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Finding the Perfect Thyroid Medication (Part 1)

September 27, 2012 30 Comments by Scott Isaacs, M.D.

If there’s a positive aspect about hypothyroidism, it is treatable. Although it may take time to find the perfect treatment, in my experience, most people do eventually achieve ideal thyroid hormone balance. There is no one-size-fits-all treatment. Your symptoms and blood tests both matter when assessing thyroid hormone status. You need to work with your physician (endocrinologist) closely to make sure you are taking the right type and the correct dose of thyroid medication. But to truly achieve ideal thyroid hormone balance, there is even more you can do to get the full benefit from your medication.

 Treatment of Hypothyroidism with Levothyroxine

With time and persistence, 80 to 90% of patients with hypothyroidism have the best results using pure levothyroxine for thyroid hormone replacement. But for 10-20% of patients, a variety of alternative treatments are necessary to completely reverse all symptoms and restore total health.  A study published in Clinical Endocrinology reports that as many as 34-49% of patients with hypothyroidism still have symptoms despite treatment with levothyroxine. However, in that study, there was no effort to truly optimize levothyroxine with tighter ranges for blood tests and attention to dietary and lifestyle requirements. This article will discuss how to get the most out of treatment with pure levothyroxine. In my next article, I discuss T3, personalized thyroid replacement and other alternative treatments.

The main goal of therapy is to restore thyroid hormone levels to normal and to eliminate the symptoms of hypothyroidism.  This means that you must have periodic blood tests to make sure all your levels remain in the proper range. Most people who need thyroid hormone replacement have permanent hypothyroidism and need to take thyroid hormone replacement medication for the rest of their lives.

If you are one of the 80-90% of people who respond to levothyroxine, one pill daily essentially cures hypothyroidism. However, many people don’t give levothyroxine an adequate chance to work before they try other treatments. They never get a chance to see if optimizing levothyroxine therapy is their best option. I understand the desire to explore new and different treatments, but I urge you to give levothyroxine a fair shot before moving on. In my experience, many patients who take alternative thyroid medications had symptoms because they were on the wrong dose of levothyroxine or for causes other than hypothyroidism.

Levothyroxine is a synthetic form of T4 that is chemically identical to the natural form produced by the body and is available as a generic or as the brands Synthroid, Levoxyl, Levothroid, and Tirosint. Levothyroxine is naturally converted by the body to the active form, T3, and provides the base of the thyroid cycle. A healthy thyroid gland produces mostly T4, which is naturally converted by the body to the active form, T3. The medication levothyroxine most closely reproduces this cycle by providing a pure source of T4, enabling T3 conversion to occur naturally.

The average dose of levothyroxine needed is about 0.75 mcg per pound of body weight, so a 150-pound person usually needs to take the 112 mcg tablet. This calculation is just an estimate. The dose must also be adjusted according to a person’s symptoms and TSH level. Despite its effectiveness in the vast majority of patients, levothyroxine has been much maligned. Critics claim that levothyroxine is not ideal because it is not a natural product or because it contains T4 but not T3.

Are You Still Having Symptoms While Taking Levothyroxine?

Ten to 20 percent of patients have persistent symptoms despite treatment with adequate doses of levothyroxine. Many doctors dismiss these symptoms; however, the following suggestions may be helpful.

Get Healthy

Health problems of any kind can magnify symptoms of hypothyroidism and impair the body’s ability to convert levothyroxine to the active form.

Stress Less

Stressful situations, chronic stress, and even the stress of being overweight can be major catalysts in disrupting the normal performance of the thyroid. When under stress, the body sends messages triggering responses from many hormones. Many of these responses are short lived and beneficial. The production of adrenaline, for example, provides people with the extra shot of energy and excitement often needed to get through a stressful situation. (Think of how you feel when making a public speech: the palms sweat, the heart beats faster, you feel afraid and very alive—all part of the “fight-or-flight” instinct developed over millions of years.)

