# Adding Cytomel, is this dose right?



## Jlgsmom (Feb 11, 2013)

Does this roller coaster ever stop? My daughter has secondary hypothyroidism so she has a low TSH as well as low Free T3 and Free T4. She started out at 112 mcg of Synthroid and was reduced down to 100 mcgs. About four weeks after the dose change she started having the hypo symptoms again, cold, tired, constipated, weight gain. Now this was obviously not as bad as her symptoms before starting Synthroid, but she said something was off so I called the Dr. and she said to come in for labs. Dr. said everything looked pretty good, Free T4 at 1.56, TSH obviously low due to the secondary hypothyroid and addition of Synthroid. However, she said her Free T3 really should be higher than it is and could be causing some of her symptoms. She said she doesn't use it often but thought we should try adding some T3 in a small dose. I just picked up her prescription and it's 25 mcgs once per day, that doesn't seem like a small dose from what I've read on here. I asked the pharmacists and he assured me it was a very small dose that is was micrograms. I'm thinking of at least halfing the pill and letting her start there. I'm thankful I didn't have to ask and that the Dr. was forward thinking enough to see her Free T3 lagging. However we live in a smaller community and she said she rarely uses the drug so I'm worried about the dose, I'm also naturally overprotective and sometimes worry too obsessively. I also hate that I feel like I need to second guess these medical professionals but I feel like I get better information and real world experience from this community. Should I have her cut the pill to start with? I see many on here take 5 mgs, but is 5 mgs more that 25 mcgs? I'm getting confused with the mg and mcgs. I put her labs up, you can see she is significantly lower in FT3 compared to her FT4 numbers. Also I know her FT4 is up there in the range but she is not having any Hyper symptoms at all. I'm just thinking it may be safer to split this dose and see how she does than to send her into a hyper swing.

2/6/13- prescribed 112 mcgs Synthroid

TSH .881 (.45-4.50)

FT4 .87 (.93-1.60)

FT3 1.4 (2.3-5.0)

3/20/13- changed to 100 mcgs Synthroid

TSH .019 (.450-4.50)

FT4 1.61 (.93-1.60)

FT3 3.0 (2.3-5.0)

4/22/13- will add Cytomel 25 mcgs

TSH .01 (.450-4.50)

FT4 1.56 (.93-1.60)

FT3 2.5 (2.3-5.0)


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## delski (Oct 17, 2012)

I had the same reservations when my doctor gave me a prescription for 25 mcg. I felt very wired and had lots of energy, followed by extreme fatigue when the effects wore off. I have decided to split the dose into quarters and I usually only take 2 quarters of a pill each day but that's the dose that makes me feel the most normal though I crash in the late evening. I usually avoid taking it too late in the evening because I've read it can cause sleeplessness but I took one at 8 pm yesterday and had no problem sleeping. I'm still trying to find out what works best for me though.


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## jenny v (May 6, 2012)

25 mcg is 0.025 mg, so it's actually not a huge amount. I'm on 5mcg of Cytomel, but I started out low and slow, splitting the dose up over several weeks until I made it up to the full 5mcg.


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## Jlgsmom (Feb 11, 2013)

Thank you both so much. I definitely feel better about it now. I think we will go ahead and just try half for a few days. Then either add the second half or try it in one dose.


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## Andros (Aug 26, 2009)

Jlgsmom said:


> Does this roller coaster ever stop? My daughter has secondary hypothyroidism so she has a low TSH as well as low Free T3 and Free T4. She started out at 112 mcg of Synthroid and was reduced down to 100 mcgs. About four weeks after the dose change she started having the hypo symptoms again, cold, tired, constipated, weight gain. Now this was obviously not as bad as her symptoms before starting Synthroid, but she said something was off so I called the Dr. and she said to come in for labs. Dr. said everything looked pretty good, Free T4 at 1.56, TSH obviously low due to the secondary hypothyroid and addition of Synthroid. However, she said her Free T3 really should be higher than it is and could be causing some of her symptoms. She said she doesn't use it often but thought we should try adding some T3 in a small dose. I just picked up her prescription and it's 25 mcgs once per day, that doesn't seem like a small dose from what I've read on here. I asked the pharmacists and he assured me it was a very small dose that is was micrograms. I'm thinking of at least halfing the pill and letting her start there. I'm thankful I didn't have to ask and that the Dr. was forward thinking enough to see her Free T3 lagging. However we live in a smaller community and she said she rarely uses the drug so I'm worried about the dose, I'm also naturally overprotective and sometimes worry too obsessively. I also hate that I feel like I need to second guess these medical professionals but I feel like I get better information and real world experience from this community. Should I have her cut the pill to start with? I see many on here take 5 mgs, but is 5 mgs more that 25 mcgs? I'm getting confused with the mg and mcgs. I put her labs up, you can see she is significantly lower in FT3 compared to her FT4 numbers. Also I know her FT4 is up there in the range but she is not having any Hyper symptoms at all. I'm just thinking it may be safer to split this dose and see how she does than to send her into a hyper swing.
> 
> 2/6/13- prescribed 112 mcgs Synthroid
> 
> ...


