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When it comes to taking your thyroid hormone replacement medication, the standard recommendation is to take it in the morning, an hour before eating or drinking coffee. But is daily administration of your thyroid medication truly the best way to dose your thyroid drugs?
There’s no one-size-fits-all answer to this question. The solution depends on your response to treatment and the medication you’re taking. Ahead, some questions and answers about alternative ways of dosing your thyroid hormone replacement medication.
If you take all your thyroid medication in the morning, your levels are optimized, and you have good relief of symptoms, there’s no reason to change.
You should consider changing to twice-a-dosing, however, if your levels are optimized but you still have symptoms of your thyroid disease, especially in the afternoon or evening.
Levothyroxine (T4) drugs are the most commonly prescribed form of thyroid hormone replacement. They include brand-name drugs like Synthroid, Levoxyl, Unithroid, and Tirosint.
Levothyroxine is long-acting and has a half-life of around seven to eight days. It’s absorbed slowly, and levels tend to stabilize, so splitting a dose doesn’t significantly impact absorption or symptom relief. If you’re taking levothyroxine – the synthetic form of the T4 hormone – there’s no clear benefit to taking it more than once a day.
Most people take their daily dose of levothyroxine in the morning, but some people find a bedtime dose helpful. According to Thyroid Patients Canada:
“Timing a levothyroxine dose is more about absorption than circadian rhythms…With T4 dosing, it’s almost all about maintaining a steady absorption rate from day to day by NOT taking calcium, magnesium or iron or even coffee too close to it…Many people even take T4 at bedtime and find improved absorption.”
For more information, Paloma has a detailed guide on foods and drugs that interfere with absorption.
Note that some patients with hypothyroidism who have trouble remembering daily levothyroxine even take their total weekly dose just one day a week, with no noticeable impact on treatment effectiveness.
Some hypothyroid patients do best when their thyroid hormone replacement treatment includes a second hormone – T3. T3 therapy can be accomplished by adding the synthetic medication liothyronine (Cytomel) to levothyroxine treatment or taking natural desiccated thyroid (NDT), which includes natural forms of both T4 and T3.
According to research, T3 levels peak quickly, typically within three to four hours after taking the medication. The levels then fall and return to normal quickly, usually within 12 hours. The short timeframe creates daily peaks and valleys in the T3 levels, and, as the active thyroid hormone, this can affect symptoms.
As a result, dividing your doses of T3 thyroid medication is worth considering if you have continuing symptoms. In the new book Patient-Focused Hypothyroidism Treatment, Dr. Donna Hurlock discusses her strong preference for twice-a-day dosing of these hypothyroidism medications. Says Dr. Hurlock:
“Having done thyroid dose titration with thousands of patients over the last two decades, I strongly prefer twice-a-day dosing. When patients take all their thyroid medication in the morning, the effect of the morning dose seems to be gone by mid-afternoon. A second dose is needed to get through the rest of the day.”
Dr. Hurlock also finds that morning dosing can create characteristic symptoms later in the day.
“…by mid-afternoon, patients are exhausted and desperate for a nap. Feeling especially tired, many women will also reach for sugary snacks, soda, or caffeine drinks for energy to get through the afternoon. Since weight loss is a common goal for many women with hypothyroidism, sugary and calorie-rich ‘pick-me-up snacks’ are clearly counterproductive. “
In addition to the fatigue or hunger described by Dr. Hurlock, afternoon brain fog and muscle aches suggest that a divided dose of T3 may be helpful.
Twice-a-day dosing is recommended by a nationally-known endocrinologist and thyroid expert, Theodore Friedman, MD, for T4/T3 combination therapy or NDT. According to Dr. Friedman:
“The T3, either when given alone or when given as part of desiccated thyroid, has a short half life, which means that it disappears from the body in a couple hours. Therefore, if you take your desiccated thyroid, or your T3 preparation, once a day in the morning, it is gone by the late afternoon and is certainly gone by the next morning. This will give you a period of hypothyroidism in the evening and next morning, and most people will feel worse on this. To overcome this problem, the T3, or the desiccated thyroid, needs to be given twice a day. The second dose is given in the mid-to-late afternoon and will be around in the evening, and some of it will still be around the next morning in time for the next dose.”
McCall McPherson, PA-C, founder of Modern Thyroid Clinic, also recommends twice-a-day dosing for her hypothyroid patients. Says McPherson:
“These medications are short acting (think 6-8 hours) so they are best taken during the waking hours…. I believe most people actually need these medications dosed twice a day: in the morning and around 2-3 pm.”
For T3 medications, McPherson prefers to prescribe them in a compounded, sustained-release form and dose them twice daily.
Dr. Hurlock also recommends twice-a-day dosing to her hypothyroid patients who want to lose weight. According to Dr. Hurlock, “Dosing twice a day helped patients burn calories for more than just eight or ten hours each day, sometimes resulting in some weight loss.”
You should be aware that taking a T3 medication late in the day may result in a peak T3 level after bedtime, potentially making it harder to fall asleep or disrupting your sleep. Says Dr. Hurlock:
“If taken after work or around dinner time, women will likely reach peak energy around bedtime, which can play havoc with the ability to fall asleep. I did, however, have several patients who took their entire thyroid medication dose at bedtime and seemed to do fine with it and woke up rested. I saw no reason to argue with success in those few cases.”
When it comes to dosing T3 or NDT, you may experience the best results when –instead of taking all your medication in the morning –you spread out the dose throughout the day. There are two ways to achieve this:
1. Take your T3 medication twice or three times a day, or
2. Take a sustained-release, compounded form of T3.
You don’t have to figure it out on your own, however! Paloma’s knowledgeable practitioners can work with you to determine the best possible thyroid hormone replacement treatment – and dosing schedule – to not only optimize your thyroid levels but relieve your symptoms.