New test results (Armour)
Amethyst Ivy
odd, because I'm on Armour. Let me know what you all think.
I'll post the last few of them so you can get the picture. I felt best on 120mg
and think I should have always been left at that dose, but my doctor was afraid
of the 0.071 TSH back in June. I'll be seeing the doctor on Monday.
Ranges
TSh - 0.3 to 5.0
FT3 - 230 to 420
FT4 - 0.89 to 1.76
5/5/03
TSH -1.948 on 1 grain Armour increased to 120mg
6/16/03
TSH-0.071 on 2 grains Armour decreased to 90mg
Free T3 - 337
Free T4 - 0.94
7/30/03 Armour increased to 105mg
TSH- 1.386
Free T3 - 275
Free T4 - 0.80 (low)
9/4/03
TSH-1.575 Armour 105 mg. Hoping to
increase
Free T3 - 130 (low)
Free T4 - 0.72 (low)
Primrose
ameth...@aol.com says...
> 9/4/03
> TSH-1.575 Armour 105 mg. Hoping to
> increase
> Free T3 - 130 (low)
> Free T4 - 0.72 (low)
All I can say is if my dr. saw those results I'm sure he'd increase my
armour dosage.
I think your doc should worry less about the tsh and more about those
low results on the ft4 and ft3.
Amethyst Ivy
>low results on the ft4 and ft3.
I think so too, but she thinks TSH is the most important. She likes it between
o.5 to 1.5. I brought info to her on Armour and how the dosage should be
determined by the Free T3 and Free T4, but she thinks the info is by doctors
who have a paid interest in Armour.
Skipperbeers
>I think so too, but she thinks TSH is the most important. She likes it
>between
>o.5 to 1.5. I brought info to her on Armour and how the dosage should be
>determined by the Free T3 and Free T4, but she thinks the info is by doctors
>who have a paid interest in Armour.
My TSH was slightly low, as was my T4, but the TSH ruled and my dose was cut
and I declined slowly to a very bad place. I didn't know enough to fight at
the time.
Anyway, your doctor's solution would help almost any thyroid patient. So, it's
not an unusually terrible position, it's actually better than most. Arem in
his excellent book "The Thyroid Solution" says you have to monitor TSH, you
can't ignore it and he says to keep it between .5 and 2. Langer in "Solved the
Riddle of Illness" doesn't want usually give more than 3 grains of Armour and
never more than 4, and if your pulse rate is over 80 will reduce your dosage.
Doctors have different philosophies and if you want to be treated by anything
other than strict TSH, then you need to convince your doctor or go elsewhere.
They are afraid of lawsuit because if a patient is not adequately treated as
long as TSH is OK, the patient isn't going to be considered to have much of a
case regardless of the damage. On the other hand, if the patient dies of heart
attack or breaks bones that have become frail and TSH was kept low, they do
have a case. The latter scenario is not likely because the worst thing for
your heart is a low thyroid and thyroid meds do not cause osteoporosis, but
doctors are worried about those problems and the law suits.
I think you need more thyroid, you will never do really well until you find
someone who will give you an adequate amount for you, but you've got to decide
whether to accept what the doctor gives you, fight hard to persuade her and at
this point if she won't listed she probably isn't going to, or go elsewhere.
Skipper
Amethyst Ivy
>someone who will give you an adequate amount for you, but you've got to
>decide
>whether to accept what the doctor gives you, fight hard to persuade her and
>at
>this point if she won't listed she probably isn't going to, or go elsewhere.
>
>Skipper
I have an appointment on Monday to discuss the test results. I have kept all
my records including the ones where I was on Levoxyl-Cytomel. It shows that
when I was on the Levoxyl-Cytomel and anytime my TSH was above 1.5, the endo
increased my dose of Levoxyl. I'm hoping this will convince her to increase
the Armour back to 120 mg.
Primrose
ameth...@aol.com says...
> I brought info to her on Armour and how the dosage should be
> determined by the Free T3 and Free T4, but she thinks the info is by doctors
> who have a paid interest in Armour.
It sounds to me like she's doing a "CYA" thing. (That means "cover your
ass.")
