Healing hashimotos slides

Healing Hashimoto’sPHYSICIANS’ TRAINING

Statement of Disclosures The following potential conflict of interest relationships are germane to this presentation.Event Support: RLC Labs manufacturers of Nature Throid, Westhroid and Westhroid P

Employment: None

Speakers Bureau: None

Stock Shareholder: None Grant/Research Support: NoneConsultant: None

Publications: Complete Idiot’s Guide to Thyroid Disease, Healing Hashimoto’s A Savvy Patient’s Guide

Information Products: Hypothyroid App, Hypothyroid App ProStatus of FDA devices used for the material being presented NA/Non-ClinicalStatus of off-label use of devices, drugs or other materials that constitute the subject of this presentationNA/Non-Clinical

• Fat• Sick• Epileptic kid

Health By Default

Healthy & Happy • Physician• Author• Patient Advocate

Health By Design

• SCNM Premier Class

• Began Thyroid focused practice in 1996.

• American Thyroid Association

• American Academy of Clinical Endocrinology

• Broda Barnes Foundation

• Wilson Temperature Syndrome

Alan Christianson, NMD

Introduction

The guidelines of conventional medicine tend to under-diagnose and under-treat hypothyroid symptoms.

The guidelines in alternative medicine tend to over-diagnose and over-treat hypothyroid symptoms.

Emerging evidence will be used to evaluate both sides’ strengths and weaknesses and create an evidence-based Integrative model.

Pre Event Quiz

Which of the following would mandate thyroid replacement in a symptomatic patient with a TSH between 2.5 to 4.5?

A. Delayed Achilles reflexB. AM Axillary body temperature below 97.2C. Positive prior response to thyroid replacementD. Ultrasonographic signs of autoimmunity

Pre Event Quiz

Most hypothyroidism in the USA and Europe is caused by:

A. Iodine deficiencyB. Autoimmune diseaseC. ObesityD. Bromide toxicity

Pre Event Quiz

Thyroid dosing can be safely increased until:

A. AM Axillary body temperature rises above 98.9

B. Symptoms have resolvedC. TSH is suppressed below 0.4 mIU/LD. free T3 elevates above 4.8 pg/mL

Learning Objectives•Conventional diagnostic criteria for Hypothyroidism and their shortcomings

•Alternative diagnostic criteria for Hypothyroidism and their shortcomings

•Diagnostic guidelines that predict which non-‘Hypothyroid’ patients can benefit from thyroid treatment and which may not.

•Thyroid medications and dosing guidelines

•Advanced strategies for managing Hashimoto’s

Program Overview Introduction

Section 1 – Overview and Diagnosis

Section 2 – Replacement Dosing

Section 3 – Nutrition

Section 4 – Immunology

Section 5 – Toxicology

Section 6 - Thyroid Imaging – SMIL

Section 7 – Endocrine Connections

Section 8 - Q/A – Case Review

Section 1 Part 1THYROID OVERVIEW

Hypothyroidism•> 30 Million American Adults

•10% of population – undisputed

•20% of population – hypothetical and probable

•25-50% of those with disease have been diagnosed

•50% of those diagnosed still symptomatic

•8 Times more common in women

Hypothyroidism in Women•25% of Women will develop hypothyroidism in their lifespans (conservative estimates)

•Scientists are not clear why women get more autoimmune diseases, top theories:• Microchimerism (persistent foreign cells from baby)• Lower Testosterone• Expression of X-linked immune abnormalities

•Yet, Scientists do now know why women live longer . . .

http://www.thyroidmanager.org/chapter/ontogeny-anatomy-metabolism-and-physiology-of-the-thyroid/

Thyroid Hormones in Other Organisms

Thyroid Anatomy

•Thyroid Mass Average = 60-100 grams•Size = deck of cards•Shape = (approximate) Butterfly•Non-palpable when healthy

Thyroid Hormone Synthesis

Thyroid Hormones

Thyroid hormones

◦Triiodothyronine=T3=liothyronine = 30 micrograms/day◦20% produced by thyroid gland◦80% by deiodination◦4 x as potent as T4

◦T1 and T2 in trace amounts

Thyroid Hormone Metabolism

Thyroid Hormone Excretion

Thyroid Hormone Regulation

Williams Textbook of Endocrinology. Page: 312

Thyroid Physiology

•Stimulates all cells to form energy•Burns carbohydrate and fat•Body temperature•Hair, skin and nails• Immune function•Regulates ovaries and adrenals•Repair of brain cells• Intestinal peristalsis

Thyroid Hormone Effects on Tissues

http://www.lfhk.cuni.cz/patfyz/Intranet/Tables/60/12.1.jpg

Thyroid Pathology Overview•Primary (Thyroid)•Secondary (Pituitary)•Tertiary (Hypothalamus)•ATD•Hashimoto’s•Graves

•Thyroiditis

•Thyroid Cancer•Papillary•Medullary•Anaplastic

•Structural Issues• Nodules• Goiter• Toxic• Non-toxic

Genes •Family History of Thyroid Disease - Any Type•Variations in Sodium Iodine Symporter