If the stress lasts for a long time, though, such as the kind of stress felt after surviving a tragedy or losing a loved one, your endocrine system and your immune system become overburdened. Naturally it can lead to health problems. In particular, the immune system becomes dysfunctional, because your brain—using the flood of stress-inspired chemicals as a guide—is focusing its responses elsewhere. With the immune system out of whack, the body is helpless against viruses and other toxins that attack the thyroid. The immune system can become overactive, attacking and destroying the thyroid gland or stimulating it to produces excessive amounts of thyroid hormone. Autoimmune problems are the most common cause of both an underactive and overactive thyroid gland.

When the body is under stress, T4:T3 conversion problems can also occur. In one scenario, the wrong iodine—the inner-ring iodine—can be removed from the thyroid hormone, which creates an inactive form of the hormone called reverse T3. Given the inert state of reverse T3, metabolism slows to a crawl.

Change the Dose of Levothyroxine

Precise thyroid hormone levels are necessary for optimal hormonal balance. If you are taking levothyroxine and still have symptoms, adjusting the dose may help. The reference range for TSH varies among labs but is usually 0.5–4.5 µU/ml. The reference range is not the same as the therapeutic target for thyroid hormone replacement therapy, which is a TSH level near 1 µU/ml, because most people feel best when the TSH is at the lower end of the reference range. Increasing the dose of levothyroxine by a tiny amount (sometimes just an extra half-tablet once a week) is often enough to bring the TSH closer to the therapeutic target of 1 µU/ml. Some patients have symptoms of an overactive thyroid if the TSH is treated to reach this range. For these patients, I recommend decreasing the dose to maintain the TSH in the mid-normal range.

Try Branded Levothyroxine or Try a Different Brand

Brand-name levothyroxine—Synthroid, Levothroid, Tirosint, or Levoxyl—may offer an advantage over generics. The quality control for the branded versions is better than generics, although generics have improved somewhat in recent years. Differences in the inert ingredients or fillers that make up the tablet lead to differences in absorption of the medication, which can affect blood levels. The cost between brand name and generic levothyroxine is only a few dollars each month. I have had many patients that for unknown reasons did much better with a particular brand. I haven’t seen that one brand is better than another, just different. Some times making a change can make a big difference in symptoms even when blood tests stay the same.

Check Your Other Medications

Several medications, vitamins, and minerals interfere with the absorption of levothyroxine from the bowels. Among them are serataline, cholestyramine, iron supplements or vitamins with iron, calcium supplements, Maalox, Mylanta, and other aluminum-containing antacids. It is recommended that patients avoid taking other medications for four hours after taking thyroid medications. Drugs that reduce stomach acid, known as proton pump inhibitors, including omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium), can inhibit the absorption of thyroid medications.

Estrogen-containing medications, including birth control pills and hormone replacement, will also affect thyroid dosing. When women start taking estrogen medications, most of them need a 20–40 percent increase in their dose of thyroid medication. The reverse is also true when estrogen medications are discontinued.

Are You Pregnant?

Pregnancy can increase thyroid hormone requirements as early as four weeks into pregnancy. Hypothyroidism in pregnancy is a serious issue. It is estimated that 2.5 percent of pregnant women have some form of hypothyroidism; however, the symptoms of hypothyroidism may overlap those of simply being pregnant and the diagnosis may be missed. Hypothyroidism is associated with an increased risk of pregnancy complications. One study showed that women with mild thyroid deficiency during their pregnancies had children with subsequent developmental and intelligence defects. All pregnant women should have their thyroid level tested. If you are pregnant and have hypothyroidism, you should have your levels tested every four weeks. Most women need a 40–50 percent increase in their thyroid medication dose by the end of the second trimester. Having thyroid peroxidase antibodies or thyroglobulin antibodies will increase the risk of a miscarriage even if thyroid hormone levels are normal throughout pregnancy. Current guidelines recommend keeping the TSH less than 2.5 µU/ml during pregnancy.

Take Thyroid Medication on an Empty Stomach

Take thyroid medication at least one hour before or after food and two hours from soy and peanuts. Food, especially soy products and peanuts, can decrease the absorption of thyroid medications.

