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REPOST: Dr. Ain (4) Re: meds., cytomel, to & from HyPo --> Shelagh

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***(I, like you, am a

patient) Nick***

Hello Shelagh,

***25 mcg of Cytomel is equivalent to 0.100 mcg of thyroxine. 25 mcg 3x per

day is equal to 0.300 mcg of thoroxine.

Lets say that when your own thyroid was still there.. that it, too, was

producing 0.100 mcg of t4/t3 per day. That's 0.400

mcg. ..total per day. You say " roughly 2 weeks " since tt. Fine, but the body

wasn't influenced (did not notice) by the loss of the thyroid gland until week 2

following tt. (the reason for this is explained by Dr. Ain in the following

REPOSTS)

Due to the 6-8 day half-life of thyroxine..at the 2 week post tt moment, you

_really_ were only depleted (by effect) by one week's amount of thyroxine.

So.. even if _all_ you were taking was 0.25 mcg of Cytomel TWICE a day.. your

system was still working with 0.300 mcg of thyroxine-equivalent each day when

your body was normally used to only 0.100 mcg. (est.)

This is quite a shock/stress to/for the body because, unlike t4 (thorixine)

t3 (Cytomel) is direct, main-line, usable, on the spot, available, a very real

JOLT/shock to your system.

Reasonably speaking.. your doctor should have started you on 0.25 mcg of

Cytomel, split into 4 and taken at 3 to 4 hr intervals and then to have you tell

him how you were doing. If you were feeling no ill effects from 0.25 mcg

(Cytomel) but weren't feeling normal.. and felt that more was needed.. he could

have prescribed additional t3 which you then could have spaced apart every 2

hours or so. None of which would have stressed your system as may be the case,

at present.

When we think of prescription medicine.. we are speaking of a dosage amounts

relative to a 24 hour-day. And I don't think that you're getting up in the

middle of the night in order to take your last dose. So this means that the

dosage-taking period is closer to 16 hours then it is to the whole 24 thereby

making your circumstance even _more severe_ then even first glance would

indicate. (way too much med.) The effect of the stress of too much t4/t3 can be

very damaging to the heart.

With Cytomel.. less is always safer/better to start with.. esp. on the way TO

going hypo, as your system still has thyroxine left over from your own thyroid

gland production.. and will continue to have for the next 4 to 6 weeks.

I would not take 0.75 mcg of Cytomel, _ever_ .. in a 24 hour period. No

way.. no how.. _never_.

Your doctor doesn't understand much about thyroid hormone and it's effects.

Tell him I said so. Better yet.. gimme' his address and I'll tell him. Or.. at

the very least, show him Dr. Ain's Post's, please :-)

Sincerely,

Nick

********************************************************************************\

************************************************************

Levothyroxine (T4) is the major product of the thyroid gland and is

essentially a prohormone with minimal (if, debatedly, any) activity of its own.

It has a long and stable half-life in the blood (one week) and is transported

into cells where it is converted into T3, which directly interacts with

receptors which bind DNA and regulate genes. All of this has been well-studied

and constitutes a vast medical and molecular biology literature. (Dr. Ain)

********************************************************************************\

************************************************************

(Dr. Ain # 1 )

Date: Thu, 04 Jan 2001 14:08:49 -0500

Subject: Re: What dosage to start on

In-reply-to:

>According to Dr. Ain, " the mean replacement dose of levothyroxine is 2.0

>micrograms per kilogram (2.2 lbs) per day " , which would start you off at

>100mcg/day.

Dear ThyCa Members:

Fortunately, I am not often misquoted; however there is a slight error in the

quotation above.

The mean " replacement dose " of levothyroxine (to obtain a normal TSH 0.5-4.0) is

1.6 micrograms per kilogram per day. The mean " suppression dose " of

levothyroxine (to suppress TSH less than 0.1) is 2.0 micrograms per kilogram per

day.

There is a wide variation in individual patients so that these mean values are

only starting approximations for estimating levothyroxine dosages. Following at

least 6-8 weeks of such medication, the TSH and free T4 should be checked to see

if the suppression target has been reached: TSH < 0.1 while the free T4 not

much above the upper normal limit. If a levothyroxine dosage needs to be

changed, then another 6-8 weeks must be waited before checking the labs again.

**************PLEASE BE ADVISED*********************

THE INFORMATION CONTAINED IN THIS COMMUNICATION IS INTENDED

FOR EDUCATIONAL PURPOSES ONLY. IT IS NOT INTENDED, NOR SHOULD

IT BE CONSTRUED, AS SPECIFIC MEDICAL ADVICE OR DIRECTIONS. ANY

PERSON VIEWING THIS INFORMATION IS ADVISED TO CONSULT THEIR OWN

PHYSICIAN(S) ABOUT ANY MATTER REGARDING THEIR MEDICAL CARE.