Toxins •Iodine, Fluoride, Perchlorate, Mercury, Cadmium

Vit D •Vitamin D - Below optimal levels (50-70 ng/dl)

Infections •EBV, hepatitis C, human parvovirus B19, coxsackie, herpes virus

Auto Immune Thyroid Disease

Hashimoto's Thyroiditis

• Immune system attacks thyroid

• Both hyper/hypo symptoms

• 97% of hypothyroidism

Dr. Hakuru Hashimoto1881 - 1934

Hashimoto’sThyroiditis

• Autoimmune

• Most Common Thyroid Disease in America

• Higher Risk of other Autoimmune diseases

• 8 /1 Female to Male ratio

• Higher risk of thyroid cancer

• NAFL

Autoimmune Thyroid Disease: New Models of Cell Death in Autoimmunity. Giorgio Stassi & Ruggero De MariaNature Reviews Immunology 2, 195-204 (March 2002).

Section 1 Part 2THYROID DIAGNOSIS

Hypothyroidism - Historical Perspective

". . there are a large number of patients who suffer from thyroid poverty and who drift from physician to physician without the cause of their symptoms being suspected. . . . In doubtful cases thyroid extract may be given in small doses as a therapeutic test, and continued if it does good and discontinued if it does harm."

The Profit and Loss Account of Modern Medicine, and Other Papers By Stuart McGuire Published 1915 L. H. Jenkins

The condition in which hypothyroid symptoms are present without other immediate causes and can be improved with thyroid replacement therapy.

•Hypothyroidism•Subclinical hypothyroidism•Type 2 hypothyroidism•Functional hypothyroidism•Sublaboratory hypothyroidism•(Clinical) Hypothyroid Syndrome

Definitions: Suboptimal Thyroid Status

•TSH•T4/fT4•T3/fT3•Antithyroid antibodies (TPO, TG, TSI)

Normal and abnormal defined by local reference laboratory ranges

Definitions: Thyroid Serology

Value Normal low Normal high

TSH 0.4 4.5 – 7.0

fT3 1.4 4.2

fT4 0.7 2.0

Definitions: Normal Serology

Thyroid reference ranges have been skewed to the hypo side by including the thyroid disease population.

[Evidence Level A, RCT]

Erden g, Oanzden A, Tezcan G, et al. Biological Variation and Reference Change Values of TSH, Free T3, and Free T4 Levels in Serum of Healthy Turkish Individuals. Turk J Med Sci 2008; 38 (2): 153-158.

Definitions: Optimal Serology

The average TSH, free T3 and free T4 scores of healthy individuals without thyroid disease was compared to current normal ranges. Those chosen were free of thyroid disease and had no chronic disease such as diabetes, hypertension coronary artery disease or anemia. Subjects were excluded if they had any major medical illness such as other endocrine or autoimmune disease, any medication use including oral contraceptives, pregnancy or history of substance abuse.

This population showed less variation in thyroid blood levels than established reference ranges would predict. Most notably TSH levels did not exceed the middle of the normal reference range.


By testing each individual 4 times over two weeks under consistent conditions, the study also showed that intra-individual variation in thyroid serology was nearly identical to inter-individual variation in this healthy population.


Value Median Min. Max

TSH 0.99 0.36 1.91

fT3 2.69 1.99 3.17

fT4 0.93 1.09 1.9


Obesity within normal TSH

•Positive association between BMI and TSH (P < 0.001)

•When TSH values all in normal ranges . . .

•Highest to lowest TSH = 12.1 pound weight difference in women

•Negative association between BMI and free T4 (P < 0.001)

Knudsen N et al. Small differences in thyroid function may be important for body mass index and the occurrence of obesity in the population.J Clin Endocrinol Metab. 2005 Jul;90(7):4019-24

Less stamina than othersLess energy than othersLong recovery period after any activityInability to hold children for very longArms feeling like dead weights after activityChronic Low Grade DepressionSuicidal ThoughtsOften feeling coldCold hands and feetHigh or rising cholesterolHeart diseasePalpitationsFibrillationsPlaque buildupBizarre and Debilitating reaction to exerciseHard stoolsConstipationNo eyebrows or thinning outer eyebrowsDry HairWhite hairs growing inNo hair growth, breaks faster than it growsDry cracking skinNodding off easily

Requires naps in the afternoonSleep Apnea (which can also be associated with low cortisol)Air Hunger (feeling like you can’t get enough air)Inability to concentrate or read long periods of timeForgetfulnessFoggy thinkingInability to lose weightAlways gaining weightInability to function in a relationship with anyoneNO sex driveFailure to ovulate and/or constant bleedingMoody periodsPMSInability to get pregnant; miscarriagesExcruciating pain during periodNauseaSwelling/edema/puffinessAching bones/musclesOsteoporosisBumpsAcne on face and in hairBreakout on chest and armsHivesExhaustion in every dimension–physical, mental, spiritual, emotional

Inability to work full-timeInability to stand on feet for long periodsComplete lack of motivationSlowing to a snail’s pace when walking up slight gradeExtremely crabby, irritable, intolerant of othersHandwriting nearly illegibleInternal itching of earsBroken/peeling fingernailsDry skin or snake skinMajor anxiety/worryRinging in earsLactose IntoleranceInability to eat in the morningsJoint painCarpal tunnel symptomsNo AppetiteFluid retention to the point of Congestive Heart FailureSwollen legs that prevented walkingfluid on the inner ear

Definitions: Possible Symptoms

Possible symptoms are far too numerous and non-specific to be of diagnostic value.

