Brief Answer:
Relevant medical facts provided.

Detailed Answer:
Hi Madam,

I understand your concern.

Many of your symptoms are directly related to underfunctioning of the thyroid gland -These include
Severe constipation, swelling, severe fatigue, scaly and itchy skin, skin rashes and daytime somnolence.

The spectrum of disease in your case has two components-
1. Hypothyroidism.
2. Hashimoto's disease.

In spite of correction of the hypothyroid state with thyronorm, many of symptoms have not improved.

This suggests uncorrection of Hashimotos disease caused by continued autoimmune destruction of thyroid glands. For this you need an additional immunosuppresant drug.

Joint pain needs a special mention-The association of Rheumatoid arthritis/RA with Hashimoto's is very high. For this I advise you to get anti CCP antibody testing. Once positive you need additional drugs against RA.

Likewise Type 1 diabetes is more common than Type 2 in patients with Hashimoto's disease. Likewise, this needs confirmation with Anti Islet cell antibodies. This needs insulin replacement along with Glimisave. Insulin in such cases is needed to correct latent metabolic abnormalities.

Coming to the lab values you seem to have elevated T4 with low TSH and low T3.
This implies a mild hyperthyroid state -a therapeutic complication of Hashimoto's disease. This can be corrected by giving a drug holiday for Thyronorm on every Sunday.

Tailor and titrate the dose of levothyroxine sodium to meet the individual patient's requirements. This can be achieved after consulting your physician. The goal of therapy is to restore a clinically and biochemically euthyroid state.

Coming to actual improvement of symptoms-As already said Immunesuppresant drugs are needed. Once you start using them you will feel overall wellbeing.

In your case the need for short term- Prednisone, Hydoxychloroquine is high. I advise you to discuss this need with your treating doctor and find if he/she is of the same view and can prescribe them to you.

Special mention in your case-Yearly thyroid ultrasonographic evaluation is important in Hashimoto thyroiditis because of the increased risk of thyroid nodules in these patients (possible risk of malignancy) and for follow-up of patients with existing benign thyroid nodules.

Post your further queries if any.
Thank you.

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Brief Answer:
Consider adding LT3 (liothyronine) after diagnostic work up.

Detailed Answer:
Hi Madam,

I understand your concern.

First of all I would appreciate your follow up highlighting the positive concern you have for your health.

You have significantly elevated levels of TPO which explain the autoimmune nature of hypothyroidism-Hashimoto's disease.

Now the clinical situation is peculiar in your case.

This needs a careful and a professional approach.

You seem to have symptoms of hypothyroidism in spite of treatment with T4/thyronorm since many years. At this stage further increase in the dose is not warranted and is unsafe or unwise. (Already unnecessary increase in thyroxine/LT4 is being reflected in your lab results as high T4, low TSH and very low) -ie; If levothyroxine dose requirements are much higher than expected-

This scenario can arise in 2 conditions.

1. Improper absorption of the LT4 (thyronorm) tablet from the stomach-This is possible in Hashimoto's disease if there is coexistent Gastrointestinal disorders such as -Helicobacter pylori related gastritis, Atrophic gastritis, or Celiac disease; if such disorders are detected (by upper GI endoscopy) and effectively treated, re-evaluation of thyroid function and levothyroxine dosage is recommended.

2. The normal function of the thyroid is carried by LT3 hormone and not LT4.

Normally the produced LT4 as well as that given externally in the form of thyronorm is converted to LT3 in the peripheral circulation as well as in the brain in the presence of an enzyme.

This conversion is affected in patients with Hashimoto's disease due to an inherent defect in the conversion enzyme. Hence, symptoms are not controlled in spite of adequate doses of supplemented thyronorm.

In such situations on lab results, LT3 is markedly reduced (which is evident in your case) and much of LT4 is converted into rT3 (REVERSE T3). This can be confirmed on lab basis by testing rT3.This condition may sometimes be termed as Euthyroid Sick Syndrome.

In all such patients treating hypothyroidism with a combination of both LT4 (levothyroxine) and LT3 (Liothyronine) will ameliorate all symptoms quite effectively.

Hence, in my opinion, combining or adding LT3/LIOTHYRONINE/Cytomel to Thyronorm will improve your symptoms quite effectively provided you do dot have any associated gastrointestinal disorder.

Hence, I advise you to get a gastroenterology clearance and then a blood work up for rT3 (Reverse T3) before adding LT3 to your external thyroid supplementation.

TSH assessment should be performed 4-6 weeks after any dosage change.

I suggest you to please see a doctor if his/her views are same and if they can prescribe these drugs and drug modifications for you.

Post your further queries if any,
Thank you.

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Brief Answer:
LT3 supplementation can be considered.

Detailed Answer:
Hi Madam,

I understand your concern.

Its good that you had these tests.

Delayed gastric movements can be expected with long standing diabetes-known as Gastroparesis.This does not always need therapy.

Now since gastroenterology clearance is made,you can take Liothyronine/LT3 addition with thyronorm.

Discuss this with your doctor about recommended dosage.

Post your further queries if any.
Thank

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