Suggest Treatment For Persistent High TSH Levels Despite Medications

Posted on Mon, 27 Feb 2017

Question: Three months ago my TSH level was a little over 96. Todays result, after an increase in my thyroid meds (to 300 mcg per day) was 56.48, at what point are these high numbers dangerously high and should I be concerned? The plan is now to increase yet again to 350 mcg/day. I have been on thyroid meds since college and dosage has increased slowly over the years.

Answered by Dr. Binu Parameswaran Pillai (53 minutes later)

Brief Answer:
Need to investigate the cause of high TSH

Detailed Answer:
Good day,

Noted your question . we need to get your TSH with in normal range. In most individuals I like to keep TSH around 2.5. Despite being on 300mcg of Thyroxine, your TSH is still high. We need to find out the reason why TSH is still high.

Some of the possible reasons are, a) malabsorption of medicine from your stomach. b) medicines getting damaged by exposure to heat or sunlight. c) Bacterial infection in stomach like H. Pylori infection. d) not giving adequate gap between food and thyroid medications. e) Skipping medication often.

There is no cutoff level of dangerously high TSH level. May I know what is your Free T4 level?
Could you please let me know your height and weight? Dose calculation is usually done based on weight.
Regards
Binu

Above answer was peer-reviewed by : Dr. Nagamani Ng

Follow up: Dr. Binu Parameswaran Pillai (12 hours later)

To answer your questions:
b) No exposure issues or storage issues with temp variations
c) Was tested for H Pylori about 6 mo ago and it was negative
d) Take meds in a.m. about an hour to 1 1/2 hrs before eating and I don't drink coffee
e) I NEVER skip meds. It is part of my morning routine and I understand the need for consistency.

Height: 5'6"
WT: 180

Answered by Dr. Binu Parameswaran Pillai (27 hours later)

Brief Answer:
Thyroxine malabsorption

Detailed Answer:
Thank you for the reply.

Normal Thyroxine requirement is around 1.6 mcg per kilogram. As you are taking more than double the required dose and if TSH is still high, mal-absorption of the medicine should be suspected.

Do you have any intolerance to wheat /gluten ? There is an approved Thyroxine malabsorption test done at many places by endocrinologists and it may be good to discuss with your endocrinologist. Interested to know about your free T4 results, if available.

Regards
Binu

Above answer was peer-reviewed by : Dr. Arnab Banerjee

Follow up: Dr. Binu Parameswaran Pillai (3 hours later)

Thank you. I will follow up and get the free T4 results if they were included in the testing this round. And yes, gluten has been a problem. I stay away from it as much as possible though haven't been fanatical. Digestive issues have clearly been a problem. I followed the FODMAP diet for awhile and that settled things down on the dietary front but didn't test the thyroid during that time frame to see if there was a connection.

Answered by Dr. Binu Parameswaran Pillai (5 hours later)

Brief Answer:
Gluten insensitivity ( celiac disease) can coexist with hypothyroidism

Detailed Answer:
Good day,
If digestive issues/gluten is an issue, that probably is responsible for the mal absorption of thyroid hormones. It is good to prove gluten insensitivity by doing tests ( Total IGA , ttg IGA and Anti Gliadin antibody). If it is positive, you may try a gluten free diet which will dramatically improve the absorptive capacity and your TSH levels might improve well and the dose of thyroxine may need to be reduced as well.( i have many patients with gluten insensitivity and hypothyroidism). Gluten insensitivity and hypothyroidism can co exist in many patients .

And yes, free T4 levels will surely help the clinician in adddition to TSH levels.
regards
Binu

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Above answer was peer-reviewed by : Dr. Nagamani Ng