Autoimmune Thyroid Disease - Restorative Medicine...Autoimmune Thyroid Disease Michael Friedman, ND...
46
Autoimmune Thyroid Disease Michael Friedman, ND Executive Director Association for the Advancement of Restorative Medicine Financial Disclosure:Owner and Science officer of Restorative Formulations 1
Transcript of Autoimmune Thyroid Disease - Restorative Medicine...Autoimmune Thyroid Disease Michael Friedman, ND...
Autoimmune Thyroid Disease
Michael Friedman ND
Executive Director
Association for the Advancement of Restorative Medicine
Financial DisclosureOwner and Science officer of Restorative Formulations
1
Thyroid Prevalence
Diseases of the thyroid are not common in medical practice -
1967
13 million nationally may have undiagnosed abnormal thyroid
function in 1995
117 abnormal TSH
20 million 2017
Canaris GJ Manowitz NR Mayor G Ridgway EC The Colorado Thyroid Disease Prevalence Study Arch Intern Med 2000160526-534
2
Autoimmunity
Steady increase in the incidence and prevalence of autoimmunity
worldwide
Rate of increase ( increase every year) globally ndash 191plusmn
431
Lerner A Jeremias P amp Matthias T (2015) The World Incidence and Prevalence of Autoimmune
Diseases is Increasing International Journal of Celiac Disease 3(4) 151-155
4
5
6
wwwhscmissouriedu~davegthyroidthy_dishtml
Examples of Thyroid Diseases
1deg Hypothyroidism Hyperthyroidism
7
8
9
Autoimmunity ndash Genetics Vs
Environment
Brent GA Environmental Exposures and Autoimmune Thyroid DiseaseThyroid 201020(7)755-761
doi101089thy20101636
Autoimmune thyroid disease
Genetics ~ Environmental triggers ~
10
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Thyroid Prevalence
Diseases of the thyroid are not common in medical practice -
1967
13 million nationally may have undiagnosed abnormal thyroid
function in 1995
117 abnormal TSH
20 million 2017
Canaris GJ Manowitz NR Mayor G Ridgway EC The Colorado Thyroid Disease Prevalence Study Arch Intern Med 2000160526-534
2
Autoimmunity
Steady increase in the incidence and prevalence of autoimmunity
worldwide
Rate of increase ( increase every year) globally ndash 191plusmn
431
Lerner A Jeremias P amp Matthias T (2015) The World Incidence and Prevalence of Autoimmune
Diseases is Increasing International Journal of Celiac Disease 3(4) 151-155
4
5
6
wwwhscmissouriedu~davegthyroidthy_dishtml
Examples of Thyroid Diseases
1deg Hypothyroidism Hyperthyroidism
7
8
9
Autoimmunity ndash Genetics Vs
Environment
Brent GA Environmental Exposures and Autoimmune Thyroid DiseaseThyroid 201020(7)755-761
doi101089thy20101636
Autoimmune thyroid disease
Genetics ~ Environmental triggers ~
10
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Autoimmunity
Steady increase in the incidence and prevalence of autoimmunity
worldwide
Rate of increase ( increase every year) globally ndash 191plusmn
431
Lerner A Jeremias P amp Matthias T (2015) The World Incidence and Prevalence of Autoimmune
Diseases is Increasing International Journal of Celiac Disease 3(4) 151-155
4
5
6
wwwhscmissouriedu~davegthyroidthy_dishtml
Examples of Thyroid Diseases
1deg Hypothyroidism Hyperthyroidism
7
8
9
Autoimmunity ndash Genetics Vs
Environment
Brent GA Environmental Exposures and Autoimmune Thyroid DiseaseThyroid 201020(7)755-761
doi101089thy20101636
Autoimmune thyroid disease
Genetics ~ Environmental triggers ~
10
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
5
6
wwwhscmissouriedu~davegthyroidthy_dishtml
Examples of Thyroid Diseases
1deg Hypothyroidism Hyperthyroidism
7
8
9
Autoimmunity ndash Genetics Vs
Environment
Brent GA Environmental Exposures and Autoimmune Thyroid DiseaseThyroid 201020(7)755-761
doi101089thy20101636
Autoimmune thyroid disease
Genetics ~ Environmental triggers ~
10
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
6
wwwhscmissouriedu~davegthyroidthy_dishtml
Examples of Thyroid Diseases