************************************************

B. Ain, M.D.

Associate Professor of Internal Medicine

Director, Thyroid Nodule & Oncology Clinical Service

Director, Thyroid Cancer Research Laboratory

Division of Endocrinology and Molecular Medicine

Department of Internal Medicine, Room MN524

University of Kentucky Medical Center

800 Rose Street, Lexington, Kentucky 40536-0298

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(Dr. Ain # 2 )

Date: Tue, 07 Nov 2000 11:22:54 -0500

Subject: Cytomel Dosing for Scan/I-131 Prep

In-reply-to:

>Dear Ellen -

>

>Are you sure about the Cytomel - 50 mg twice a day??? Unless I'm mistaken,

that's equivalent to 400 mcg Synthroid! Sounds like quite a lot.

repost from 10/6/00

Dear ThyCa Members:

When Cytomel (L-T3) is used to mollify the discontinuation of levothyroxine, the

typical dose is 25 mcg given every 12 hours (total daily dose 50 mcg).

Sometimes this creates peaks of L-T3 which cause symptoms, which can be

alleviated by splitting the pills and taking 12.5 mcg four times daily (same

total dose of 50 mcg). For some patients, particularly those who were on

levothyroxine dosages of 112 mcg or less, the optimal Cytomel dose may be 1/2

pill (12.5 mcg) three times daily or sometimes twice daily. Dosages in excess

of 50 mcg daily are rarely needed and usually cause thyrotoxic symptoms in

patients used to 200 mcg or less of levothyroxine. This Cytomel therapy should

be discontinued 2 weeks prior to I-131 scanning, when performing the traditional

scan preparation.

*********************************************

PLEASE BE ADVISED --- YOU HAVE CHOSEN TO COMMUNICATE VIA

AN UNSECURED ELECTRONIC MAIL SYSTEM. ALTHOUGH THE CHANCES

ARE NOT KNOWN, THERE IS A POSSIBILITY OF UNAUTHORIZED ACCESS

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LIMITED, TO TAKE THIS INTO ACCOUNT.

(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((

B. Ain, M.D.

Associate Professor of Internal Medicine

Director, Thyroid Nodule & Oncology Clinical Service

Division of Endocrinology and Molecular Medicine

Department of Internal Medicine, Room MN520

University of Kentucky Medical Center

800 Rose Street, Lexington, Kentucky 40536-0298

Telephone: FAX:

email: kbain1@...

)))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))))

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################################################################################\

####################

(Dr. Ain # 3 )

Date: Sun, 16 Jul 2000 16:02:56 -0500

Subject: Re: Starting meds after RAI

In-reply-to:

>Hello all,

>

>Can somebody give me a good reference I can give the nuc med doctor. I spoke

>with the nuc med tech Friday. He said they don't have people start back on

>meds until after their scan, which is 10 days after receiving RAI. I told

>him I started back last time 2 days after RAI. He said if I started back on

>meds it would interfere with the uptake.

>

>HELP!

>

>Roxanne

>dx pap ca with invasion 8/99; TT 9/99; RAI 150 mCi 10/99 (outpatient);

>Scan 6/28 TG <0.05 Uptake in thyroid bed. 100 mCi scheduled for 7/28 Off

>Levoxyl since 4/30.

>, CO

>USA

Dear ThyCa Members:

The information requested above is far from new, in fact, it is ancient.

Even in patients with intravenous infusions of levothyroxine supplemented with

an initial dose of 500-800 mcg, it takes at least 4 days to lower the TSH by

50% and at least one week to lower the TSH below 30. [Ridgway EC, McCammon JA,

Benotti J & Maloof F (1972) Acute metabolic responses in myxedema to large doses

of intravenous L-thyroxine. Ann Intern Med 77, 549-555.] Administration of daily

intravenous levothyroxine doses of 100 mcg required more than one week to reduce

the TSH by 50%. [Ladenson PW, Goldenheim PD, DS, MA & Ridgway EC

(1982) Early peripheral responses to intravenous L-thyroxine in primary

hypothyroidism. Am J Med 73, 467-474.] Elevated TSH is the mechanism of

stimulation of thyroid cancer cells to take up I-131 and the reason for

with-holding levothyroxine.