If you have possible thyroid symptoms but no objective sign of thyroid disease, you just have symptoms.

Definitions: Possible Symptoms

The Colorado Thyroid Disease Prevalence Study represents our best scholarly examination of which symptoms best predicted thyroid disease.

In 1995, over 25,000 people participated in health fairs in Colorado to get some basic medical screening for vision, blood pressure, colon cancer and skin cancer.

Participants also had serum TSH measured and were given a thyroid symptom survey.

Definitions: Probable Symptoms

The thyroid scores were categorized into four ranges:1. Normal defined as TSH scores 0.3 - 5.12. Subclinical hypothyroid defined as TSH scores greater than 5.1 but with normal T4 levels3. Hypothyroid defined as TSH scores greater than 5.1 and low T4 levels4. Hyperthyroid defined as TSH scores lower than 0.01.

Of many symptoms surveyed, the following were those that served as the best predictors of which patients would have significantly abnormal blood thyroid levels:


Of many symptoms surveyed, the following were those that served as the best predictors of which patients would have significantly abnormal blood thyroid levels.

Note high specificities and low sensitivities:


Symptom Sensitivity Specificity

Hoarse voice 6.7 94.5

Slower thinking 22.3 81.5

More constipation 6.1 95

Hoarser voice 5.5 95

Deeper voice 2.9 97.6

Drier skin 28.3 74.7

Feeling colder 14.6 88.2

More tired 18.3 84

Puffier eyes 11.3 90.2

Muscle cramps 17.6 84.9

Weaker muscles 22.2 81.5

Hypothyroidism - Conventional Diagnosis

Per Merck Manual:

•TSH elevationand•T4/fT4 suppression•Dose titration until TSH normal, symptoms not factored into dosing

Hypothyroidism - Conventional Diagnosis

Hypothyroid symptoms are known to often be present but their presence or absence does not change the diagnosis.

Serology w/o symptoms = hypothyroidism

Symptoms w/o serology ≠ Hypothyroidism

Conventional Diagnosis - Shortcomings

• Thyroid symptoms can emerge with normal thyroid serology

• Some patients with thyroid symptoms and normal serology can benefit from thyroid replacement.

• Some patients with thyroid symptoms and normal serology are at higher medical risk without thyroid replacement

• ‘Normal’ thyroid serology is biased to thyroid pathology

Thyroid symptoms with normal thyroid serology

In America, hypothyroidism is caused primarily by Hashimoto’s thyroiditis.

In most cases, clear signs of the disease can be documented several years before hypothyroid serology manifests.

Symptoms can be present at the earliest stages of the disease, prior to elevation of TSH and suppression of fT3 or fT4.

[Evidence Level C, Expert Consensus]

Tomer Y, Huber A. The etiology of autoimmune thyroid disease: a story of genes and environment. J Autoimmune. 2009; 32: 231-239.

Thyroid symptoms with normal thyroid serology

The early stages of this disease can be documented via blood tests for anti thyroid antibodies, palpable thyroid changes on physical exam, ultrasound findings or tissue biopsy.

Serum antibodies in their absence do not rule out Hashimoto’s.

[Evidence level C, Expert Consensus]Thyroid Disease Manager. Chapter 8. Hashimoto's Thyroiditis. Takashi Akamizu, Nobuyuki Amino, and Leslie J De Groot. http://www.thyroidmanager.org/Chapter8/8-frame.htm. Accessed 4.3.11.Stephanie L Lee, MD, PhD; Chief Editor: George T Griffing, M.Hashimoto Thyroiditis. http://emedicine.medscape.com/article/120937-overview accessed 4/9/11.

http://www.thyroidmanager.org/Chapter8/8-frame.htm

http://emedicine.medscape.com/article/120937-overview

Patients benefit from early treatment

Treatment with thyroid replacement therapy at this early stage of Hashimoto’s can:

•Reduce symptoms•Slow disease progression•Reduce the risk of nodules and goiter•Shrink existing nodules and goiter

[Evidence Level B, Clinical Trial]Padberg S, et. al. ."One-year prophylactic treatment of euthyroid Hashimoto's thyroiditis patients with levothyroxine: is there a benefit?" Thyroid. 2001 Mar;11(3):249-55.

Medical risks for untreated early Hashimoto’s

Patients with Hashimoto’s disease, even without positive antithyroid antibodies and serum hypothyroidism still have higher risks for heart disease. Patients with Hashimoto’s Thyroiditis whose TSH is above 2.0 have an increased risk of thyroid cancer.