Take Thyroid Medication Properly

For best results, take thyroid medication every day. If you forget to take a pill, you can take a double dose the next day to maintain adequate thyroid levels. Even forgetting one pill a month can lead to less than optimal thyroid levels. Because levothyroxine is so long acting, if you forget a pill or two, you can take a double or triple dose to make up the difference. Here is a suggestion to make sure you get the right dose. Place seven levothyroxine tablets in a separate pill bottle once a week. Each day, take your medication from this bottle. At the end of the week, if there are any leftover pills, take them all. This method ensures that you take seven tablets every week.

Take Thyroid Medication at Night

Studies have also shown higher blood levels when thyroid medication is taken at night. Taking thyroid medication at night will not cause sleep problems.

Are Your Pills Damaged or Expired?

Always check the expiration date, which can be particularly short with some thyroid medications. Thyroid medication can be damaged by heat if left in a hot car or over the stove.

Cut Back on Gluten

Many thyroid patients have gluten intolerance. Reducing gluten may improve bowel function, allowing better absorption of thyroid medications.

Check Your Vitamin B12

Thyroid patients tend to have lower vitamin B12 levels. Supplementation with vitamin B12 pills, injections, or nasal spray is sometimes necessary to replace a deficiency.

See a Gastroenterologist

Thyroid patients are at increased risk for autoimmune bowel disease. Bowel problems can impair the ability to absorb mediations. Celiac disease, irritable bowel syndrome, and Crohn’s disease are more common in patients who have hypothyroidism.

Get a Full Hormone Evaluation

If you have thyroid problems, you are at risk for other hormonal problems. Even if you are on the right dose of thyroid medication, you won’t feel right unless all your hormone problems have been addressed.

Look for Other Issues

Many symptoms can have more than one cause. If thyroid levels are optimized and symptoms persist, there could be another cause such as sleep apnea, congestive heart failure or chronic kidney disease.

Be Patient

Levothyroxine is a very long-acting medication. When you start taking it, it takes five to six weeks to achieve stable blood levels, but because it takes even longer to achieve stable tissue levels, the resolution of symptoms may take longer. Every time your dose is changed, it will take another five to six weeks for levels to stabilize.

What to Do When Levothyroxine Doesn’t Work

For some patients, despite valiant efforts, levothyroxine alone is not enough to restore optimal hormone balance. In my next article, I discuss personalized and alternative treatments for hypothyroidism.

For more information on thyroid disease and ideal treatments, please read my book Hormonal Balance: How to Lose Weight by Understanding Your Hormones and Metabolism or visit my Facebook page.

www.YourEndocrinologist.com
www.IntelligentHealthCenter.com

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30 Comments

  1. Kay says:
    Thursday, September 27, 2012 at 8:31pm

    Wondering what you could suggest for a person that has had a subtotal thyroidectomy. I’m on levothyroxine .75mcg

  2. Scott Isaacs, MD says:
    Friday, September 28, 2012 at 6:20am

    Kay, the best approach is to work closely with your doctor because the dose can vary and your symptoms and blood tests matter a lot in making this decision. I hope this article (and Part 2) help you on your journey.

  3. Ann Williams says:
    Saturday, November 10, 2012 at 12:32am

    Dr. Isaac, I was reading your response tp BoNita, and it was very very informative. I too have been fighting a weight issue as a result of Graves Disease.. This article is dynamic! I feel there is still hope for me. I am going to try your recomendations on how to take my medication…Thank you so much!

  4. Pam says:
    Saturday, April 27, 2013 at 11:39am

    I have been on lythroxine in many different doses since 2009 and yet it is not working for me. Tested negative for gluten intolerance, have labs drawn every 6 weeks and yet I go from hyper to hypo and back with each lab test. My weight is up, I am miserable an no one seems to figure out how to help me anymore

  5. Theresa says:
    Sunday, April 28, 2013 at 12:39am

    In my opinion and from my own experience, natural thyroid hormones should never be saved as an “alternative” treatment. It should be the first line of defense, along with the testing of adrenals and iron. Some top thyroid docs won’t even treat the thyroid until the adrenals and iron are optimal since they can severely impact a patients reaction to any thyroid hormone replacement. If I had been treated in this manner over twenty years ago it would have saved me years of misery.