How old is your daughter? I personally would not do this. Your daughter should be started out on 2.5 mcgs. which would be 1/2 of a 5 mcg. tablet. Makes me wonder if someone missed the decimal.

Give this some serious thought. Many adults while eventually end up on 25 mcgs. cannot even tolerate the usual starting dose of 5 mcg. and they have to split the tablet to start out.

Please keep us informed re this matter. Too much could be life-threatening.

Others will chime in, I am sure.


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## bigfoot (May 13, 2011)

If your daughter is already on 100 mcg of Synthroid (T4) and her doc is adding in 25 mcg of Cytomel (T3), that is likely *waaay* too much medication, IMHO. (Bear in mind, I'm not a doc.) When I've tried Cytomel, it was usually in 5 mcg dose increments, starting low and slow. Some people even split those 5 mcg pills because even that can be too much.

T3 (Triiodothyronine) is roughly FOUR times as potent as T4, and much, much shorter acting. A dose of T3 will begin working in a few hours, and the half-life is measured in hours to days, instead of like T4 where they measure half-life in weeks. So essentially, your daughter will be getting up to the equivalent of 200 mcg of T4 (100 mcg T4 + 25 mcg T3 x 4 factor) relatively quickly. Yowsers!

With her TSH being so low, her FT4 already in the top end of the range, and the FT3 in the lower part of the range, I'd be looking at problems with _conversion_ of T4 -> T3, or else something blocking the active form of it from being absorbed. Are there any liver problems, gastrointestinal problems, food allergies, elevated cortisol or adrenal problems, other illnesses going on in the background? How about diet -- you want to be low in soy, goitrogens (broccoli, bok choy, cabbage, etc.), and gluten consumption. That last one can be a real doozy -- gluten is in nearly everything. Going gluten-free _could_ be a large part of this. And how about other vitamin levels -- D-25, B-12, etc.? And a high "Reverse T3" level can be significant, depending on which doc you ask, because it can block the receptor sites with 'dummy' inactive T3, which means that the true active form is not being used. Not only that, some think a high Reverse T3 can be indicative of an overall inflammation process, too. There are also blocking, binding, and stimulating thyroid antibodies that could be interfering.

Your doc will probably balk at all of this, but you should really ask to check into this stuff, especially now at the beginning of this journey. It may save a *lot* of speed bumps down the road. And I want to reiterate, be sure to go "low and slow" with these dose changes and increases.


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## jenny v (May 6, 2012)

Oh, that's a very good point Andros and bigfoot make--did the doc adjust her Synthroid at all before adding in the Cytomel?

My endo dropped me from 75mcgs of Synthroid to 50mcgs (which ended up being too big of a drop, but that's a different story) when we added in the Cytomel; 100mcg of Synthroid is a pretty big dose for someone who still has a thyroid so the Cytomel addition on top of that might push her into hyper and she's already hovering near hyper with that low TSH and high FT4.


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## Jlgsmom (Feb 11, 2013)

Okay, she is not taking this pill tomorrow! One more day without it won't hurt. I've called the Dr. to confirm the dose. She is 15 and as far as I know non of those things have been tested. She does eat a low carb diet as that was the only way she could stop/slow the weight gain. They did not lower her Synthroid. The Dr. seems to be eager to help, but not really looking at why this is happening.


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## Octavia (Aug 1, 2011)

My doc started me out on 5 mg of Cytomel, and several people here (on this board) were concerned that it was too much...so my guess is 25 is sky high.

(It turned out that I was able to tolerate the 5mg just fine.)


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## Jlgsmom (Feb 11, 2013)

Had a message from the Dr. this morning, she confirmed it is 25 mcgs. I'm going to do by best to quarter this pill and she will just take 1/4th of the dose once per day and see how it goes. Thank you all, I'll keep you posted as we go.


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## Andros (Aug 26, 2009)

Jlgsmom said:


> Had a message from the Dr. this morning, she confirmed it is 25 mcgs. I'm going to do by best to quarter this pill and she will just take 1/4th of the dose once per day and see how it goes. Thank you all, I'll keep you posted as we go.


Wow! Please do keep us informed.


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## bigfoot (May 13, 2011)

Jlgsmom said:


> She is 15 and as far as I know non of those things have been tested. She does eat a low carb diet as that was the only way she could stop/slow the weight gain. They did not lower her Synthroid. The Dr. seems to be eager to help, but not really looking at why this is happening.