Not only can these patients be treated, they are placed at greater medical risk if not treated.

[Evidence level B, Clinical Trial]Bastenie PA, Vanhaelst L, Golstein J, Smets P, et al. Asymptomatic autoimmune thyroiditis and coronary heart-disease. Lancet. 1977. 1:155. Heinonen OP, Aho K, Pyorala K, et al. Symptomless autoimmune thyroiditis in coronary heart disease. Lancet. 1972. 1:785.

Hypothyroidism - Alternative Diagnosis

Per Broda Barnes:•Hypothyroid symptoms - including weight gain, fatigue, depression, hair loss but not stringently defined.•AM Axillary BBT <97.8•Dose increase until symptoms resolve or BBT >98.2•OK to ignore both hypothyroid serology at diagnosis and hyperthyroid serology with dose titration

Alternative Diagnosis - Shortcomings

•Ranges used to evaluate BBT

•Dangers of hyperthyroid serology


Ranges used to evaluate BBT

BBT can be suppressed by hypothyroidism, but: •Significant temperature suppression is not consistent with early disease•Normal variance of BBT greater than Barnes estimates •Too many other factors influence BBT


Per Barnes:“Thus, it seemed that axillary, or underarm, temperature might serve as a simple guide to determining low thyroid function and the need for thyroid therapy. And over the past thirty years, it has served as such.

In that time, based on many thousands of readings, it has been established that normal values for underarm temperature are in the range of 97.8 - 98.2 degrees Fahrenheit.”

Barnes B. Hypothyroidism: The Unsuspected Illness, HarperCollins. 1976:46.


In 2002 a comprehensive review of credible papers on normal human body temperatures from 1935 - 1999 was published.

This paper showed that the range of normal temperatures was from 91.8 - 100.6 degrees Fahrenheit for women and 96.2 - 99.9 for men. Axillary temperatures are held to be within a degree of oral temperatures.

The conclusion of the meta-analysis was that: “The ranges of normal body temperature need to be adjusted, especially for the lower values. When assessing body temperature it is important to take place of measurement and gender into consideration.”

[Evidence level B, Clinical Trial]

Sund-Levander M, Forsberg C, Wahren L, et al. Normal oral, rectal, tympanic and axillary body temperature in adult men and women: a systematic literature review. Scand J Caring Sci. 2002 Jun;16(2):122-8.


Dangers of hyperthyroid serology

Barnes claims that patients with any persistent possible hypothyroid symptoms can safely increase thyroid dosing as long as BBT does not elevate above 98.2 degrees.



Yet in many cases, patients can end up on significantly supraphysiologic doses of thyroid with complete TSH suppression before BBT elevates. Barnes argues that TSH suppression and T4/T3 elevations can be safely ignored.


Substantial bodies of data tracking patients with suppressed TSH levels show that even without obvious hyperthyroid symptoms, morbidity and mortality increase.

The largest bodies of data come from three groups:

1. Those found from screening to have sub-clinical hyperthyroidism, meaning abnormally low TSH, normal T3 and T4 and no obvious hyperthyroid symptoms.


2. Patients with refractory endogenous hyperthyroidism, typically Graves disease.

3. Patients with intentional endogenous hyperthyroidism, generally to lower risk of thyroid cancer recurrence.


Specific problems that become apparent with hyperthyroid serology include:•Atrial fibrillation •Stroke•Osteoporosis•Dementia•Grave’s eye disease•Increase in Total Mortality

[Evidence level A, RCT]Frost L, Vestergaard P, Mosekilde L. Hyperthyroidism and risk of atrial fibrillation or flutter: a population-based study. Arch Intern Med. 2004. 164(15):1675-1678.Woeber KA. Thyrotoxicosis and the heart. N Engl J Med. 1992;327(2):94-98. Petersen P, Hansen JM. Stroke in thyrotoxicosis with atrial fibrillation. Stroke. 1988. 19(1):15-18. Sun L, Davies T, Blair H, et al. TSH and Bone Loss. Annals of the New York Academy of Sciences. 1068: 1. 2006. 1749-6632.Bensenor I, Paulo L, Paulo M, et al. Subclinical hyperthyroidism and dementia: the Sao Paulo Ageing & Health Study (SPAH). J BMC Public Health. 1. 2010. 1471-2458-10-298.Osman F, Gammage MD, Franklyn JA, et al. Hyperthyroidism and cardiovascular morbidity and mortality.Thyroid. 2002. Jun;12(6):483-7.

Uniting the Models

Best of Alternative Worst of Alternative

Symptoms considered Patients over-diagnosed

Multiple treatment options Patients over-treated

Uniting the Models

Best of Conventional Worst of Conventional

Serology considered Patients under-diagnosed

Ambiguous symptoms given due merit Patients under-treated

Clinical Hypothyroid Syndrome

•Clinical - data gathered from patient’s history, reported symptoms and physical examination are considered

•Hypothyroid - the condition can improve from thyroid replacement like hypothyroidism

•Syndrome - the diagnosis is not a single bio-medical finding but a constellation of findings and symptoms

Closest current concept is early stage symptomatic Hashimoto's thyroiditis.

