I would suggest consider doing a 1mg thyroxine loading test - it is amazing how well patients can absorb thyroxine under supervised conditions.
Ian
-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Reynolds Tim (RJF) BHFT
Sent: 10 September 2014 08:23
To: [log in to unmask]
Subject: Re: Low T3 syndrome
I have had a lot of meetings with her and am convinced she is taking the tablets. Also, the symptomatic improvement from the T3 is remarkable. On reflection, I think I will have to try to get the histology results and possibly the notes from the hospital that did the op. It would be interesting to know what symptoms were / lab results before she had the thyroidectomy.
**************************************************************************************
Prof. Tim Reynolds
Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D Lead, Burton Hospitals NHS Foundation Trust work tel: 01283 511511 ext 4035 work fax: 01283 593064 work email: [log in to unmask] work URL: www.burtonhospitals.nhs.uk This e-mail, and any files transmitted with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person. If you have received this e-mail in error, please notify me on 01283 511511 Ext 4035
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-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Mohammad Al-Jubouri
Sent: 09 September 2014 6:59 PM
To: [log in to unmask]
Subject: Re: Low T3 syndrome
Thanks Tim, fascinating case, at least we know now that despite the industrial doses of T4 & T3, they don't seem to have found their way to the circulation so we can't blame the pituitary gland protesting against insufficient thyroid hormones by sending massive TSH shout. She is either non/partially compliant or not able to absorb thyroid hormones. A trial of witnessed weekly dose or parenteral T3 should resolve the issue.
Mohammad
--------------------------------------------
On Tue, 9/9/14, Reynolds Tim (RJF) BHFT <[log in to unmask]> wrote:
Subject: Re: Low T3 syndrome
To: [log in to unmask]
Date: Tuesday, 9 September, 2014, 17:18
A brief history:
PH - total thyroidectomy for hashimoto's. Histology not done here so I cannot look to see what was found.
Symptomatically very hypothyroid - cold, sluggish significant weight gainetc.
April 2013 TSH 299 fT4 0.7 fT3 1.4:
Referral from GP - taking 200 ug T4 at same time as Ca supplements - advised dose timing change May 2013 TSH 314 fT4 0.8:
Increased dose to 300 ug T4
July 2013 TSH 308 fT4 0.7 fT3
0.4 Missed treatment due to UTI - left dose at 300 ug Sept 2013 TSH 331 fT4 0.3 fT3 0.7
Had definitely been taking tablets
- no improvement: changed to T3 40am/40pm Nov 2013 TSH 100 fT4 0.3 fT3
0.4 Symptomatically improved
but not 'normal - increased to T3 60/40 am/pm Jan 2014 TSH 100 fT4 0.3 fT3
0.4 Feeling improved - dose left unchanged Mar 2014 TSH 100 fT4 0.3 fT3 1.0 Still tired but improved
- increased to T3 80/40 am/pm
May 2014 TSH 164 fT4 0.3 fT3
0.4 Now lost 2 stone in wt
[back to mormal], able to wake up in the morning, not feeling cold. Symptomatically feels much better [like she was before thyroidectomy]
As she is on a high dose of T3, I have not increased the dose and she is symptomatically well. So, I am monitoring but not increasing doses to get the numbers correct.
**************************************************************************************
Prof. Tim Reynolds
Consultant Chemical Pathologist / Clinical Director - Diagnostics / R&D Lead, Burton Hospitals NHS Foundation Trust work tel: 01283 511511 ext 4035 work fax: 01283 593064 work email: [log in to unmask]
work URL: www.burtonhospitals.nhs.uk
This e-mail, and any files transmitted with it, are confidential and intended solely for the use of the individual to whom it is addressed. If you are not the intended recipient please destroy this message, delete any copies held on your systems, and notify the sender immediately. You should not retain copy or use this e-mail for any purpose, nor disclose all or any part of its content to any other person. If you have received this e-mail in error, please notify me on 01283 511511 Ext 4035
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-----Original Message-----
From: Mohammad Al-Jubouri [mailto:[log in to unmask]]
Sent: 09 September 2014 4:55 PM
To: [log in to unmask];
Reynolds Tim (RJF) BHFT
Subject: Re: Low T3 syndrome
Really Tim, 500 mcg thyroxine and no effect on TSH >100?
what was the FT4 level? I would seriously consider false elevation of TSH due to HAMA, HARA ore even Macro-TSH especially that even T3 didn't suppress it.