It really behooves the doctor (and you guys) to ask the tough question of "why". In today's era of 10-minute office visits, that's not really enough time to get to the bottom of things. Seeing as how your daughter is only 15 years old, any doctor she sees should be turning over a LOT of rocks during this process.

The fact that her doctor confirmed she wants her to take 25 mcg of Cytomel, and hasn't lowered her Synthroid dose at all, doesn't exactly instill a lot of faith. Be on the close lookout for hyper symptoms, which BTW, can somewhat mirror hypo symptoms. You might ask your daughter to check her pulse throughout the day. If it is screaming fast or up over 100 just sitting around, she is likely getting too much RX.

Best of luck with this and keep us in the loop. arty0030:


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## Jlgsmom (Feb 11, 2013)

Hi all. Just wanted to briefly update all those who so kindly took the time to help me with my daughter. I quartered the 25 mcg Cytomel pill best I could, even with a pill splitter it was tough, and she started taking the pill Saturday. She said Saturday somewhere between an hour and two hours after she took the pill she had a brief (couple minutes) where she felt sort of odd, somewhat anxious. It passed quickly and she had no other issues that day. She has now taken the quartered Cytomel for four days and feels fine after taking it. She has not felt “weird” or “anxious” since that first dose. As of now it has not helped any of her hypo symptoms that came back after the Synthroid was lowered in March (cold, tired, constipated, slight weight gain). If she’s not having any side effects from the Cytomel or relief of symptoms after 7 days would that be the time to add a quarter in the afternoon? I know Cytomel is fast acting so if she was going to go hyper would we see it in a week or do we need to wait longer, 4 to 6 weeks like Synthroid? If this one dose turns her around I plan to have the Dr. call in a prescription for 5 mcgs because cutting this tiny pill is not easy or very accurate I’m sure. The Dr. did tell me she rarely if ever uses Cytomel, she’s a pediatric endocrinologist in a smaller community and I’m sure she’s never seen anyone with labs like my daughter. No endocrinologist in our area will see her until she’s 17. We are taking it one day at a time.


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## bigfoot (May 13, 2011)

I think your plan to get in touch with the doctor and go for a 5 mcg Cytomel prescription is a good idea. Perhaps she can write the RX as "twice a day," so that you can accommodate that afternoon dose trial you were thinking about. The trouble with thyroid issues is they can move at a glacial-like speed; plus, we are all going to react differently. At first, for me, 5 mcgs of Cytomel was like taking jet fuel. For your daughter, it appears that ~6.25 mcgs (25 mcgs / 4) was enough to only give her a few minutes of anxiety. That's a good sign.

I think you have two separate things to watch for:

1) A week or so for signs of being over-medicated or hyper on a certain dose of Cytomel.
2) Multiple weeks (or months) to start noticing big improvements in her signs & symptoms.

And kudos to you for monitoring this stuff so closely and taking an active role!


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## Jlgsmom (Feb 11, 2013)

Feel like I’ve had some success! Hopefully I’m not going to have to bother you all with this thyroid stuff anymore or for awhile at least, I just say I’m obsession compulsive when it comes to my daughter! I couldn’t help myself and called the Dr. yesterday afternoon to ask for the 5 mcgs. One nice thing about this Dr. is she actually calls me back, not her nurse or staff member. I just told her we wanted to work up to the 25 mcgs, so she’s writing a new RX for the 5 mcgs twice a day. She didn’t think 5 mcgs would be enough for her but was 100% on board with working into the 25 mcgs if needed. I feel so much better now! Now if the 5 mcgs in the morning isn’t enough, she can add 2.5 in the afternoon and work up slowly until she finds the right dose! I really feel good about this. Thank you all so much!


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## Andros (Aug 26, 2009)

Jlgsmom said:


> Feel like I've had some success! Hopefully I'm not going to have to bother you all with this thyroid stuff anymore or for awhile at least, I just say I'm obsession compulsive when it comes to my daughter! I couldn't help myself and called the Dr. yesterday afternoon to ask for the 5 mcgs. One nice thing about this Dr. is she actually calls me back, not her nurse or staff member. I just told her we wanted to work up to the 25 mcgs, so she's writing a new RX for the 5 mcgs twice a day. She didn't think 5 mcgs would be enough for her but was 100% on board with working into the 25 mcgs if needed. I feel so much better now! Now if the 5 mcgs in the morning isn't enough, she can add 2.5 in the afternoon and work up slowly until she finds the right dose! I really feel good about this. Thank you all so much!


You know what? This is awesome and I can tell you we all are breathing a sigh of relief re this.

You are not a bother; that is why we are here.


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## bigfoot (May 13, 2011)

Outstanding!!!

Seriously, you are spending a little more time on the "front end" with slow adjustments, but will be saving a lot of headaches down the road.


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