Clinical Hypothyroid Syndrome = Hashimoto’s

Thyroid specific symptoms in the absence of other causes +

Objective signs of autoimmune thyroid disease +

Suboptimal thyroid serology

Hashimoto’s- Diagnosis1. Patient presents with thyroid suspicious symptoms, especially those of recent onset such as:

•Fatigue•Dry Skin•Cold intolerance•Muscular weakness•Dysphagia•Chronic irritability•Nervousness•Mood swings

Hashimoto’s - Diagnosis

2. Perform physical exam and blood tests to rule out other conditions, including but not limited to:

Addison’s Disease, Anemia, Cardiovascular disease, Diabetes, Infectious mononucleosis, Malignancy, Medication side effects, Rheumatologic disease, Sleep apnea

3. If thyroid exam abnormal, follow up with ultrasound/FNA

Hashimoto’s - Diagnosis

Thyroid exam, ultrasound, or antithyroid antibodies abnormal?

TSH >2.0?

If both of the above are yes, treat Hashimoto’s

If Ultrasound shows clear Hashimoto’s, OK to treat even if antibodies are negative and TSH optimal.

[Evidence level B, Clinical Trial]

Hashimoto’s

Signs of Hashimoto’

s

TSH >2.0

Specific Symptom

s

Specific Symptoms =

• Slower thinking• More constipation• Hoarser/deeper voice• Drier skin• Feeling colder• More tired• Puffier eyes• Cramping / Weaker muscles

Signs of Hashimoto’s =

• Positive Thyroid Antibodies• (Negative antibodies not a rule out)• Abnormal Physical Exam• Abnormal Ultrasound

Diagnosing Hashimoto’s

After Ruling Out Other Causes

Section 2STEP 1 – DOSING STRATEGIES

Dosing

Nutrition

Immunology

Toxicology

Other glands

Prescribing Overview Drug classification:

Endocrine / Metabolism – Thyroid / Hypothyroidism

Indications for use:Hypothyroidism / Thyroid Suppression Test

Methods of administration:Oral Dosing / NPO

Prescribing Overview Adverse Reactions (Epocrates)

- Serious Reactions (dose related)1. Arrhythmias2. CHF3. HTN4. Angina

Prescribing OverviewAdverse Reactions (Epocrates) - Common Reactions (dose related)

1. Tachycardia2. Insomnia3. Nervousness4. Headache5. Diarrhea6. Tremor7. Arrhythmia8. Heat Intolerance

Prescribing OverviewBlack Box Warnings (Epocrates)

Not for Obesity/ Weight LossNot for obesity/weight loss alone or as combo tx; in euthyroid pts doses within range of hormonal requirements ineffective for weight loss; larger doses may cause serious or life-threatening toxicity, especially given in combo w/ sympathomimetic amines including those w/ anorectic effects.

Prescribing Overview Contraindications / Cautions (Epocrates)

1. hypersens. to drug/class/components2. MI3. adrenal insufficiency4. thyrotoxicosis5. caution if cardiovascular dz6. caution if HTN7. caution if diabetes mellitus8. caution in elderly pts

Prescribing Overview

• Iodine

• Oral contraceptives

• Calcium

• Fiber supplements

• Caffeine

• Barbiturates

• Digoxin

• Sudafed

• Decongestants

• Insulin

• Iron

• Sulfonylureas

• Phenytoin

• Lithium

• Carbamazapine

• Aspirin

• Antacids

Drug &/or Food/Herb Interactions (Partial)

T4 Absorption timeframe: 40-80% within 6 hours

T4 Biological Half-life: 5-7 days


T3 Absorption timeframe: 95% within 4 hours

T3 Biological Half-life: 60 hours on average


Prescribing Overview Pharmacology (Epocrates)

Metabolism: tissues, liver minimally; CYP450: unknown

Excretion: bile; Half-life: 2-7 days

Mechanism of Actionnatural T3 and T4 mixture: produces various physiologic effects, including increasing metabolism


Synthetic T4 only•Brands: Synthroid, Levoxyl, Unithroid, Tirosint, Levothyroid•Generic: levothyroxine

Synthetic T3 only•Brand: Cytomel•Generic: liothyronine

Synthetic T3/T4 combo•Thyrolar/liotrix

Drug Classification

Compounded thyroid

•Encapsulated NDT powder (unstandardized post production)•Tableted synthetic T3, T4 or T3/T4 Combos (un-standardized pre and post production) – case report

NDT vs. Synthetics

• Helps w/ Hashimoto’s• Increase BMR 250+ calories• T3 and T2• qd dosing• OTC NDT

NDT Concepts

• NDT manufacturing• USP guidelines• Manufacturer's policies• Compounded NDT• OTC NDT

NDT for Hashimoto’s?

