WHY AVOIDING PANIC AND KNEE-JERK DOSAGE CHANGES IS SO IMPORTANT

In another blog post I talk about the need to be patient and systematic when managing thyroid treatment:
https://paulrobinsonthyroid.com/be-patient-and-systematic-when-changing-thyroid-medication-dosage/

This post goes one step further than that and discusses why avoiding large changes is critical and what problems can ensue if care is not taken.

As thyroid medication is being adjusted, sometimes one or more changes may be made that turn out to have been mistakes. This might mean that a type of thyroid medication has been added, or stopped. More frequently, it is due to an increase in thyroid medication or even a series of increases. Individual changes may have been quite small but collectively, over a few weeks, the overall change in thyroid medication may have been significant enough to now cause issues. The issues might have various symptoms which all add to the anxiety of the patient. They potentially include raised anxiety, tension, tremors, nervousness, sweating and signs that often include raised heart rate (tachycardia), and elevated BP. This is exactly the situation where the need to be patient and systematic is most needed. Unfortunately, it is often the situation when all thoughts of patience and systematic change just get forgotten.

I have been working with thyroid patients for well over fifteen years. In that time, I think rarely a month goes by when I do not get contacted by a thyroid patient who has abandoned patience and then caused more problems for themselves. The most typical situation is when a thyroid patient has been relatively stable and has been slowly adjusting their thyroid medication dosage. This applies to all types of thyroid medication, but medication that includes some T3 is usually the most common source of the problem that I am going to describe.

It may be that the thyroid patient has not realised, from signs and symptoms, that the last one or two dosage changes have not been good and that they have strayed into the territory of being over-stimulated. However, it can just take time for the cumulative effect of several small changes to begin to have an impact. Perhaps, at this stage of adjusting the thyroid medication, a far longer time interval between changes should have been used – I discuss the need for this in my books.

After the most recent thyroid dosage change, the signs and symptoms begin to worsen significantly and ‘Boom!’, panic sets in. This is absolutely the time that being calm and systematic is most needed.

What is required is:

• Any changes in medication dosage over the past weeks needs to be reviewed.
• The signs and symptoms that were present pre-change and post-change need to be looked at carefully, given the now far worse situation.
• Some change needs to be made to adjust the medication. However, this often only needs to be a retracement to the last successful dosage that the thyroid patient was on. In some cases, two small dosage changes may need to be undone.
• Typically, the size of the medication dosage reduction does not have to be large for the symptoms and signs to settle down in some hours or a day.

It is important to realise that, for the majority of thyroid patients, elevated heart rate, raised BP or even very uncomfortable symptoms are not dangerous at all, if they are only there for a short space of time.

However, what can sometimes happen is that the thyroid patient thinks that they must stop these symptoms and calm down the signs quickly. So, they may cut their thyroid medication dosage in half or even stop it. This is when things can go very wrong indeed.

A large change in what has been mainly a stable situation makes things very unstable. The sudden drop in FT3 level that often comes when any T3 content is lowered, will cause TSH to rise over the coming days. As TSH rises the cells make more D1 and D2 deiodinase enzymes so the conversion rate from any FT4 to FT3 begins to rise. If the thyroid patient is on any T4-based medication then the conversion rate is now in a state of flux and more FT3 is being generated. If the thyroid patient has some working thyroid tissue, the rising TSH begins to make the thyroid gland more active – this also makes the situation less stable.

So, at this point, the thyroid patient has made a large reduction in their thyroid dosage but this has introduced instability into the system which is now continuing to occur. Every day following the reduction there can be a different situation and it can be incredibly confusing for the thyroid patient who was only really trying to get back to being stable once again.  The thyroid patient may eventually become hypothyroid and think that they have now resolved the crisis. Sometimes, they try and add some of their thyroid medication back in. This can be even more confusing and stressful as they may find that it causes even higher heart rate, BP or worse symptoms than they had to begin with!

It is common for patients to have done something like this, and then one or two weeks later they contact me and are desperate for help as they do not understand what is going on. They may say to me that they think they have become intolerant or allergic to T3 medication, whereas in actual fact, all they have really done is overreacted, made too big of a change and caused their own system to become highly unstable.

At this stage, when someone has already created an unstable situation, it is important that they get back on most of the medication that they were previously on. The total dosage may well need to be lower than when the symptoms and signs deteriorated, but not dramatically so. Having considered a suitable dosage, my main message is then to tell them to be patient and to wait for their own body to calm down and become stable once again.

Being patient and systematic is critically important when managing thyroid hormone dosage. This is especially true when things go very wrong and bad symptoms and signs begin to occur.

Inside the blog post I referenced at the start, I refer to a famous fable by Aesop, called “The Hare and the Tortoise”. The two animals have a race but the hare gets too excited and runs around too much and gets distracted and makes mistakes. The Tortoise just plods on slowly, and systematically, and wins the race. Being the tortoise and not the hare at the time when symptoms and signs have seriously deteriorated is a challenge but invariably it is the right thing to do.

Once a huge dosage change has been made, many aspects of the endocrine system relating to thyroid hormones become highly unstable and can make regaining stability once again a real challenge. This can take weeks to rectify. So, making a smaller adjustment and being patient will often result in the thyroid patient regaining some stability and alleviation of symptoms far faster and far more effectively.

Best wishes, Paul