Q:  Meds to Lower TSH Level? & Update

Hi Dr. Phelps,
My 21 year old sons' TSH level was 3.719 at his last lithium blood draw/Thyroid test and his lithium level was .9. He has been on Lithium( lithobid) now about 1 year.  I was wondering what Thyroid medications you would use to bring the TSH level down to below 2? His T4 was 7.4 and T3 uptake 35 and Free Thyroid index 2.6 and T3ria was 122. How are your patients on the Thyroid medications doing this year? I really appreciate the work you are doing. Best Regards..


Dear Ms. B

Most of the patients who demonstrated improvement on thyroid  still look to me to be improved.  However, my enthusiasm has tempered just a little, as many of those folks have gone on to require yet more medication adjustments.  On the other hand, some are still doing so well, of people who had previously had T4 alone, that I am still routinely using T3/T4 combinations instead of T4 alone.  There have been a few folks who have clearly had their symptoms worsened  by T3/T4, about two more than appear in the table, out of another 20 or 30 patients I've been able to follow, so it's not without some risk compared to T4 alone, as best I can now tell.   

One way to approach your son's situation would be to start with T4, as that's the usual routine; then switch later when T4 alone was understood and not working well enough.  I would go ahead and start though, as I think we have enough data to show that a TSH up there is associated with more depressive symptoms, or at least with not responding as well to antidepressant efforts.  I.e. I wouldn't wait for a TSH of 6 or higher.  I especially wouldn't wait if his TSH used to be 1.5 before lithium. 

Of course, all that's just for review with your son and his doctor.  Good luck with that. 

Dr. Phelps