Medical literature searches from 1998 to January 5th 2013 yielded zero primary sources for this concern.

The literature on the topic is scant and dated but all of it shows NDT is helpful or of no harm to Hashimoto’s Thyroiditis.


“ . . . oral feeding of animal thyroglobulin (TG) might induce tolerance to antigen in human autoimmune thyroid disease (AITD)”

Induction of oral tolerance in human autoimmune thyroid disease. Lee S, et. al. Thyroid. 1998 Mar;8(3):229-34.


“the goiters that were caused by lymphocytic thyroiditis (Hashimoto’s) responded to treatment with desiccated thyroid”

Effect of Desiccated Thyroid in Lymphocytic (Hashimoto’s) Thyroiditis. McConahey W, et. al. Journal of Clinical Endocrinology & Metabolism. January 1, 1959 vol. 19 no. 1 45-52.

Typical Case report 39 YO female• + Hashimoto’s and symptomatic • On levothyroxine prior 4 years• Changed to NDT As part of overall plan• Antibodies reversed over following 6 months

Case report - intake labs

Case report follow up labs

NDT for Hashimoto’s• NDT can be helpful as part of a comprehensive approach• Hashimoto’s antibodies are inherently variable• Larger numbers of readings over longer timeframes are

necessary

NDT Recalls

Recalls on levothyroxine from 1990 – 2008: “10 (mandatory) recalls, 150 lots, and 100 million tablets.”

Recalls on NDT from 1990 – 2008: 1 mandatory, 1 voluntary, both for Armour brand Thyroid.

Stability, Effectiveness, and Safety of Desiccated Thyroid vs. Levothyroxine: A Rebuttal to the British Thyroid Association. Lowe J. Thyroid Science 4(3):C1-12, 2009.

NDT BrandsBrand Manufacturor•Armour Forest Labs•Nature-Throid RLC Labs•Westhroid RLC Labs•Westhroid-P RLC Labs•NP Thyroid Acella

NDT BrandsBrand Allowed T3+T4 Variance•Armour +/- 20%•Nature-Throid +/- 2%•Westhroid +/- 2%•Westhroid-P +/- 2%•NP Thyroid +/- 20%

P = Pure Full Ingredient List: 1. USP NDT Powder2. Inulin (Jerusalem Artichoke) 3. Medium Chain Triglycerides (Coconut)

OTC Thyroid Glandulars

Not a viable option - Recent assay done on 10 OTC thyroid supplements - amount of active hormone ranged from zero to 91.6 mcg T4, and zero to over 10 mcg T3.

Prior independent assays found similar variability's both from product to product and from batch to batch with the same products

Victor Bernet MD, Mayo Clinic, presented for ATA

•Dietary thyroid powders can be derived from ANY animal – including pigs (as there are no “exclusions”)

•Per FDA/FTC – Dietary supplement companies CANNOT claim that there are ANY presence of ANY hormones in the powder/product


•Most reputable companies indicate that the powder is “Thyroxin-Free” to denote differentiation between dietary vs.. prescription, yet no known t4 removal mechanism

•Any claim as such would be making a drug reference to a dietary supplement which is against the FTC and FDA law

•When tested, consistencies of hormonal values greatly varied from batch to batch (much more beyond USP reference for RX version)


Value Median Min. Max

TSH 0.99 0.36 1.91

fT3 2.69 1.99 3.17

fT4 0.93 1.09 1.9

Dosing Strategy

TSH = Central control of thyroid hormones.

fT4 / fT3 = Peripheral control of thyroid hormones

Free T3 / Free T4 Regulation


•TSH relative to fT3/fT3 is non-linear at the extremes

•Adjusting T4 or T3 intake separately will not correct this . . .

• . . . unless peripheral regulation becomes overwhelmed.

0.01 0.01 0.01 0.01 0.01 0.01 0.08 0.1 0.15

5

4 43.5

2.52 1.8

2.9 3

3

2.52

1.8

1.7

1.51

1.1 1.2fT4 fT3

TSH


Reverse T3 - Issues•Fatigue

•Difficulty losing fat

•Brain Fog

•Muscle aches

•Increased with chronic illness CF/FM

•Increased with yo-yo dieting

•Increased with heavy metals, infections, mental and physical stress

Managing Reverse T3High rT3 = Euthyroid Sick Syndrome

rT3 is the body’s attempt to deliberately slow metabolism like a block under a gas pedal.

108

(Peripheral Metabolism of Thyroid Hormones Kelly G. Altern Med Rev 2000;5(4):306-333)

Managing Reverse T3

Managing Reverse T3

• GI Disease• Pulmonary disease• Cardiovascular disease• Renal disease• Metabolic disorders• Inflammatory states

• Protein calorie malnutrition• Chronic infections• Malignancy• Trauma• Toxicology

High rT3 = Euthyroid Sick Syndrome

Reverse T3 Management

Excess cortisol blocks T4 to T3 conversion and increases T4 to rT3◦ Test Diurnal salivary levels of cortisol and correct◦ Correct the reasons for poor conversion – nutritional deficiencies, toxins,

medications

Growth Hormone increases T3 production◦ Oral estrogen inhibits growth hormone; change to transdermal if appropriate ◦ Modify lifestyle (exercise, sleep) and nutrition to increase natural growth hormone

production

Physiologic Dosing

Replacement doses of thyroid within the amount of thyroid hormone normally secreted by healthy adults or the typical maintenance dose of individuals post thyroidectomy.

