a bottle of Synthroid 50 mcg tablets, T3 with T4

Pharmacists and pharmacy technicians make an unbelievable number of mistakes. It is the dirty little secret that most patients never hear about. And the profession of pharmacy is not anxious to study it. It fell to ABC News 20/20 to fund research into pharmacy errors. A study published in the Journal of the American Pharmacists Association (March-April, 2009)  revealed that of 100 prescriptions dispensed, one out of every five had an error. This newspaper column reader reports what happened to her when she mistakenly received a bad thyroid dose.

Too Little Levothyroxine is Dangerous:

Q. I had a prescription for levothyroxine filled in February and just now noticed that it was for 25 mcg [micrograms]. It should have been 75 mcg.

My internist raised the dose to 100 mcg when my TSH came back as 4.99. CVS made a dispensing mistake. (The pharmacist admitted it.) As a result, I have been taking a third of the prescribed dose.

Symptoms of Inadequate Thyroid Hormone:

Since this started, my hair has been brittle and falling out, my skin has been thinning and slow to heal and I’ve experienced muscle and weight loss and sleep disturbances.

Do I have any recourse besides letting you know that others should check all their prescriptions carefully? I am happy to have lived through this nightmare.

A. We can’t tell you about any legal recourse, but you should contact the CVS corporate office to let them know. We are glad that you are finally back on track with the correct dose.

Taking an underdose means you have been living with hypothyroidism. As you learned, that can be a harrowing experience.

Symptoms of Low Thyroid:

In our Guide to Thyroid Hormones we have a detailed list of symptoms associated with hypothyroidism. You will also learn about various treatment options. Many people do not realize that a standard TSH test may not always reveal the full story about thyroid function. Common symptoms include:

  • Fatigue
  • Mental Fogginess
  • Clumsiness
  • Hair loss
  • Brittle nails
  • Puffy Eyes
  • Constipation
  • Dry skin
  • Slow pulse

Avoid Bad Thyroid Dose by Double Checking!

Your admonition to check prescriptions conscientiously is critical. Do this before leaving the pharmacy counter!

Here is what Cari in North Carolina shared about her experience with a bad thyroid dose:

“I have had this happen more than once. I have been finding larger doses of thyroid medication mixed in with my prescribed dose. I reported this once and the pharmacist I spoke with was very apologetic because she happened to be the one who filled the prescription.

“Now, I find this happening again. Nor infrequently the pharmacy technicians fill the prescriptions. The pharmacist is supposed to check them.

“If they don’t pour out all the medicine and check each pill they won’t catch mistakes. I am a nurse, so I am better able to see the difference. I am concerned about people who just go ahead and take what is given them with no questions asked. Overdosing on thyroid medication could cause atrial fibrillation.

“Taking other wrong prescriptions can be dangerous. I do not know how this situation can be remedied because pharmacists are so busy. I guess I just need to keep informing them when this happens. That way they can teach the person filling the prescription and make sure the techs are taking it from the correct container.”

Pharmacy Technicians Are Underpaid:

Karin in Schaumburg, Illinois, points out that pharmacy techs do not get paid as nearly as much as pharmacists!

“I live in suburban Chicago. The two pharmacy techs I know make $11 and $12 dollars per hour. It’s inexcusable.

“By the way, you can’t teach experience.”

Dispensing mistakes may involve completely different medications and cause even more havoc in a patient’s life. People have died when they got the wrong medicine.

You can learn more about pharmacy errors and how to protect yourself in our book, Top Screwups. It is available at this link.

Reader Experience:

Share your experience at the pharmacy below in the comment section. Do you always check your prescription before leaving the store or do you grab and go?

In our experience, people seem far more careful about checking the money the bank clerk gives them than the medicine dispensed at the pharmacy. Which do you think is more important to your overall health?

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  1. pina

    On NP thyroid now. Had strange reaction to synthroid. My levels kept dropping. Did better with natural brands. Took armour for years; then it stopped working. I wonder if it was the change in the manufacturing company.

  2. Ann H.

    In Canada Synthroid comes in different colors depending on the dose.

  3. Mary

    I had been perfectly fine on a low dose of Nature Throid for years. Then my TSH went up slightly and the doctor doubled the dose. This produced a weird itching sensation on my scalp. So we switched to an equivalent dose of Levothyroxine but there was no relief from the itching, and it developed in other spots, most notably my waistband area. It was very strange and was worse than just plain itching, because it seemed inflamed. So we switched to Synthroid, but still no improvement from this weirdly inflamed and itchy skin. Finally after a year, I went to an endocrinologist who thought my slightly elevated TSH number didn’t warrant doubling the medication, so I went back to the original dose, but this time of Armour Thyroid (because Nature Throid is impossible to find), and the itching totally went away. My pharmacist never dispensed the medications incorrectly, but I wonder if anyone else ever experienced itchiness and inflamed skin as a result of thyroid medications. I do check the pills by sight, and my pharmacist for a while would open the pill bottle before bagging it, so that I could double check.