1deg Hypothyroidism Hyperthyroidism
7
8
9
Autoimmunity ndash Genetics Vs
Environment
Brent GA Environmental Exposures and Autoimmune Thyroid DiseaseThyroid 201020(7)755-761
doi101089thy20101636
Autoimmune thyroid disease
Genetics ~ Environmental triggers ~
10
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
wwwhscmissouriedu~davegthyroidthy_dishtml
Examples of Thyroid Diseases
1deg Hypothyroidism Hyperthyroidism
7
8
9
Autoimmunity ndash Genetics Vs
Environment
Brent GA Environmental Exposures and Autoimmune Thyroid DiseaseThyroid 201020(7)755-761
doi101089thy20101636
Autoimmune thyroid disease
Genetics ~ Environmental triggers ~
10
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
8
9
Autoimmunity ndash Genetics Vs
Environment
Brent GA Environmental Exposures and Autoimmune Thyroid DiseaseThyroid 201020(7)755-761
doi101089thy20101636
Autoimmune thyroid disease
Genetics ~ Environmental triggers ~
10
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
9
Autoimmunity ndash Genetics Vs
Environment
Brent GA Environmental Exposures and Autoimmune Thyroid DiseaseThyroid 201020(7)755-761
doi101089thy20101636
Autoimmune thyroid disease
Genetics ~ Environmental triggers ~
10
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Autoimmunity ndash Genetics Vs
Environment
Brent GA Environmental Exposures and Autoimmune Thyroid DiseaseThyroid 201020(7)755-761
doi101089thy20101636
Autoimmune thyroid disease
Genetics ~ Environmental triggers ~
10
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Life stress
Infections
Nutritional deficiencies (iodine
selenium)
Smoking
Medications such as Amiodarone and
interferon
Radiation
Heavy metals amp Pesticides
Environmental toxicants
Intestinal dysbiosis
Environmental triggers
11
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Environmental Factors
Coal combustion 400 metric tons
a year of mercury
Rocket Fuel Combustion- 20 million
pounds perchlorates in US per year
(Lausanne) 2017 Mar 20850 doi 103389fendo201700050 eCollection 2017Mercury emissions from the eight highest emitting industry sectors Data for 2010 from the 2013 UNEP Global Mercury Assessment Total estimated global anthropog Ferrari SM Fallahi P Antonelli A Benvenga S Environmental Issues in Thyroid Diseases Front Endocrinol enic mercury emissions are 1960 metric tons
12
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Antibodies and Toxins
The Five Crucial Players That Affect
Thyroid Function
Sodium Iodide Symporter (NIS)
Thyroglobulin
Thyroid Peroxidase
Iodothyronine Deiodinase (Conversion)
Thyroid Receptors
13
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Radiation affects NIS
Release of Iodine 131 from
nuclear power plants and
nuclear weapon facilities
US atomic weapons tests in
Nevada Millstone nuclear
power plant in Connecticut
14
Voumllzke H1J Clin Endocrinol Metab 2005 Aug90(8)4587-92 Epub 2005 May 10
Occupational exposure to ionizing radiation is associated with autoimmune
thyroid disease
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Halogens affect NIS
Chlorine fluorine and bromine - chemically related
to iodine and compete with it blocking iodine
receptors in the thyroid gland
Chlorine Fluoride - once and still used as a
treatment option for hyperactive thyroid gland
15
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Perchlorate affects NIS
Perchlorate - Environmental contaminant that blocks
iodineiodide uptake into the thyroid gland by affecting the
iodine transport mechanism (the sodiumiodine
symporter)
Wolff J Perchlorate and the thyroid gland Pharmacol Rev 1998 Mar50(1)89-105
16
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Polybrominated diphenyl ethers
(PBDEs)
Found in 97 of US residents serum TSH
declined 16 for every tenfold increase in PBDErsquos
Lin SM Chen FA Huang YF Hsing LL Chen LL Wu LS Liu TS Chang-Chien GP Chen KC Chao HR Negative associations between PBDE levels and thyroid hormones
