# Should I lower my anti thyroid dosage?



## slivola (Jun 27, 2012)

Hi Everyone,

I would appreciate your advice! I was diagnosed with graves disease in June and started methimazole 30mg/day on June 11th. I got my thyroid rested on July 30th and showed great improvement. Here are my results:

Name Standard range 6/7/2012 7/30/202
*T4 FREE* 0.8-1.5 ng/dL 3.08 1.3

Name Standard range 6/7/2012 7/30/2012
*T3 * 58-159 ng/dL 341 118

Name Standard range 6/7/2012 7/30/2012
*TSH* 0.35 - 4.00 uIU/mL <0.01 <0.01

My T4 Free and T3 are now in the normal range. My endocrinologist emailed saying my labs have improved and I should continue taking the 30mg/daily dose. I wrote back expressing concern that if my levels dropped by more than 50% for T4 and T3, would they continue to drop so that I would be hypo if I continued at my current 30mg? Here is the response I received:

_"Your thyroid hormone levels will not vary much day to day as half the hormone you make today will be still in your bloodstream a week from now (plus all the new hormone made in the next 7 days). You are correct in assuming that I am using an educated guess as to how much methimazole to use. I'm quite content to have you lower your dose of methimazole so you won't worry about it. Please decrease to 20 mg daily and repeat your lab testing in 6 weeks."_

I feel like it's kind of my decision now if I want to lower to 20mg, which I'm leaning towards. I would really welcome any of your thought and insights into this!

Thank you!


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## slivola (Jun 27, 2012)

Sorry, it was hard to read my test results in my post above. Here they are:

T4 FREE Standard range 0.8-1.5 ng/dL 
6/7/2012: 3.08
7/30/2012: 1.3

T3 standard range: 58-159 ng/dL 
6/7/2012: 341 
7/30/12 : 118

TSH standard range: 0.35 - 4.00 uIU/mL 
6/7/2012: <0.01
7/30/12 : <0.01

Thank you for any insights into if you think I should lower my dose from 30 to 20mg. My endocrinologist seems to think it's a guessing game and he's letting me decide.

Thanks!


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## adenure (May 7, 2012)

Hi!

It sounds like you have a great endo- willing to communicate & work with you- that's great!

I would lower the dose to 20 mg. I was on 5 mg. of methimazole for 7 weeks and it brought my TSH to 1.28 and my free T4 & T3 within a good range as well. Unfortunately my liver enzymes were 8 times the normal amount (I had a baseline that was normal), so I had to stop the meds. My thyroid levels stayed stable for the 6 weeks that I waited to have a TT though (7 weeks ago today), so for that I'm grateful.

I do know some people who have gone hypo bc of too much methimazole (pretty powerful stuff), so I would definitely lower it to 20 mg. and keep tabs on your symptoms in case even that much makes you hypo over the next 6 weeks.

Alexis


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## slivola (Jun 27, 2012)

Thank you for your encouragement to switch to the 20 mg. You started off only taking 5mg and had such great results? Usually people start off much higher- that's so great it worked so well for you and kept you steady while waiting for the TT. How are you feeling now after surgery?

Thank you!


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## Lovlkn (Dec 20, 2009)

slivola,

How do you feel?

My opinion is that 6 weeks is too long between tests at this point in your treatment.

At 20mg with your current labs you are likely to go completely hypo in 6 weeks.

In my opinion you need to insist your doctor test you in 3-4 weeks.

You could also order a FT-3 and FT-4 test which comes with a TSH test online at www.healthcheckusa.com

It costs $85 and is money well spent - you really want to avoid going hypo. Ferquent testing early in the anti thyroid meds treatment is key for proper medication


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## slivola (Jun 27, 2012)

Lovlkn- thanks for your thoughts. My understanding about thyroid testing is that the halflife of the thyroid takes about 5 weeks to cycle through so testing it earlier wouldn't necessary yield helpful results. My doctor also emailed explaining "thyroid hormone levels will not vary much day to day as half the hormone you make today will be still in your bloodstream a week from now (plus all the new hormone made in the next 7 days)." So he generally recommends testing in 6 weeks so that the full 5 week half life has run its course.