• Most common ending dose = 1.5 – 2.25 grains NDT• Typical range of ending dose = 0.75 – 2.5 grains• Very rarely need doses above 2.5 grains (0.3% of patients)• Best dose increase rate = ¼ grain increments per 4-6 weeks

Supraphysiologic Dosing

Replacement doses of thyroid that exceed the full amount of thyroid hormone secreted by healthy adults or the typical maintenance dose of individuals post thyroidectomy.

Paradox of Hypothyroid symptoms when on supraphysiologic doses


Estimates of average normal secretion for euthyroid humans are 94-110 µg T4 and 10-22 µg T3 daily.

This equals roughly 150-200 mcg of T4, 30-50 mcg of T3,1.5 - 2 grains of NDT.

Doses above these are supraphysiologic and rarely indicated.

[Evidence Level B, Clinical Trial]

Fisher, D. A., Oddie, T. H. & Thompson, C. S. (1971) Thyroidal thyronine and non-thyronine iodine secretion in euthyroid subjects. J. Clin. Endocrinol. Metab 33: 647-652.


Case report – NP ‘Allison’ 34 yo female, teacher. 7 year history of hypothyroidism per labs, 3 year history of treatment. On NDT , frustrated because only times she was free of fatigue and brain fog was when TSH <0.1. Hashimoto’s came on after 4 month viral illness. Treated repeatedly w/ antibiotics w/o success. Hx lymphocytosis ever since.

Well received conversation regarding short term and long term goals.


Case report – longer term patient ‘Amy’ 38 yo female, 3 year history of debilitating fibromyalgia. Mixed responses to therapies, none dramatic. Hypothyroid, stable on blood levels. Patient read Metabolic Treatment of Fibromyalgia and wishes to pursue intentional supraphysiologic dosing.

Complication: Graves eye disease, lost to follow up.

Thyroid Dose Conversions

The Old Fashioned Way

Thyroid Dose Conversions

There’s an App for That!

Testing Schedules

Initial Workup (Ideal), Fasting, pre-AM thyroid meds, menstrual days 17-23:

• Thyroid Ultrasound• TSH, fT4, fT3, TG• Anti TPO, anti TG• TSI, rT3

• Fe(male) hormone panel, Cortisol, DHEA• CBC, Chem, Vitamin D, A1C, Ferritin, Magnesium, Lipids• HSV, EBV, Candida (Antibodies or skin)

• Urine toxic metals, food allergy panel, salivary cortisol x 4

Testing Schedules

Initial Retest - 6 weeks. Fasting, pre-AM thyroid dose: •TSH•Chem panel•Other significant abnormals

Note that TSH may still drift by 25% more than it’s initial change before stabilizing.

Testing Schedules

Second Retest – 3 Months. Fasting, pre-AM thyroid dose: •TSH, free T3, free T4, rT3•Chem panel, Cortisol•Other significant abnormals


Testing Schedules

Third Retest – 6 months. Fasting, pre-AM thyroid dose: •Ultrasound if initial abnormal•TSH•Chem panel, Cortisol•Other significant abnormals


Thyroid Dosing Summaries

•Optimal TSH = 0.4 – 1.5•Optimal TSH with structural issues or cancer history = 0.4 – 0.9•fT3/fT4 related to peripheral metabolism•rT3 related to metabolic stressors

Section 3STEP 1 - OPTIMAL NUTRITION

Dosing

Nutrition

Immunology

Toxicology

Other glands

Optimal NutritionMICRONUTRIENTS

• Iodine• Selenium• Tyrosine• Vitamin D• Vitamin A• Iron

• Zinc• B-12• Folic acid / 5MTHF• B-6• B-2

Micro-nutrients for Optimal Thyroid Function

• Goitrogens• Soy• Coconut?• Food intolerances• Celiac• Malabsorption• Glycemic Regulation

Dietary ConsiderationsOptimal Thyroid Function

Thyroid nutrients - Tyrosine

Found in most protein foods, especially:• Meats

• Dairy

• Fish

• Eggs

• Peanuts

Vitamin D Active Hashimoto’s Thyroiditis have vitamin D levels that are about half of unaffected controls

16 ng/ml versus 29 ng/ml 92% to 63% = p <0.0001

Tamer G. Relative Vitamin D Insufficiency in Hashimoto's Thyroiditis. Thyroid. 2011 Aug;21(8):891-6.

Thyroid Nutrients - Iron

Low ferritin◦ Required for transport of T3 to nucleus of cell and utilization of

hormone◦Optimal level for thyroid function is 60-110

‘Bob’ 65 year old male, extremely educated and involved in health.