in cord blood Int J Hyg Environ Health 2011214(2)115-20
Chevrier J Harley KG Bradman A Gharbi M Sjoumldin A Eskenazi B Polybrominated diphenyl ether (PBDE) flame retardants and thyroid hormone
during pregnancy Environ Health Perspect 2010118(10)1444-1449
httpwwwenvironmentalhealthnewsorgehsnewsflame-retardants-linked-to-altered-thyroid-hormones-in-pregnant-women
17
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Organochlorine Pesticides affect NIS
Can result in euthyroid goiter or hypothyroidism
Pesticide Exposure
Thyroid hormone concentration change was
consistently a response due to mixtures but NOT
usually to individual chemicals
Howdeshell KL A model of the development of the brain as a construct of the thyroid system Environ Health Perspect 2002 110 Suppl3337-348
Porter WP Jaeger JW and Carlson IH EndoEndocrine immune and behavioral effects of aldicarb (carbamate) atrazine (triazine) and nitrate (fertilizer) mixtures at groundwater concentrationsToxicology and Industrial Health 1999 15 (1-2) 133-150
18
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
HYPOTHALAMUS-PITUITARY THYROID AXIS DEIODINASE-CONTAINING TISSUES
WT D2KO
Development Growth Metabolism
copy 2013 BLab
TSH
TRH
PITUITARY
Cognition
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Exercise Triples Deiodinase 2 after Exercise
The BiancoLab at RUSH University Medical Center in Chicago
20
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Heavy Metals Sunscreen and Stress Affect Conversion-
5-deiodination Inhibition
Cadmium Mercury Lead toxicity
Stress Poor nutrition Illness Selenium deficiency
4-MBC and Octylmehtoxycinnamate (found in sunscreen)
Bioaccumulation in fish and human milk
Decreases 5rsquo deiodinase activity
Gupta P Kar A Cadmium induced thyroid dysfunction in chicken hepatic type I iodothyronine 5-monodeiodinase activity role of lipid peroxidation Comp Biochem Physiol C Pharmacol Toxicol Endocrinol 199912339-44
Schmutzler C Hamann I Hofmann PJ Kovacs G Stemmler L Mentrup B Schomburg L Ambrugger P Gruumlters A Seidlova-Wuttke D Jarry H Wuttke W Koumlhrle J Endocrine active compounds affect thyrotropin and thyroid hormone levels in serum as well as endpoints of thyroid hormone action in liver heart and kidney Toxicology 2004205(1-2)95-102
21
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
BPA ndashAffects Conversion
PhthalatesBPA - Alter the bodys thyroid hormone levels
and potentially aggravate or even lead to thyroid disease
Andra SS Makris KC Thyroid disrupting chemicals in plastic additives and thyroid health J Environ Sci
Health C Environ Carcinog Ecotoxicol Rev 201230(2)107-51 doi 101080105905012012681487
22
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
23
Polychlorinated
biphenyl (PCB) Affects
Thyroid Receptors
Structure of PCBrsquos similar to
thyroid hormone
Bind to and interact with TH
receptor
Agonists or antagonists to TH
receptor
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Intestinal Dysbiosis Microbiome
Intestinal microbiota - Crucial
for immunologic hormonal
and metabolic homeostasis
Functional thyroid disorders -
Associated with bacterial
overgrowth and a different
microbial composition
24Virili C Centanni M With a little help from my friends - The role of microbiota in thyroid hormone metabolism and enterohepatic
recyclingMol Cell Endocrinol 2017 Feb 4
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Impact of Infections on the Thyroid
Human parvovirus B19 (EVB19) and hepatitis C virus
Interleukin-1 Interleukin-6 and TNF inhibit thyrotropin
secretion
Mucocutaneous candidosis - 50 increase in
hypothyroidism
Larsen PR et al Williams Textbook of Endocrinology 10th ed 2003p101
Coleman R and Hay RJ Chronic mucocutaneous candidosis associated with hypothyroidism a distinct syndrome British Journal of Dermatology 199736 (1)24-29