  6. Scott Isaacs, MD says:
    Tuesday, May 21, 2013 at 1:09pm

    I respect your opinion Theresa. In medicine, we try to avoid making decisions based on one person’s experience. Clinical practice guidelines are based on carefully done research and the consensus of a group of experts that are at the top of their field. This way, we try to avoid biases that can occur from individual experiences.

  7. Julie Jueneman says:
    Saturday, July 6, 2013 at 8:23am

    Hyperthyroidism is a nightmare disease for me. After being treated with radioactive iodine 2 1/2 years ago I have yet to feel like my old self. This disese has created a mess of my life. It’s up and down every other month. I couldn’t hold a job if I had to, mnI never know from one day to the next how I will feel. I have NEVER had digestive issues and now I am on Nexium because several other acid reducers didn’t work for me. I wish there were some Dr. who believed that I am having a terrible time with this disease. My Dr. says I am sensitve to the medication and I am down from 125 mg/day 2 years ago to 25 mgs/day. Still miserable and hating my life. What do I do???

    Julie

  8. Scott Isaacs, MD says:
    Monday, July 8, 2013 at 12:45pm

    It will get better. Work with your endocrinologist. Your thyroid levels will eventually return to normal.

  9. Judith Bernet says:
    Monday, January 27, 2014 at 7:03am

    Very interesting. I have Hashimoto’s. I have often had low iron and never knew why. While menstruating had light periods. Now at 58 of course none. What isi the proper test for Iron, not just Ferritin is it? I have had tremendous Stress in the last years, and did have a cortisol test or something couple years ago…was ok. They were checking my hypothalamus right? Anyway, what test or was it that tests the adrenals please? I have been told Ii probably have exhausted adrenals from the continual flight/fight effect. There are times when I have laid in bed all day exhausted. I have been mobbed, and various other stresses, moving, lack of momey (worrying about our existence at times) and coping with living in a foreign country is very hard sometimes. I just had a thyroid test and my TSH was over 9, and have been told to increase my “Euythyrox” to 1 instead of .75 mg. In the last two years (Menopause years too I guess before), I have had hair falling out rapidly, extreme dry skin (for years), dry mucous membranes, aches and pains, inflammed achilles, digestive problems (acid), and have deposits of calcium in my body and osteo-arthritis. Am overweight (lack of exercise too), and was cold all the time, and attacks of acute tiredness and funny breathing like not getting enough oxygen…not too bad now, I need 9 to 10 hours sleep and tire easily but am unfit…I have had acute tense neck and shoulder muscles and calf muscles and loads problems. I am very fed up. Any further simple suggestions. I plan to eat better, exercise more. Cut down on alcohol or cut out completely. Was drinking too much. I was on the minipill nearly all my life to keep Endometriosis under control. So that hasn’t helped I guess. How often should I get my blood tested. They were saying each six months but this time it was a year, and so after complaining I was tired and cold, TSH was 9 and more. Help.

  10. Ellison says:
    Friday, July 4, 2014 at 12:26pm

    I have been taking Synthroid or Levothyroxine for 17 years now and found out recently that both contain Aluminum. This is a metall I try to stay clear of as my mother her sister and their mother suffered from Alzheimer’s I would like to know if there is a Thyroid treatment that does not contain Aliminum .

  11. Scott Isaacs, MD says:
    Thursday, August 28, 2014 at 5:01pm

    Aluminum is used for the coloring of the pills. The 50 mcg dose of Synthroid is white tablet that does not contain colorings or aluminum. Some of my patients who want to avoid colorings take the 50 mcg tablets in various combinations to match their daily dose. There aren’t any studies linking Synthroid use to Alzheimer’s disease, though.

