QUESTION: When I first saw this patient she was taking 100 mcg T3 QD, prescribed by you, at that time. Her chief complaints were fatigue (she commutes 1.5 hours to work each way and was not getting enough sleep and was under a fair amount of stress) and headaches (in the morning, in the center of forehead). She also smokes 1/2 pack of cigarettes daily. I ran labs which were as follows:
TPO >1000 (I think this was in the 500 range when you tested it)
rT3 15 (9 – 27)
TSH below lab limit
T3 2.5 H
fT3 7.8 H
I also did an ASI that showed elevated cortisol in am and noon and low cortisol in afternoon and evening. However, the other lab panel I ran also included a serum cortisol (a.m.) that was WNL (?) I had her taper down her T3 and simultaneously switch to a T3/T4 combo. She was on 40 mcg T4 and 13 mcg T3 BID for several weeks. I then retested labs which showed:
TSH below lab limit
fT4 3.2 H
T3 2.9 H
fT3 11.0 H
I then had her stop T3 and switch to 80 mcg T4 daily. A week later (two weeks ago now) she reported that she was having swelling in her neck, that her thyroid felt more enlarged than it was prior, as well as swelling in her face/eyes upon waking in the morning. She remembered that she had these sx previously when she was taking T4 a few years ago. I had her stop all thyroid medication at that time and she has started to feel better since. I’m also referring her to an endo for further workup, just to make sure I’m not missing something. To date her tx plan has consisted of:
Autoimmune diet and reducing/eliminating coffee
Selenomethionine 400 mcg QD
Adrenal support in the afternoon
Various unda #s
I’d appreciate any thoughts on her case and ideas on how to get her to an optimal dose of thyroid replacement. I’m wondering if she may possibly have antibodies against T4? Other thoughts on calming down her immune system?
ANSWER: I never intend to have folks on that much T3 for that long unless the resistance is really deep and whatever underlies it isn’t resolving. But it doesn’t sound like she had hyper sx which typically mean the resistance is broken (usually when I taper them off or to a T4/T3 rx). As for thyroid I like leaving her off while the endo work up goes on. Later unless the endo finds magic, I’d titrate up on a plain T3 Rx and then add some T4 next. She’ll likely tolerate it better. In these cases (unless hyper sx exist) I do labs but never ever treat based on them as the resistance has components we can’t test and in the absence of hyper sx the labs don’t indicate any safety advantage. (that said I do follow them). With folks on T3 I do a 48 hour wash out with no T3 then check the TSH – if it rebounds into a detectable level and they still need the T3 I leave the dose alone (or titrate to sx) if it is suppressed at 48 hours, I drop the dose and re-test (unless they have a hx of thyroid cancer).
Once the many reasons for resistance break (autoimmunity, chronic infections, toxins, food intol………) they become hyper symptom wise with the T3 and I taper them down or off and use a T3/T4 mix. You have most of the non thyroid bases covered.
For more information, listen to my webcall on T3 dosing.