25
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Medications
Radioactive Iodine
Interferon
High dose Glucocorticoids (steroids)
Oral cholecystographic agents for
visualization of the gall bladder
Sunitinib and other tyrosine kinase inhibitors
Angiogenesis inhibitors such as lenalidomide
Lithium
Amiodarone
Sulfonamides
Bexarotene
Ethionamide
Anticonvulsants
Drugs that interact with levothyroxine an observational study from the Thyroid Epidemiology
Audit and Research Study (TEARS) Clin Endocrinol (Oxf) 2014 Jul 17 doi 101111cen12559
26
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Vitamin D3 and Hashimotorsquos Disease
125-Vitamin D levels are lower in
individuals with Hashimotorsquos
disease
Supplementation with vitamin D3 in
animal models prevents the
development of autoimmune
thyroiditis and MS
27
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Selenium and Thyroid Antibodies
During the supplementation trial
50-100 mcg
bull Serum selenium (Se) increased
by 45
bull Plasma glutathione peroxidase
(GPX3) by 21
bull TPO-Ab decreased by 76
bull Graves Ophthalmopathy
28
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
In Thyroid What Happens to Iodine
After Absorption
I-NIS
I-
TSH
Oxidation (H202+TPO)
Organification
δ ndashIodolactone and
other iodinated lipids
bullProstaglandins Other Lipid Mediat 2014 Aug11227-33 doi 101016jprostaglandins201407001 Epub 2014 Jul 10
bull6-iodolactone key mediator of antitumoral properties of iodine
However organification of lipids will only occur with
iodine intake in excess of the RDA
I2
MIT DIT T3 T4
TG
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Environmental Toxins
Diagnose it
Decrease toxic load
Heavy metal removal
Eliminate halogens in diet and body
Consider alternatives to certain medications
Treat and bacterial or myco-overgrowth
30
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
General Thyroid Autoimmune Protocol
Nutrition Hypoallergenic diet treat dysbiosis
Decrease environmental toxins
Vitamin D3 50000 IU twice a week or min 4000 IU daily
Fish oils (Omega 3-6-9)
Ensure healthy gut microbiome
Antioxidant supplements (selenium vit E) which are thyro-
protective
31
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
32
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Remove Halogens
25-50 mg Iodine a day for
several months to remove
halogens
Environmental Triggers for HypothyroidEnvironmental Triggers for Hypothyroid
Lifestyle
Exercise
Treat Dysbiosis
Lifestyle
Exercise
Treat Dysbiosis
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
Remove Heavy Metals
DMSA 500 MG three
times a week
Liposomal Glutathione
500 mg Daily
Fiber-10 grams
supplementation daily
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
33
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Nutrition Supplementation
5 drops of Lugolrsquos iodine or iodine supplement solution 12 mg BID for a min of three months to help with halogen displacement and iodine supplementation
Selenium 400 IU Vitamin D3 4000 IU Methylcobalamin 800
mcg
Specifics for HypothyroidSpecifics for Hypothyroid
Botanicals
supplements
Iris Kelp Myrrh
Botanicals
supplements
Iris Kelp Myrrh
25 mcg T3 BID
Or 100 mcg T4
25 mcg T3 BID
Or 100 mcg T4
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Hashimotorsquos Disease Case Study
Initial
15 year old boy
TSH
After 5 years Initial After 5 years
TPO AB
34
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Hashimotorsquos Thyroiditis Iodine
Case Study
Initial After 3 months Initial After 3 months
27 year old female
TSH T3
35
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Graves Disease
B and T lymphocyte-mediated autoimmunity are known
to be directed at 4 well-known thyroid antigens
bull Thyroglobulin
bull Thyroid peroxidase
bull Sodium-iodide symporter
bull Thyrotropin receptor