  12. F says:
    Friday, December 26, 2014 at 3:07am

    I was diagnosed by a naturopath last year as being hypothyroid and was advised to take small amounts of t3 and t4 while keeping tabs on a sluggish pulse and low basal temperature. This after seeing an Md and blood tests came back normal but I didn’t feel right. But the MD wouldn’t listen. So I started and soon found energy levels up, certain symptoms disappeared and temp went up half a degree on average to 97.2. I have worked a highly stressful physical job four years that had me up early and home late and in winter was often frozen working in minus thirty degree Celsius and colder weather. Six weeks ago I worked in an environment with diesel exhaust and some occasional fumes from melting vinyl and little ventilation. I felt dizzy, sick, and funny that week. I went to the doctor and he gave me few minutes of time and wrote some stuff and that was it. I looked for another job in my confused and sick state, found one, and gave notice to the other one. I didn’t sleep literally for three nights. Went to emergency. They said see a doc. Went to doc. Wanted to give me anxiety pills. Walked out frustrated. Slept better that night as was exhausted by then. Have experienced severe insomnia every couple nights since that week, head feels tingly, pressure behind the eyes, pressure in the head and odd sensations in general, memory issues, problems concentrating, confusion, ringing in the ears, occasional nausea, often catch myself recently walking in circles for no reason. Saw a local ND and she was glad i quit the job and recommended various vitamins, diet, etc which i was already mostly doing and wanted to cut back thyroid medicine and make sure it’s not the adrenals before jumping on the thyroid and to have blood tests redone. I changed MDs. Another blood test showed i now DO have hypothyroidism, though I had known that already for a year. How much of these symptoms are job related and hypothyroidism is my question. The doc instantly jumped on the latter without even bothering to listen to anything about it being possibly work related. Just strange how suddenly after that one week I have become so sick and wretched with all these symptoms, that do sound like hypothyroidism, but why so suddenly and just like that when the other symptoms were getting better.

  13. Dana says:
    Saturday, July 4, 2015 at 11:03am

    I have been on levothyroxine for over a year now I’m taking 150 mcg every morning at 5:45 with a full glass of water I’m 5’7.5″ and I weigh 180. Threw out the year of taking it 3months ago when my blood was drawn my tsh was 200 it is suppose to be 3 I fell tired, depressed, my muscles hurt me a lot like I’m trying to push my self all the time. And I’m only 21 it is genetic in my family!! Should I try a different medication? Because I feel it isn’t working I eat fruit and veggies daily!! I really need help tired of felling this way.

  14. Shari says:
    Thursday, July 16, 2015 at 8:04am

    I am almost 41 and I am in the process of becoming a gestational surrogate. I was put on 100mcg of synthroid due to TSH levels being 6.5. I have also been put on 8mg of estradiol a day. What should I expect and is this safe?

  15. Scott Isaacs, MD says:
    Thursday, July 23, 2015 at 8:23am

    Guidelines for thyroid in pregnancy recommend a TSH less than 2.5 to prevent fetal loss.

  16. Scott Isaacs, MD says:
    Thursday, July 23, 2015 at 8:24am

    Throw away your pills and get new ones. They are not working. They may have become exposed to heat leading to inactivation.

  17. suzanne says:
    Saturday, July 25, 2015 at 7:40pm

    I had miscarriage issues due to hypothyroidism. After 5 all around 8-10 weeks.i found one wonderful doctor who put me on vag. Suppositories of specially blended progesterone until the end of my first trimester. She explained that Once you reach end of first trimester the placenta then produces the hormones needed for baby vs. Robbing momma. It worked like a charm. Had I not been led to this one amazing doctor i would have never carried full term….and had my happy healthy baby boy who is now 21.

  18. Jolene says:
    Saturday, August 1, 2015 at 7:49pm

    180lbs what should my levo mcg be? I take .5.

  19. Ijen says:
    Monday, August 24, 2015 at 12:05am

    I take synthroid, alternating between 0.050 mg and 0.075 mg each day. My doctor recommended this dosage strategy because my TSH and T4 levels indicate I fall somewhere in between the two. I usually take my meds around 7:30 am. By 4 or 5 pm daily, I usually feel either a rise in anxiety (on 0.075 mg days), or a noticable fatigue (0.050 mg days). Is this due to the absorption pattern of Synthroid? Does this drug work evenly throughout the day, or am I experiencing its peak around late afternoon? Thank you.