I'm sorry but I think that saying doctors must have a paid interest in
armour, is total BS. Since armour is so much cheaper than synthroid,
I'd say if anyone wanted to make money they'd invest in the drug company
that makes synthroid, since it's among the top few most Rx'd drugs in
the US. ;-)
My dr. Rx's armour and I take my Rx to the drugstore like anyone else.
He doesn't make any money off of it. If I wasn't doing as well on
armour, he'd try cytomel or something else. Basically the difference is
it matters to him if my condition is improving, not which drug I'm
taking or what the TSH is.
I don't know...it's only my opinion but if I were in your shoes I'd go
to someone else. It just seems like when you try to educate this dr.
she won't listen. The bottom line is you need to get clinically well,
not just look well on paper. Anyway, good luck to you and I hope you
are able to get what you need. :-)
Skipperbeers
>I don't know...it's only my opinion but if I were in your shoes I'd go
>to someone else. It just seems like when you try to educate this dr.
>she won't listen.
That's a good summation of the whole issue. If your doctor can be educated and
willing to listen she can still be a great help to you. But, if she's not and
she can't be convinced that you need your TSH in the range they call
"subclinical hyperthyroid" , she will not help you, you will continue to
decline and get worse. The risk of "Subclinical hyperthyroidism" could
eventually be heart attack or osteoporosis, but the cost of where she wants you
to remain can be a lot of your life wasted because you are too tired and too
brain dead to live well.
My doctor usually looks for handouts from me now when I come in. Because I've
learned if you don't have things in writing, your doctor won't cover them it
works better for me. Below are some of the points I would make, and I would
have the summary on top with the supporting printouts attached.
The case for letting you go into the range she's afraid of is -
1. Frequently, a low TSH is only transitory.
(http://knowledge.emedicine.com/cgi-bin/knijavascript.htm?va=the%20only%20
defined%20risk)
"The risks associated with a slightly low level of TSH in otherwise healthy
patients are low, and changing their thyroid dose is often not necessary.
Because TSH levels vary on a daily basis, changing doses frequently may
complicate and raise the cost of therapy. Compliance with daily dosing is a
major reason for TSH changes in individual patients (which a careful history
reveals) and thus militates against prescribing a new dose of medication."
2. There is a possibility of "subclinical hyperthyroidism" (that is, low TSH
without hyper symptoms.). It does need to be monitored to be sure that it
doesn't become real hyperthyroidism.
(http://knowledge.emedicine.com/cgi-bin/knijavascript.htm?va=the%20only%20
defined%20risk)
"The risk for a patient with a low TSH and normal T4 and T3 levels is the risk
of subclinical hyperthyroidism. Some subclinical hyperthyroidism disappears and
some slowly progresses."
.
3. You know the risks and since the additional hormone will probably make you
"normal" you consider the risks to be reasonable. Some sources state that
aspirin kills 5,000 people a year, and you realize no medication comes without
risk.
(http://knowledge.emedicine.com/cgi-bin/knijavascript.htm?va=the%20only%20
defined%20risk)
The only defined risk associated with subclinical hyperthyroidism is a higher
prevalence of atrial fibrillation (or other tachyarrhythmias) and a higher
prevalence of thrombotic events.
4. Studies showing that this causes osteoporosis haven't been consistent, so
can probably be ruled out.
(http://knowledge.emedicine.com/cgi-bin/knijavascript.htm?va=the%20only%20
defined%20risk)
"Previously, osteoporosis was thought to be a risk; however, more recent
studies have not consistently confirmed this hypothesis."
All the above quotes were from an endocrinologist who doesn't even like Armour
Thyroid.
5. You believe the following applies to undertreatment as well as untreated
hypothyroidism. It is bad for your heart too.
http://www.pslgroup.com/dg/3E1A6.htm
"Left untreated over time, a thyroid disorder can affect a patient's
cardiovascular system, reproductive system and major organs."
6. Another study on osteoporosis, they used patients who had never been
hyperthyroid, but had thyroids removed because of thyroid cancer. These
patients typically have their TSH suppressed.
http://www.thyroid.ca/Articles/EngE4J.html
" Studies of the effect of thyroxine replacement therapy on bone mineral
density have given conflicting results; the reductions in bone mass reported by
some have prompted recommendations that prescribed doses of thyroxine should be
reduced. We have examined the effect of long-term thyroxine treatment in a
large homogeneous group of patients; all had undergone thyroidectomy for
differentiated thyroid cancer but had no history of other thyroid disorders.