There is no longer sufficient I-131 circulating in the bloodstream after 48

hours from swallowing I-131 to contribute to the treatment of the tumor. Also,

as shown above, starting levothyroxine does not suppress the TSH significantly

for several days. For this reason, I start patients back on their full

levothyroxine daily dose at 24 hours after administering their radioactive

iodine.

This is another example of the " practice of medicine " differing

significantly from the " science of medicine. " I strive to make my own practice

to be consistent with science and biology, as all physicians should.

**************PLEASE BE ADVISED**********************

THE INFORMATION CONTAINED IN THIS COMMUNICATION IS INTENDED

FOR EDUCATIONAL PURPOSES ONLY. IT IS NOT INTENDED, NOR SHOULD

IT BE CONSTRUED, AS SPECIFIC MEDICAL ADVICE OR DIRECTIONS. ANY

PERSON VIEWING THIS INFORMATION IS ADVISED TO CONSULT THEIR OWN

PHYSICIAN(S) ABOUT ANY MATTER REGARDING THEIR MEDICAL CARE.

*************************************************

B. Ain, M.D.

Associate Professor of Internal Medicine

Director, Thyroid Nodule & Oncology Clinical Service

Director, Thyroid Cancer Research Laboratory

Division of Endocrinology and Molecular Medicine

Department of Internal Medicine, Room MN524

University of Kentucky Medical Center

800 Rose Street, Lexington, Kentucky 40536-0298

################################################################################\

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(Dr. Ain # 4 )

Date: Wed, 05 Jan 2000 20:40:23 -0400

Subject: Re: Resumption of Levothyroxine

In-reply-to:

>Peggy;

>it takes a while for the synthroid to kick back in.

>It has something like an 8 day life so on day 1 of

>synthroid you kind of have 1/8th and day 2 2/8ths and

>by the 8th day (or so) you are finally replacing the

>synthroid that is leaving your body from day 1. so if

>you started the 17th it would be the 25th before you

>were even up to a whole level (and if my math is bad

>and its more like 10 days then it would be the 27th)

>then since our bodies (unfortunately )are not really

>totally logical machines then it takes a while for the

>body to say...

Dear ThyCa members:

The above quote, though well-intentioned, is quite incorrect. The

half-life of levothyroxine is 7 days. It takes from 6-8 half-lives,

when resuming any medication, for the level of the medication to

reach its ultimate steady-state level in the body. For levothyroxine

(Synthroid, Levothroid, Levoxyl, etc.), this means that it will take

fully 6-8 WEEKS for the levels to come back to normal.

When stopping levothyroxine, the curve is identical although

reversed. That is why the TSH level does not typically become

sufficiently elevated for I-131 scans or therapy until 6 weeks after

stopping the medication.

**************PLEASE BE ADVISED**********************

THE INFORMATION CONTAINED IN THIS COMMUNICATION IS INTENDED

FOR EDUCATIONAL PURPOSES ONLY. IT IS NOT INTENDED, NOR SHOULD

IT BE CONSTRUED, AS SPECIFIC MEDICAL ADVICE OR DIRECTIONS. ANY

PERSON VIEWING THIS INFORMATION IS ADVISED TO CONSULT THEIR OWN

PHYSICIAN(S) ABOUT ANY MATTER REGARDING THEIR MEDICAL CARE.

*************************************************

B. Ain, M.D.

Associate Professor of Internal Medicine

Director, Thyroid Nodule & Oncology Clinical Service

Director, Thyroid Cancer Research Laboratory

Division of Endocrinology and Molecular Medicine

Department of Internal Medicine, Room MN520

University of Kentucky Medical Center

800 Rose Street, Lexington, Kentucky 40536-0084

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At 11/12/01 03:21 PM, you wrote:

>I am not a medical professional but I experienced the same symptoms that soon

after the thyroidectomy. I cut back to 50 mg/day and gradually increased up to

75/mg by cutting the pills in half. After about 4 weeks post op I was okay with

the dose. I think some of the stored T4 has to get used up out of your body

before you can tolerate this much T3-but this is very individual thing. I took

the 75/day the day after surgery! I was flying high, dropping everything and

having skipped heart beats. I was kinda of scarey.

>

>Nick will probably repost Dr Ain's dosing schedule for stopping and restarting

cytomel(T3). I think the idea is to gradually restart and stop.

>

>Debbi E

> cytomel

>

>

> I am curious about dosage/experience w/ cytomel? Roughly two weeks

> ago I had my thyroid and lymph nodes removed, doctor prescribed

> Cytomel 25 mcg 3X daily. I am very dizzy and one cup of coffee

> resulted in mild hand tremors! Wondering if this sounds familiar - I

> have been advised to remain w/ the recommended dose.

> Shelagh

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