36
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Thyroid Stimulating Antibodies
Thyroid Stimulating Immunoglobulin -Elevated in about
80 patients with Graves Disease (both treated and
untreated)
Elevated in 5 to 10 in patients with Hashimotorsquos
disease
37
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Different Side of Same Coin
Graves disease may sometimes evolve into Hashimotos
thyroiditis (and vice versa) indicating that the two
disorders are closely related patho-physiologically
Tamai H Ohsako N Takeno K et al Changes in thyroid function in euthyroid subjects with a family history of Graves disease a follow-up study of 69 patients J Clin Endocrinol Metab 1980 511123
Kraiem Z Baron E Kahana L et al Changes in stimulating and blocking TSH receptor antibodies in a patient undergoing three cycles of transition from hypo to hyper-thyroidism and back to hypothyroidism Clin Endocrinol (Oxf) 1992 36211
Case Rep Endocrinol 201620166029415 doi 10115520166029415 Epub 2016 Mar 2
Hashimotos Thyroiditis and Graves Disease in One Patient The Extremes of Thyroid Dysfunction Associated with Interferon Treatment
Bishay RH1 Chen RC138
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Botanicals containing Rosmarinic Acid
bull Lowers Thyroid Stimulating Immunoglobulin levels
Sourgens H Winterhoff H Gumbinger HG and Kemper FH Effects of Lithospermum officinale and Related Plants on
Hypophyseal and Thyroid Hormones in the Rat Pharmaceutical Biology 1986 24 (2)53-63
Rosmarinic Acid and Thyroid Antibodies
39
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Watt T Cramon P Bjorner J Bonnema S Feldt- Rasmussen U Gludd C Selenium supplementation for patients with Gravesrsquo hyperthyroidism (the GRASS trial) study protocol for a randomized controlled trial Trials 20131411940
Selenium Selenium
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Influences the regulation of T3 levels an
important component of glutathione peroxidase
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
Decreases inflammatory cytokines via NF-
kappa-B inhibition attenuating the
inflammatory response
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
An ongoing double-blind placebo controlled
clinical trial the Gravesrsquo Disease Selenium
Supplementation trial (GRASS) which aims to
establish the clinical role of selenium in the
treatment
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
41
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Nutrient Supplementation
5 drops of Lugolrsquos iodine or
iodine supplement (125 mg) 3
times a day for 3 days
125 mg followed by 300 mg of
lithium carbonate 3 times
Specifics for HyperthyroidSpecifics for Hyperthyroid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Botanicals supplements
Rosmarinic Acid 335 mg
BID
Traditional Botanical
Medicine Formula
Bugleweed Lemon Balm
Extracts that contain
Rosmarinic Acid
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Treat Cardiovascular
Symptoms Immediately-
Beta blockers -
Atenolol (25 to
50 mgday)
Rauwolfia (Reserpine) -
decreases the release and
accumulation of
noradrenaline and
contributes to hypotensive
effects
Use with thianamides
concurrently is safe
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Graves Disease
Initial
TSI Reference Values (under 130)
TSI
After 2 months
42
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Toxic Multi Nodular Goiter
After 3 months
TSH Reference Values (35-5 mIUml)
Total T3 Reference Values (60-181 ngdl)
Total T3
Initial
43
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Hyperthyroid Lab Report
44
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Hyperthyroid Lab Report
45
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
Antonio C Bianco MD PhD Division of Endocrinology and Metabolism
Rush University Medical Center
Chicago IL
Acknowledgements
47
47