  4. Crystal

    I am an RN and spend alot of time double-checking my & hub’s medications. We do use some generics since I know which ones are usually effective (older drugs) and which ones aren’t. I know we hear so much about not buying drugs from Canada, etc. but I’m here to tell you that there are tons of pills, etc. that are NOT manufactured in the USA but are dispensed here every day. The companies have headquarters here and a lot of the research is done here but the actual making of the drug is not necessarily done here. India is one of the places that has a very large number of manufacturing facilities.

    I am also seeing atrocious prices on insulin. I use Lantus. My MC Part D provider doesn’t cover it. If I order from them, it’s $1600 for 90 days and lands me in the donut hole with the second filling. Good Rx is about $900 & doesn’t count toward the donut hole. But if I ask for a script for a 10 ml vial to draw up my own dosage with an insulin syringe, the cost is about $190 for 90 days and doesn’t count either. Those fancy pens are VERY expensive. In fact, any injectible in a fancy delivery device will cost a lot more. For insulin, hospitals don’t buy the pens. They use multi-dose vials because it is so much cheaper.

  5. Cari

    First, do not rely on the TSH only to determine your thyroid health. When I got the correct tests and natural dessicated thyroid, I lost the fifty lbs. I had gained from being on too low a dose of the wrong medicine. Natural dessicated thyroid contains all of the hormones in a healthy thyroid, not just T4. It has T4, T3, T2, T1 and calcitonin. Most MDs and pharmacists will argue that Synthroid generics are best. Many of us beg to differ. Also, I had the clerk tell me I should take Synthroid. He has no training in pharmacology other than what he hears by ringing up orders. But, one has to find a provider who is willing to let go of the “gold standard” of generic Synthroid.

    Regarding wrong dosage: I have opened a bottle to find a little of this and a little of that. The tech filled the Rx, and the pharmacist checked but she could not see what was in the bottle. Another thing is that generics can be manufactured in any country. I check to see where mine comes from. The fillers are not the same as in the name brands. One has to be very careful with any aspect of medicine. I would like to get my medicine in the original container but often the pharmacy will not do that.

  6. Maggie

    My doctor refuses to prescribe the generic Levothyroxine because it is infamously dosed high and low from what it’s supposed to be. He only prescribes Synthroid, which is a bit expensive. I guess if you tell him you can’t afford it he would prescribe the generic. Synthroid is about $45-$50 a month.

    • J S.
      South Carolina

      You can go generic ‘if’ you request that the pharmacy refill using the same manufacture each time. Different manufactures use different ‘recipes,’ if you will, for their levothyroxine.

    • Pat

      The pharmacist knows more about drug interactions and drugs than doctors

  7. Margaret

    This happened to my brother. He is a recovering alcoholic and goes to the V.A. hospital in Seattle. He had been taking Antabuse for a while. Since he lives in a small town about 40 miles from Seattle his medicine would be mailed to him. About 7 years ago, he got a refill by mail, and after taking one dose that evening didn’t feel well. The next day he took another dose, and this time was almost sick. He decided to take a bus to the V.A. hospital in Seattle to see a doctor, thinking he was coming down with something. He collapsed while on the bus and the aid unit took him to the nearest hospital, Harborview, which is in Seattle. The doctor asked my brother how long he had been a diabetic and my brother said he wasn’t. My brother had brought the medicine with him and the doctor at Harborview saw it among his belongings and told him that it was a drug for diabetics.

    The pharmacist at the V.A. hospital had sent my brother the wrong medicine, and it almost killed him. My brother wouldn’t report this to the V.A. hospital because he didn’t want to get the pharmacist in trouble. I tried to reason with him that the person who did this would probably keep on making mistakes until someone did die because of the wrong medicine. But he still wouldn’t report it.

  8. Barb
    Mooresville, NC

    When Synthroid was first prescribed for me, the doctor neglected to check the box requiring the brand. The pharmacist filled the script with generic, much to the chagrin of my doctor. I took it for the 30 days, then had it refilled. When I took the first two doses (2 consecutive days), the medication knocked me out. I went back to the pharmacy, thinking they mis-filed the prescription. After a discussion, I asked them to show me the box of the medication they filled the prescription from. There, on the box, was a big red sticker that said “new formula”, potentially a problem with generics (along with not knowing if there is a switch in manufacturers). I went back to the brand Synthroid and have not had problems since. I have noticed if I get a 90 day supply, it is filled with a sealed bottle from the factory, not by hand in the pharmacy.

  9. Lin

    I received a dark color version of a brand name levothyroxine a few years ago. I called the brand name company, and they sent an envelope, pre- stamped and asked for one of the pills. They told me to go back to the pharmacy and check if these are the the correct dose. Pharm tech said it was slightly too low and refilled the rest. After sending the pill, I never heard from the company. This happened with a small independent pharmacy. I now realize it was the wrong dose or counterfeit pills. I now open all bottles at the drugstore, count them and verify on my cell phone the size, color, and shape at pill identifier site. Reliability is a thing of the past. I have caught errors since then.