I have been feeling tired this past week but also have a sore throat and feel like I'm fighting something. I had a CBC to make sure it wasn't my white blood cells from the medicine, and they were normal. I asked my endocrinologist if my tiredness is related to turning hypo, but he said because I just had my labs done on Monday and they were normal, then this is just a virus and not thyroid related. My retesting is ordered between Sept 1-14 and I was going to go on the 14th, but after reading your email, I will go in Sept 1st since I am just starting the 20mg dose tonight. That will be about 4 weeks instead of 6. My doctor told me that once my virus clears up to email him if I start gaining weight or feeling hypo and we will lower it again.

Thank you for your encouragement to retest sooner. I would have waited for 6 weeks instead of 4.


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## slivola (Jun 27, 2012)

Hi again Lovlkn. I just looked at the FDA dosage guidelines and it says 5-15mg/day for maintenance. Would I be considered in maintenance since my levels are in range? I emailed this to my doctor to see if I can get some 5mg pills or if the 10mg can be split with a pill cutter. Thank you for getting me to look into this. My doctor must think I'm a pain in the neck since I'm always questioning his dosage, but as he said, it's really just a guessing game to get the right dose.
Thank you again!


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## adenure (May 7, 2012)

No, I think I win the "pain in the butt" award as far as questioning my endo!!! I must have the record on emails to him  But, he's always great about answering my questions the day I ask him either by email or phone.

Yes, my dose was small (5 mg); my endo. seems to be the cautious type (which I appreciate) and starts small and inches up if needed. For example, I started on Synthroid 100 mcg after surgery and he upped me this week to 112 mcg. (next increment up). We'll wait 6 weeks and then test blood again. My TSH was 6.15 at 6 weeks post op while on the 100 mcg. Synthroid. Odd thing was that my Free T4 & T3 were in range (T4 in the upper 75% and T3 below mid range)- ah well, what can you do? So, hoping the 112 will do the trick.

I feel really great as far as surgery healing is concerned. I had a super surgeon who did a great job- no complications, thanks be to God! As far as the Synthroid... well, early stages still. So, I'm not feeling like my old self exactly, but I'm trying to forge ahead with my life and "dance through the rain" instead of waiting for the storm to pass so to speak. I have 4 boys and we homeschool. Graves really took me out there for a good 6 or 7 months. Fortunately I was diagnosed fairly quickly and I'm now on the road to recovery- so that is great & I'm very grateful! Not easy, but I'm doing the best I can.

Alexis


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## slivola (Jun 27, 2012)

So glad to hear you are recovering as well as can be expected and were able to find such a great endocrinologist. Happy healing!


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## Lovlkn (Dec 20, 2009)

I made an error on my testing recommendation - I saw I posted 2 weeks and meant to post 3-4 weeks.

When you begin to drop your dose after beginning anti thyroid meds - I think more frequent testing is required to help stabilize your dose.

The FT-4 and FT-3 are the active hormones you are testing - TSH is completely useless as it can indeed lag behind by up to 6 weeks.

All I scan suggest is lower your dose, keep a log of symptoms and if you have symptoms go and have labs drawn. Do not take your meds before your draw.

For me in the beginning I would lower for 4 weeks then raise then lower then raise - it was unbelievable how a slight decrease or increase would mess with my labs.


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## Andros (Aug 26, 2009)

slivola said:


> Hi Everyone,
> 
> I would appreciate your advice! I was diagnosed with graves disease in June and started methimazole 30mg/day on June 11th. I got my thyroid rested on July 30th and showed great improvement. Here are my results:
> 
> ...


My thoughts are that the dose you are currently on is the dose that got you to the area of improvement. Therefore, to maintain, it might be prudent to stay on that dose for another 6 to 8 weeks and get labs again.

Also, it is very important to know how you feel w/your current numbers. So, how do you feel?

And.................you doc ran a Total 3, not a Free T3. Free T3 is the active hormone. That would have been very helpful under the circumstances.

Free T3 etc. 
http://www.thyroid-info.com/articles/freet3woliner.htm

Another good test would be to see where this number would be at........