The 49 patients were matched with controls for age, sex, menopausal status,
body mass index, smoking history, and calcium intake score; in all subjects
bone mineral density at several femoral and vertebral sites was measured by
dual-energy X-ray absorptiometry. Despite long-term thyroxine therapy (mean
duration 7-9 [range 1-19] years) at doses (mean 191 [SD 50] şg/day) that
resulted in higher serum thyroxine and lower serum thyrotropin concentrations
than in the controls, the patients showed no evidence of lower bone mineral
density than the controls at any site. Nor was bone mineral density correlated
with dose, duration of therapy, or cumulative intake, or with tests of thyroid
function. There was a decrease in bone density with age in both groups."
7. There are risks to both under treatment or overtreatment, but as this study
says, the risks have not been quantified by any large study. I think that
means that whereas "evidence-based" doctors don't seem to like anecdotal
evidence, that is what they are basing their fear of a low TSH on.
http://freespace.virgin.net/p.mc_gowan/aud10.htm
"There does appear to be a significant incidence of abnormal TSH level in
patients taking thyroxine. Unfortunately there is no definite evidence
available on the optimum TSH level for patients on thyroxine and particularly
in cases where the TSH level is only mildly outside the normal reference range.
Undertreatment can have the effect of persisting symptoms though it is
difficult to assess the prevalence of this. Undertreatment could also increase
serum lipids with an increased risk of cardiovascular disease. Overtreatment
could lead to symptoms of thyrotoxicosis, with potentially toxic effects on the
heart and a possible risk of osteoporosis. However, it is very difficult to
quantify the risk as there have been no large studies."
8. Armour literature says the effectiveness of thyroid hormone should be tested
by total T4 levels. If T4 levels are low but TSH is normal, to test for free
T4. Again, remember normal is 95.5 % of the population and you would like to
be where healthy people are which is probably high in the normal range (but I
don't have anything that tells that. The closest is with total T4, Dr. Alford
says it should be 8 if you are converting T4 to T3 well, which he says can be
measured by the T3 uptake test.)
"Laboratory Tests - Treatment of patients with thyroid hormones requires the
periodic assessment of thyroid status by means of appropriate
laboratory tests besides the full clinical evaluation. The TSH suppression test
can be used to test the effectiveness of any thyroid preparation
bearing in mind the relative insensitivity of the infant pituitary to the
negative feedback effect of thyroid hormones. Serum T4 levels
can be used to test the effectiveness of all thyroid medications except T3.
When the total serum T4 is low but TSH is normal, a test specific
to assess unbound (free) T4 levels is warranted. Specific measurements of T4
and T3 by competitive protein binding or radioimmunoassay
are not influenced by blood levels of organic or inorganic iodine."
Skipper
Lois
I felt best on 120mg
: and think I should have always been left at that dose, but my doctor was
afraid
: of the 0.071 TSH back in June. I'll be seeing the doctor on Monday.
Here's some material from the new website in progress, below my name. The
quotes are blockquotes on the web page. It's true that some other studies
don't have the same conclusions, but look at how many studies say that a
suppressed TSH level is not necessarily a problem, and look at how many hypo
patients feel well (not hypo or hyper) only when their TSH level is
suppressed.
I'm not one of those patients; I sometimes start to feel hyper symptoms even
before my TSH level is in the hyper area. The point is that we're all
different, and the TSH test alone can't determine how much medication each
thyroid patient needs.
Lois
------
Suppressed TSH Levels: Medical Journals
Purpose of this compilation
To show that a suppressed TSH (thyroid stimulating hormone) level in
patients on treatment for hypothyroidism or hyperthyroidism doesn't
necessarily indicate a non-euthyroid state.
A. Suppressed TSH, thyroid hormone levels, and euthyroidism
1. "Thyroid function tests and hypothyroidism" (UK, 2003)
We have long taken the view that most hypothyroid patients are content with
a dose of thyroxine that restores serum concentrations of thyroid
stimulating hormone to the low normal range. However, some achieve a sense
of wellbeing only when serum thyroid stimulating hormone is suppressed, when
we take care to ensure that serum tri-iodothyronine is unequivocally normal.
