TSH 0.32 - 4.00
FT4 9 - 19
FT3 2.6 - 5.8

1) Hi there, I noticed that there is a difference between taking MMI once a day versus taking it twice a day. Whenever I take MMI once a day, my FT4 goes over the normal range. But when I split the dose and take it twice a day, my FT4 remains stable or goes even lower. Will I be able to achieve remission if I’m unable to take MMI once a day because it seems like my body needs MMI in constant circulation.

2) I also noticed that my TSH goes up when my FT4 is 12 or lower. Is this hypothyroid even though it’s still within the normal range. Can one achieve remission at the lowered part of the reference range.
I know you say to keep FT4 at higher reference range to achieve remission.

3) I have been taking MMI for roughly 5 years with not much to show for it, and looks like my Endo might stop seeing me if I refuse surgery or RAI next time we meet. What are my options if my Endo refuses to attend to my care any longer. Thanks for your time.

Hi,
Having thyroid hormone levels that are too low for your body's needs prevents remission. This is because your pituitary tries to fix the problem by speeding up thyroid activity, including increased thyroid antibodies..
We all have different genes for drug metabolism. You may metabolize MMI quickly so need to take it twice a day. I metabolize drugs slowly so can't have caffeine or other stimulants after 10 am or I can't sleep at night.
Usually, when you're on an appropriate dose of MMI your TSH stays below 0.4, often <.01. If it rises higher most likely your MMI dose is too high.
Since Graves' disease is a self resolving autoimmune condition, lifestyle and dietary changes are also important. By this I mean avoiding environmental triggers, including stress....or finding better ways to handle stress.Your goal is to lower the production of the TSH receptor antibodies that are causing the problem. Some people find avoiding grains and luten helps. Others have to control seasonal allergies before they can achieve remission. If your doctor isn't helpful or insistent on aggressive treatment, look for an intergrationist or functional medicine doctor. Some older endos don't really understand autoimmune conditions. Best, Elaine