friedman, MD, PhD and Winnie Yu Scherer:

"Although the majority of people with Hashimoto's will not develop any other disorders, it's important to know what some of these autoimmune conditions are in case you do start to experience symptoms. Keep in mind, too, that you may be more likely to develop Hashimoto's if you have one of these other conditions.

Type 1 diabetes
Pernicious Anaemia
Addison's Disease
Vitiligo
Celiac Disease
Alopecia Areta
Systematic Lupus Erthematosus (SLE)
Rheumatoid Arthritis
Sjogren's Syndrome
Inflammatory Bowel Disease
Multiple Sclerosis (MS)"

***

*Excerpt from The New England Journal Of Medicine - Spurious Elevations of Vitamin B12 with Pernicious Anemia:

"Within a 3-week period, two women, 46 and 48 years of age, presented with peripheral neuropathy and associated pancytopenia with macrocytic anemia. Clinical suspicion for pernicious anemia was high, but vitamin B12 levels were 1644 pg per milliliter (1228 pmol per liter) and 1321 pg per milliliter (975 pmol per liter), respectively (reference range, 246 to 1320 pg per milliliter [181 to 974 pmol per liter]).

On subsequent bone-marrow evaluation, specimens from both patients showed profound megaloblastic features. Additional findings on laboratory tests included elevated levels of homocysteine and methylmalonic acid combined with detection of intrinsic factor–blocking antibodies and antiparietal-cell antibodies, which further supported the diagnosis of pernicious anemia."

***

This is my info I found online from various sources that I put together...

Increased vitamin B12 serum may be due to:

* Supplementing with vitamin B12/high dietary intake of vitamin B12
* Active (functional) vitamin B12 deficiency
* MTHFR genetic defect
* Polycythaemia Rubra Vera  
* Leukaemia:
- Chronic myelogenous leukaemia aka chronic granulocytic leukaemia
- Acute myeloblastic leukaemia
- Acute promyelocytic leukaemia
* Hypereosinophilic syndrome
* Myelosclerosis
* Carcinomatosis
* Liver disease:
- Acute hepatitis
- Cirrhosis
- Chronic liver disease
- Hepatic coma
* Non-leukaemic leucocytosis
* Chloral Hydrate