T3 Resin Uptake (hyper if high)
http://www.nlm.nih.gov/medlineplus/ency/article/003688.htm

What are your plans for the long haul? Any input on this from your doctor?


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## slivola (Jun 27, 2012)

Lovlkn- thank you for clarifying about the restesting interval. My doctor puts in a lab order that allows me to go in anywhere from about 4-7 weeks to retest depending on how I'm feeling.

Andros- I will inquire about testing Free 3 verses Total 3. I've been feeling tired for the past week. Before that, I was feeling great from the 30mg. I'm concerned that even the 20mg will throw me into hypo since my lab ranges are good right now. My labs from Monday look good but it takes the thyroid 6-8 weeks to fully cycle through and show the results of what I'm currently feeling.

I'm doing more research about it today. I've been reading some of Elaine Moore's research on her website. Her research highly recommends keeping the T3 and Free T4 ranges in the higher end of normal and then switching to maintenance of 2.5-10mg (after the first initial 6-8 weeks on a higher level.)


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## Andros (Aug 26, 2009)

slivola said:


> Lovlkn- thank you for clarifying about the restesting interval. My doctor puts in a lab order that allows me to go in anywhere from about 4-7 weeks to retest depending on how I'm feeling.
> 
> Andros- I will inquire about testing Free 3 verses Total 3. I've been feeling tired for the past week. Before that, I was feeling great from the 30mg. I'm concerned that even the 20mg will throw me into hypo since my lab ranges are good right now. My labs from Monday look good but it takes the thyroid 6-8 weeks to fully cycle through and show the results of what I'm currently feeling.
> 
> I'm doing more research about it today. I've been reading some of Elaine Moore's research on her website. Her research highly recommends keeping the T3 and Free T4 ranges in the higher end of normal and then switching to maintenance of 2.5-10mg (after the first initial 6-8 weeks on a higher level.)


How about your ferritin; is it good?


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## slivola (Jun 27, 2012)

Yes, ferritin is normal and was when I first started meds in June. My RBC and hemogloblin had been slightly low when I was first diagnosed but all of my blood work came back normal with my thyroid blood work done on 7/30/12. Liver ALT was back to normal, too (had been slightly elevated prior to starting treatment.)


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## slivola (Jun 27, 2012)

FERRITIN range 13-126 ng/mL

My level is 69.6 ng.


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## Lovlkn (Dec 20, 2009)

slivola,

I just checked my lab sheet from the first year after I was dx'd and I never reduced my dose more than 1/2 of what I was taking when I tested euthyroid.

Several times I had labs within 1-2 weeks of a dose change. I remember my symptoms were intense - the fall down from being hyper can be intense.

Be prepared to lab frequently and I cannot tell you how important good lab history will be to find your set point dose.

It took me 9 months to be able to tolerate being on 5mg daily of Tapazole. Then I would swing anywhere between 2.5mg to 7.5mg. Testing monthly for 4 years before deciding I had enough and scheduled my total thyroidectomy.

Ya Mon... Life is good now.


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## slivola (Jun 27, 2012)

Thank you Lovkln, that's helpful background information. Thank you for taking the time to look up your earlier labs for a point of comparison. Maybe 15mg would be a good starting point since my doctor didn't even blink an eye when I suggested 20mg instead of staying at 30mg. I have read that 20mg is now the typical starting point instead of 30mg. I also read that often reducing a dose 50% is a good place to begin maintenance once one is euthyroid.


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## slivola (Jun 27, 2012)

Hi Everyone,

I wanted to say thank you for the encouragement to really research and look into what would be the appropriate maintenance dose after my labs were in range after 7 weeks on 30mg. I had been feeling really exhausted with cold hands for one week, but my endo said it wasn't related to my thyroid because my tests were in range (although he is the first to admit that the thyroid takes 6-8 weeks to cycle through and reflect how we feel in a lab, but in this case, he decided my symptoms were NOT thyroid related!)

Anyway, I lowered to 10 mg ten days ago and I am now feeling better! I'm curious to see what my labs will look like in early Sept. I will be seeing a new endo (thanks to adenure's referral) the day after my test results and will see his approach.

Thank you!


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