Regards
Mohammad
Dr. M A Al-Jubouri, MB ChB, MSc, EurClinChem, FRCP Edin, FRCPath Consultant Chemical Pathologist
--------------------------------------------
On Tue, 9/9/14, Reynolds Tim (RJF) BHFT <[log in to unmask]>
wrote:
Subject: Re: Low T3 syndrome
To: [log in to unmask]
Date: Tuesday, 9 September, 2014, 16:44
Whilst there are some patients who are mad there are some that really do seem to need T3. I have one patient (age
22) whose TSH remains
> 100. On doses of up to 500mg of T4 there was no change but when given T3, she lost weight and began to resume normal activities [she can even make it to clinic on time now instead of turning up 3 hours late]. Even now on T3 her TSH has not dropped much but the obviously symptomatic hypothyroidism has resolved and she is much better. Biochemistry does not always give the right answers...
**************************************************************************************
Prof. Tim
Reynolds
Consultant Chemical Pathologist /
Clinical Director -
Diagnostics / R&D Lead,
Burton Hospitals NHS
Foundation
Trust
work tel: 01283 511511 ext
4035
work fax: 01283
593064
work email:
[log in to unmask]
work URL:
www.burtonhospitals.nhs.uk
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and any files transmitted
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From: Clinical
biochemistry discussion list
[mailto:[log in to unmask]]
On Behalf Of Salter Simon (ROYAL FREE LONDON NHS FOUNDATION TRUST)
Sent: 09 September 2014 4:39
PM
To: [log in to unmask]
Subject: Re: Low T3
syndrome
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During
my short time in clinical biochemistry, I have seen a number of cases of patients desperate for their
FT3 to be measured and not being given it.
Some of the comments on the article interesting...one particularly, which blames us lab staff for being part of the problem... "The arrogance of those running the laboratory service astounded me"
"Whilst the article points
out "So, if your blood
test doesn't show you to be low in T4, you won't be prescribed thyroid hormones that could alleviate your symptoms", there's a good chance that your local lab (which supposedly works for your Doctor) won't provide a
T4 result. The testing
laboratory have their own protocol which frequently means that if the TSH result is in the Normal Range (~ usually 0.3 to 5.0), then they routinely don't provide a T4 result let alone any of the other thyroid function tests. My result was just above the Reference Range and my own doctor asked three times for more than the TSH but was ignored and when I wrote to the Area Health Authority, I received a reply which said that my own doctor ought to know better than to ask.
They said they had provided GP's with guidelines as to what they would test for and she should not have asked! The arrogance of the those running the laboratory service astounded me. "
When lab reports go directly to patients I imagine we will receive a significant number of calls from educated patients wanting
FT4/FT3 measurements
if they haven't been given one.
Simon
From: Clinical
biochemistry discussion list
[mailto:[log in to unmask]]
On Behalf Of Peter Beresford
Sent: 09 September 2014
16:19
To: [log in to unmask]
Subject: Low T3
syndrome
Dear
Mailbase,
We have
received calls from GPs who have been approached by a number of patients regarding the article below, which was published in the Daily Mail last week.
http://www.dailymail.co.uk/health/article-2734215/Cold-hands-Always-tired-It-hidden-thyroid-problem-doctors-refuse-treat.html
The
subject of the article is 'Low T3 syndrome", and it suggests to patients that they require FT3 measured routinely in addition to FT4, as well as opening up a debate with regards to treatment with T3. The article quotes respectable Endocrinologists quoted both for and against (although I suspect some of their comments may have been taken out of context).
I would be
interested to know if others have also been approached in
response to this
article and what guidance has been given to GPs responding
to these
queries.
The
guidance documents available on the British Thyroid
Association website (http://www.british-thyroid-association.org/Guidelines/
) are very helpful, but recognising that this is a complex
area I wonder if
anyone is aware of any more recent evidence or guidelines
about the role of T3
in the aetiology and treatment of hypothyroidism?
Best
wishes
Peter
Peter
Beresford
Consultant
Clinical Scientist
Southmead
Hospital
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