  10. Berge

    It happened twice at Walmart Pharmacy: first one in Boone, N.C, and the 2nd one in Coral Springs, Fl this year.
    In NC it was the wrong dose, the wrong Doctor’s name. And the pharmacist in Fl was obnoxious, when I stated to him that he charged me $159. for Dofetilide 125 mcg 60 capsules, instead of 250 mcg 60 capsules. Which meant I would have run out 125 mch caps in 2 weeks, hence I would have paid another $159 for the next 2 weeks supply of 125 mpg capsules. I always check contents before I leave, even though the cashiers appear to be annoyed.

  11. Mardee
    Denver, CO

    One of the more nasty (and sadly permanent) side effects of low thyroid isn’t listed above. I was chronically low thyroid for years until the doctor finally agreed to put me on NaturThroid. I now have neuropathy in my feet and hands, which because it is nerve damage, means it will likely be with me forever. I used to underwrite Pharmacists Liability Insurance and therefore know what what you are saying is true – one of the most common mistakes is right drug / wrong dosage. In my case, low thyroid was a prescribing issue, not the pharmacist’s fault. but I still always compare my existing meds with the new ones to make sure they exactly match, including any characters pressed into the tab, and I question it if they do not.

  12. Joseph
    San Antonio, TX

    The dosage of Levothyroxin is always checked after disposition but actually checking each pill is difficult because they are so small. A different color might be easily detectable although I am not aware that different dosages have different colors. Something I will inquire about with the pharmacist.

    • Rachelle
      CA - Chico

      Different doses do have different colors. When I discovered that the .25 dose had fillers and color added I asked my Dr. to prescribe the .50 dose which does not contain fillers or color. It is a chore to have to divide them but I’ve gotten used to it.

  13. Marjorie L B

    My endocrinologist based my dosage on my TSH 8 years ago and reduced it to the point that I was shaking so much that I could hardly write my name plus wanting to cry all the time and other symptoms. My Personal Care Physician was more caring and raised my dosage until I could find a new endocrinologist. I had my first surgery in 1973 for Hurtles Cell carcinoma and my second in 2000 for a papillary tumor. My first surgeon said Synthroid, no substitutions.

    • Sally

      Thank you for writing that you got a lot of shaking from too low a dose–I think my brother is going through the same thing (and/or he might need a different thyroid
      drug to help him better.) I appreciate reading about others who’ve
      experienced similar to what he’s got….more often, you read about
      patients who get shaking if they’ve got too much thyroid in their
      system, but I have read about a few who get shaking from too little.
      My brother’s other symptoms are consistent with low thyroid. So,
      thanks again for sharing your experience–it helps a lot.

  14. SARAH L.

    I’m wondering why pills don’t come in different colors for different doses.

  15. carol
    Raleigh NC

    Had a pharmacy who’s only employee was always talking with friends whenever I went to pick up a prescription. Had one prescription mis-filed and just had him give the right one. Next time had one for something starting with the same letter of another prescription. When I opened the bottle, which was labeled correctly, I saw that the pill looked different from the usual and checked with a doctor friend who identified it as a blood pressure pill. It was dangerous because my husband did not have high blood pressure. It could have caused him to go so low as to pass out. Kept it along with all paperwork and reported the pharmacist to the NC pharmacy board. They sent investigator out, and I gave him the bottle and all papers. Within a few weeks that pharmacist was no longer employed by the chain. No technician was employed at that location. Report mistakes, and if the person or branch has a pattern of mistakes the board will take action. It’s our health at stake. Double-check all, and double check again.

    • Bonnie

      I only take the name brand synthroid and they are color-coded according to dose. I dose my pills on a monthly basis. That way I see every pill that goes into the individual compartments.

  16. Carolyn
    North Carolina

    Pharmacy tech being “underpaid” is no excuse for dispensing an incorrect med or its dosage.

  17. Jan

    The Pharmacists Association in the UK also highlighted the ‘availability’ issue with levothyroxine. This means that the generic manufactured by multiple sources sometimes does NOT adhere to strict pharmaceutical guidelines laid down in law and can result, over time, in a cumulative decrease in medication. Quite simply, the manufacturer is cutting corners for profit. Now in 2018 in France, the major supplier of levothyroxine has been almost struck off and instead, German supplies are being used. The solution? more use of natural desiccated thyroxine.

  18. carmen
    Florida and Ohio

    My cardiologist from the Cleveland Clinic told me they are now discovering that low thyroid
    is associated with AFib.

  19. Estelle
    New Jersey

    I tried several natural thyroid meds which made me sick, jittery and nauseous. Finally I was prescribed Levothyroxine. I filled that prescription 2 times, and they also made me physically sick. Finally I was given the Levothyroxine by the manufacturer Mylan. It’s the only medication that is not making me physically sick and helps my hypothyroid/Hashimoto symptoms. When I pick up my prescription I always open the container to make sure it’s from Mylan. One time the pharmacy gave me a round pill instead the oval. I told them it was wrong, and they said Levothyroxine is Levothyroxine! NO, IT IS NOT. Make sure you are getting the correct meds. Pharmacies change vendors all the time.

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