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FOOD AND DRUG ADMINISTRATION - page 149 / 263

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yet we produce the biochemical suppression we want.

What that means is very small changes in their dose, as little as missing one thyroid pill a week or taking one extra thyroid pill a week, can tip them over the edge into clinical thyrotoxicosis.  This is not just numbers on a piece of paper.  This is phone calls to my office from real patients having rapid heart beats and nervousness and not being able to sleep.  Alternatively, if the dose is decreased a little bit, they feel perfectly fine, but the TSH is now up into the normal range and they're at risk for recurrence.

Now, to try to put this into some perspective, how big a dose change do you need?  You've already heard this morning that small dose changes, which is my usual dose increments, of 10 or 12 percent are enough to produce these symptoms, either for the worse, which is thyrotoxic symptoms, or back into the normal range.  Unlike most of the TSH measurements you do in hypothyroid patients which may be once a year, in thyroid cancer patients, we maybe do these every four to six months because fine-tuning is critical.

So, what I hope to leave you with today is

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