Until valid evidence shows that such a policy is detrimental we will
continue to treat patients holistically rather than insist on adherence to a
biochemical definition of adequacy of thyroxine replacement.
Toft AD, Beckett, GJ. Thyroid function tests and hypothyroidism. Brit Med J
2003;326:1087 (17 May) Letters.
Online at <www.bmj.com/cgi/content/full/326/7398/1087>.
2. "Suppression of Serum TSH by Graves' Ig: Evidence for a Functional
Pituitary TSH Receptor" (Netherlands, 2001)
Antithyroid treatment for Graves' hyperthyroidism restores euthyroidism
clinically within 1–2 months, but it is well known that TSH levels can
remain suppressed for many months despite normal free T4 and T3 levels....We
conclude that TSH receptor autoantibodies can directly suppress TSH levels
independently of circulating thyroid hormone levels, suggesting a
functioning pituitary TSH receptor.
...Such a mechanism may very well be responsible for the low TSH levels
observed in otherwise euthyroid Graves' patients receiving antithyroid drug
treatment.
Brokken LSJ, Scheenhart JWC, Wiersinga WM, Prummel MF. Suppression of Serum
TSH by Graves' Ig: Evidence for a Functional Pituitary TSH Receptor. J Clin
Endocrinol Metab 2001 Oct;86(10):4814-7.
Online at <http://jcem.endojournals.org/cgi/content/full/86/10/4814>.
3. "TSH as an index of L-thyroxine replacement and suppression therapy"
(Ireland, 1992)
Suppressed TSH levels were associated with...normal FT4 levels in 62.5% [of
the 90 clinically euthyroid patients receiving treatment with L-thyroxine].
Igoe D, Duffy MJ, McKenna TJ. TSH as an index of L-thyroxine replacement and
suppression therapy. Ir J Med Sci 1992 Dec;161(12):684-6.
Abstract online at <www.ncbi.nlm.nih.gov>.
4. "Thyroid stimulating hormone measurement by an ultrasensitive assay
during thyroxine replacement: comparison with other tests of thyroid
function" (UK, 1987)
Serum thyroid stimulating hormone (TSH) was measured using a highly
sensitive enzyme-amplified immunoassay in 37 clinically euthyroid patients
receiving thyroxine replacement therapy and compared with other biochemical
tests of thyroid function....A suppressed serum TSH was found in 65% of
patients with a normal serum total thyroxine.
Wheatley T, Clark PM, Clark JD, Raggatt PR, Edwards OM. Thyroid stimulating
hormone measurement by an ultrasensitive assay during thyroxine replacement:
comparison with other tests of thyroid function. Ann Clin Biochem 1987
Nov;24 (Pt 6):614-9.
Abstract online at <www.ncbi.nlm.nih.gov>.
5. "Clinical value of a sensitive immunoradiometric assay for TSH" (1985)
...our extended study here has revealed that a significant number of
euthyroid patients with undetectable TSH (1.5% in our study) are likely to
be found if TSH becomes the initial test for thyroid function. Thirty [out
of 111] of the hypothyroid patients on thyroxine were found to have
undetectable TSH, but only one showed clinical signs of thyrotoxicosis. Most
of the patients, although having raised serum free T4, had serum free T3
levels within the euthyroid range or just slightly elevated.
Allen KR, Scott RD, Hewitt JV, Watson D. Clinical value of a sensitive
immunoradiometric assay for TSH. Ann Clin Biochem 1985 Sep;22 (Pt 5):506-8.
Abstract online at <www.ncbi.nlm.nih.gov>.
6. "Therapy of primary hypothyroidism with L-triiodothyronine: discordant
cardiac and pituitary responses" (1980)
...higher doses of L-T3 or substituting L-T4 therapy could suppress TSH
secretion further without altering the other peripheral responses to thyroid
hormone.
Ridgway EC, Cooper DS, Walker H, et al. Therapy of primary hypothyroidism
with L-triiodothyronine: discordant cardiac and pituitary responses. Clin
Endocrinol (Oxf) 1980 Nov;13(5):479-88.
Abstract online at <www.ncbi.nlm.nih.gov>.
