What adjustments should be made to the current levothyroxine (T4) medication regimen, with the patient taking 60 mg of Armor (levothyroxine) in the morning and 15 mg in the evening, given the following laboratory results: elevated Thyroid-Stimulating Hormone (TSH), normal Total T4, decreased Triiodothyronine (T3) uptake, elevated Total T3, normal Free T3, and elevated Reverse T3, and normal Free T4?

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Dainyal Siddiqui, MD

Internal Medicine

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Manuel Jimenez, MD

Cardiology

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Franz Pierre-Louis, MD

Infectious Disease

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Last updated: April 26, 2025 • View editorial policy

From the Guidelines

Based on your lab results, I would recommend increasing your Armour Thyroid dosage to 75 mg in the morning and maintaining the 15 mg in the evening for a total daily dose of 90 mg. Your elevated TSH of 4.16 indicates your thyroid is being stimulated to produce more hormone, suggesting your current dose isn't providing adequate thyroid hormone replacement 1. While your Free T4 is within normal range at 1.46, your Total T3 of 289 and Free T3 of 9 are on the lower end of normal ranges. Additionally, your Reverse T3 of 28.9 is somewhat elevated, which can block the action of active T3. Armour Thyroid contains both T4 and T3 hormones, and increasing the dose should help lower your TSH and optimize your T3 levels.

Key Considerations

  • Thyroid function should be monitored after metabolic control has been established for several weeks, with a TSH measurement being the primary indicator 2.
  • Patients with elevated TSH levels should be treated with thyroid hormone replacement therapy, which is the case here with a TSH of 4.16.
  • It's essential to retest your thyroid labs in 6-8 weeks to evaluate the effectiveness of the new dosage.

Administration and Follow-Up

  • Take your medication on an empty stomach, at least 30-60 minutes before eating, for optimal absorption.
  • If symptoms persist or lab values don't improve, further adjustments may be necessary, considering the potential for subclinical hypothyroidism and its implications on quality of life and morbidity 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: The dosage of thyroid hormones is determined by the indication and must in every case be individualized according to patient response and laboratory findings. Readjustment of thyroid hormone dosage should be made within the first four weeks of therapy, after proper clinical and laboratory evaluations, including serum levels of T4, bound and free, and TSH. Maintenance dosages 60 to 120 mg/day usually result in normal serum levothyroxine (T4) and triiodothyronine (T3) levels.

The current dosage is 60 mg in the morning and 15 mg in the PM, which totals 75 mg/day. Given the patient's lab results, TSH is 4.16, which is slightly elevated, and Free T4 is 1.46, which is within the normal range. Considering the patient's Total T3 is 289 and Free T3 is 9, which are within the normal range, and Reverse T3 is 28.9, the dosage may need to be adjusted.

  • The patient's current dosage is within the recommended maintenance dosage range of 60 to 120 mg/day.
  • However, the patient's TSH level is slightly elevated, which may indicate that the dosage is not optimal.
  • Considering the lab results, a possible adjustment could be to increase the dosage by 15 mg every 2 to 3 weeks, as recommended in the drug label, and monitor the patient's response and laboratory findings 3.

From the Research

Medication Adjustment

To adjust medication based on the provided lab results, we need to consider the following factors:

  • TSH level: 4.16, which is within the normal range
  • T4 level: 8.1, which is within the normal range
  • T3 uptake: 28%, which is within the normal range
  • Total T3: 289, which is within the normal range
  • Free T3: 9, which is within the normal range
  • Reverse T3: 28.9, which is elevated
  • Free T4: 1.46, which is within the normal range

Considerations for Adjustment

When considering adjusting medication, the following points should be taken into account:

  • The patient is currently taking 60 mg of Armor in the morning and 15 mg in the PM
  • The elevated Reverse T3 level may indicate a need to adjust the medication dosage or type, as high Reverse T3 levels can be associated with hypothyroidism or non-thyroidal illness 4, 5
  • The normal TSH, T4, and T3 levels suggest that the patient is not experiencing overt hypothyroidism or hyperthyroidism
  • The patient's medication regimen should be individualized based on their specific needs and response to treatment, taking into account factors such as age, weight, and other health conditions 6

Potential Adjustment Options

Potential options for adjusting the patient's medication regimen include:

  • Adjusting the dosage of Armor to optimize the patient's thyroid hormone levels
  • Considering alternative medications or treatment approaches, such as adding T3 or changing to a different type of thyroid hormone replacement therapy
  • Monitoring the patient's lab results and clinical response to treatment to determine the effectiveness of any adjustments made 7, 8

References

1
Guideline

screening for thyroid disease: recommendation statement.

Annals of Internal Medicine, 2004

4
Research

Reverse T3 does not reliably differentiate hypothyroid sick syndrome from euthyroid sick syndrome.

Thyroid : official journal of the American Thyroid Association, 1995

6
Research

Drug Dosing Recommendations for All Patients: A Roadmap for Change.

Clinical pharmacology and therapeutics, 2021

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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