  20. Pam says:
    Tuesday, September 22, 2015 at 1:46pm

    Hashimoto’s, switched from Synthroid 75mcg (palpitations, hair falling out, difficulty with sleep). Taking Tirosont 50mcg/4 d week +Tirosint 75mcg 3/d week. Since on Tirosint craving salt and sugar. Gaining weight. Hair not falling out as much, palpitations lessened. Do you think Tirosint is harsh on Adrenals? I have seen a natural path and he wants me to try herbs but I have Thallassemia minor and sensitive physiology that I don’t want to mess up. I am Gluten free and don’t want to be back on Synthroid because of Gluten. Also take 5mcg of Cytomel daily. Thank you!

  21. Meg says:
    Wednesday, September 23, 2015 at 1:03pm

    My concern is about hair loss that began about 2 yrs.ago (70 yrs.old now). My skin doctor, and general practitioner suggested an over the counter hair replacement product for women, but I’m wondering if my significant hair loss could be due to my Levothyroxine 100 mcg, taken daily in the morning. I purchase my thyroid pills at Costco, and wondered if different brands contain higher or lower doses depending on the company that makes them. The other women in my family are not experiencing this hair loss, and several are on thyroid medication also. Could Synthroid be a better fit for me, even though it’s more expensive then Levothyroxine? My hair loss is similar to what I experienced during pregnancy……a brush full, and plugging up the tub drain. What do you suggest? Also, my TSH tests are up to date, with a lowering of dosage amount from 112 mcg recently, as it was too high ( heart beat changes). Thank you for your help with this concern, as other women may be experiencing it also.

  22. ruthann says:
    Monday, October 19, 2015 at 9:53am

    i have taken 75mg.thyroid medication for several years now. my dr. now tells me that the pill isn’t working. increased it to 88mg. about two months ago. have been in lot of stress because of a very sick husband with cancer. once you start taking that medication, i was told i will take it for the rest of my life. i accept that. what i don’t understand is that once you get regulated with the amounts of medication dosage how does it all of a sudden not work.

  23. Gill says:
    Tuesday, October 27, 2015 at 4:05pm

    I kept getting racing heartbeat and aching shoulders neck and jaw, feeling nauseas and headache on 75 mcgs. So doctor took me down to 50 mcgs. My Tsh was 7 and I am worried if I am getting enough levothyroxine but could not put up with stomach cramps.

  24. Scott Isaacs, MD says:
    Thursday, February 11, 2016 at 5:20pm

    I would suggest working with an endocrinologist. I wish you the best!

  25. Scott Isaacs, MD says:
    Thursday, February 11, 2016 at 5:23pm

    Synthroid and Tirosint both contain the same active ingredient (levothyroxine) and are both gluten free. Cytomel is not gluten free.

  26. Scott Isaacs, MD says:
    Thursday, February 11, 2016 at 5:28pm

    One dose lasts about a week. So the day to day fluctuations you are experiencing are unlikely due to the alternating dose of thyroid medication. These symptoms are concerning though and I would recommend that you see an endocrinologist.

  27. Scott Isaacs, MD says:
    Thursday, February 11, 2016 at 5:40pm

    The standard dose of levothyroxine is about 0.75 mcg per pound of body weight. But there is tremendous variability as with most cases of hypothyroidism, the thyroid is still making some thyroid hormone.

  28. Laura says:
    Saturday, September 10, 2016 at 10:21pm

    Do I need to be worried about my thyroid pills if they come from my mail order pharmacy, as in being exposed to heat sitting in the mail box.

  29. Annie says:
    Wednesday, November 2, 2016 at 2:14pm

    When I was first diagnosed with (mild) hypothyroidism, I was put on 25 mcg Synthroid and felt increasingly better for 2-3 months, then it all slid backwards (even my test results). 4 months later, the addition of 5 mcg Cytomel, and 2 Synthroid increases have not helped. What might cause this to happen and what can I do to start improving again?

  30. Scott Isaacs, M.D. says:
    Wednesday, February 15, 2017 at 10:05am

    Heat can inactivate thyroid medication.

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