B. Suppressed TSH and bone metabolism
1. "Thyroid function tests and hypothyroidism" (UK, 2003)
The weakness of the meta-analysis, showing that thyroxine induced
suppression of thyroid stimulating hormone led to reduced bone mineral
density, was recognised by the authors themselves, who said that their
design (cross sectional studies) was not appropriate because the many risk
factors for bone loss do not allow correct matching of controls with cases.4
This realistic assessment accords with the earlier views of Franklyn et al
that thyroxine treatment alone does not represent a significant risk factor
for loss of bone mineral density.5
Toft AD, Beckett, GJ. Thyroid function tests and hypothyroidism. Brit Med J
2003;326:1087 (17 May) Letters.
Online at <http://bmj.com/cgi/content/full/326/7398/1087>.
2. "[Prolonged suppressive L-thyroxine therapy. Longitudinal study of the
effect of LT4 on bone mineral density and bone metabolism markers in 71
patients]" [Article in French; abstract in English] (France, 1999)
Seventy-one patients (including 28 menopaused women) taking long-term L-T4
for thyroid carcinoma were divided into 3 groups according to their TSH
level: low (TSH < 0.04 mlU/l), moderate (0.04 TSH < or = 0.10 mlU/l) and
high (TSH > 0.10 mlU/l)....No lumbar or femoral osteopenia was observed in
these patients taking L-thyroxin, even for those with complete TSH blockade.
Rachedi F. [Prolonged suppressive L-thyroxine therapy. Longitudinal study of
the effect of LT4 on bone mineral density and bone metabolism markers in 71
patients]. Presse Med 1999 Feb 20;28(7):323-9.
Abstract online at <www.ncbi.nlm.nih.gov>.
3. "Suppressive doses of thyroxine do not accelerate age-related bone loss
in late postmenopausal women" (Japan, 1995)
One group of patients was given suppressive doses of L-T4 (TSH <0.1 mU/L, n
= 12) and the other group was given nonsuppressive doses of L-T4 (TSH > 0.1
mU/L, n = 12). There was no difference in bone metabolic markers and
incidence of vertebral deformity between the groups....These prospective and
cross-sectional data suggest that long-term levothyroxine therapy using
suppressive doses has no significant adverse effects on bone.
Fujiyama K, Kiriyama T, Ito M, et al. Suppressive doses of thyroxine do not
accelerate age-related bone loss in late postmenopausal women. Thyroid 1995
Feb;5(1):13-7.
Abstract online at <www.ncbi.nlm.nih.gov>.
4. "Suppressed TSH levels secondary to thyroxine replacement therapy are not
associated with osteoporosis" (UK, 1993)
We set out to measure bone mineral densities in two groups of
post-menopausal women receiving thyroxine replacement therapy (those with
serum TSH levels persistently suppressed or non-suppressed) and to compare
the results in both groups with those of the local control
population....CONCLUSION: In this patient population, the reduction in bone
mineral density due to thyroxine is small. It is unlikely to be of clinical
significance and should not on its own be an indication for reduction of
thyroxine dose in patients who are clinically euthyroid.
Grant DJ, McMurdo ME, Mole PA, Paterson CR, Davies RR. Suppressed TSH levels
secondary to thyroxine replacement therapy are not associated with
osteoporosis. Clin Endocrinol (Oxf) 1993 Nov;39(5):529-33.
Abstract online at <www.ncbi.nlm.nih.gov>.
C. Suppressed TSH and cardiac effects
1. "Minimal Cardiac Effects in Asymptomatic Athyreotic Patients Chronically
Treated with Thyrotropin-Suppressive Doses of L-Thyroxine" (US, 1997)
...in the absence of symptoms of thyrotoxicosis, patients treated with
TSH-suppressive doses of L-T4 may be followed clinically without specific
cardiac laboratory studies.
Shapiro LE. Minimal Cardiac Effects in Asymptomatic Athyreotic Patients
Chronically Treated with Thyrotropin-Suppressive Doses of L-Thyroxine. J
Clin Endocrinol Metab 1997 Aug;82(8):2592-5.
Online at <http://jcem.endojournals.org/cgi/content/full/82/8/2592>.
River
one of those currently going through TSH supression and have had many
of my questions answered by the articles. I'm sure that gathering all
this information was quite a bit of work - thank you for sharing it!
River