Long term seasonal patient, ‘snow bird.’

Early in winter new symptoms: sudden onset anxiety, palpitations, insomnia, night sweats.

Iodine – Case Report

Exam: thyroiditis + new nodule.

Serology: TSH 0.01, fT3 8.2, fT4 3.0

Bob’s thyroid uptake scan:


Bob’s Diagnosis: Toxic Nodular Goiter

Typical onset in American elderly males is after iodine contrast exposure or after amiodarone.

Bob had neither but was taking 25 mg Iodoral daily after being found to be ‘iodine deficient’ after an iodine challenge test.


Sarah: 33 yo female, vegetarian, newly diagnosed hypothyroid. FHx neg.

TSH 6.3; nml 0.5 - 4.50 mIU/LfT3 5.2; nml 1.4 – 4.2 pg/mLfT4 0.8; nml 0.8 -2.8 ng/dLThyroglobulin 97; nml </= 60 ng/ml

Thyroid Ab negThyroid exam neg

Sarah had begun taking 12.5 mg Iodoral tablets 1 month prior in hopes for help with weight loss.


Iodine Requirements

Adapted from Food and Nutrition Board, Institute of Medicine 2001 Dietary reference intakes. National Academy Press, Washington, D.C.

Safe Upper Limit for Adults without ATD = 1100 mcg daily

U-Shaped Curve of Iodine Intake and Thyroid Disease

100 µg/l urinary iodine 150 mcg daily adult intake≃Image Source: Comprehensive Handbook of Iodine Ed. Preedy V. Burrow G, Watson R. Elsevier 2009.


Optimal Iodine Intake30 healthy, elderly adult females, without evidence of thyroid

peroxidase antibodies (TPA), received daily doses of 500 μg

I/day (as potassium iodide) for 14 or 28 days (Chow et al.

1991). Serum concentrations of FT4

were significantly

decreased (change from pretreatment level, approximately -1

pmol/L) and serum TSH concentrations were significantly

increasedhttp://www.atsdr.cdc.gov/toxprofiles/tp158.pdf

The results of several epidemiological studies suggest that chronic exposure to excess iodine can

result in or contribute to hypothyroidism.

Thyroid status was compared in groups of children, ages 7–15 years, who resided in two areas of

China where drinking water iodide concentrations were either 462 μg/L (n=120) or 54 μg/L

(n=51) (Boyages et al. 1989; Li et al. 1987). Although the subjects were all euthyroid with normal

values for serum thyroid hormones and TSH concentrations, TSH concentrations were

significantly higher in the high iodine group. The prevalence and severity of goiter in the

population were evaluated, the latter based on a goiter severity classification scale (Grade 0, no

visible goiter; Grade 1, palpable goiter that is not visible when the neck is not extended; Grade

2, palpable and visible goiter when the neck is not extended).

The high iodide group had a 65% prevalence of goiter compared to 15% in the low iodine group.

Optimal Iodine Intake

Subjects were from one of three regions where, based on reported urinary

iodine levels of 72, 100, or

513 μg I/g creatinine, the iodine intakes were approximately 117, 163, or

834 μg/day (1.7, 2.3, or

12 μg/kg/day for low, n=119; moderate, n=135; or high intake, n=92,

respectively).

The prevalence of serum TSH concentrations above the normal range was

4.2, 10.4, and 23.9% in the low, moderate, and high iodine groups,

respectively. The prevalence of elevated serum TSH concentrations together

with serum FT4

concentrations below the normal range was 0.95, 1.5, and

7.6% in the low, moderate, and high iodine groups, respectively.



People who have autoimmune thyroid disease may be at increased risk of developing thyroid

dysfunction when exposed to excess iodide. Euthyroid patients (37 females, 3 males) from an

iodine-deficient region, who were diagnosed with Hashimoto’s thyroiditis and who were

positive for antithyroid (thyroid peroxidase) antibodies, received an oral dose of 250 μg

potassium iodide (190 μg I/day) for 4 months; a similar group of thyroiditis patients (41

females, 2 males) served as controls (Reinhardt et al. 1998). Based on urinary iodide

measurements of 72 μg I/g creatinine before the iodide supplementation, the preexisting

iodide intake was approximately 125 μg/day, for a total iodide dosage of 375 μg/day

(5.8. μg/kg/day) in the treatment group.


Seven patients in the treatment group developed elevated serum TSH concentrations (>4

mU/L) and one patient developed overt clinical hypothyroidism with a TSH concentration of

43.3 mU/L and a serum FT4

concentration of 7 pmol/L. One patient in the treatment group

became clinically hyperthyroid with a serum FT4

concentration of 30 pmol/L and TSH

concentration of <1 mU/L. One patient in the control group developed mild subclinical

hypothyroidism.

Iodine Toxicology – Largest Resource

http://www.atsdr.cdc.gov/toxprofiles/tp.asp?id=479&tid=85

Iodine in NDT

0.17-0.23% Iodine

1 grain of Desiccated Thyroid contains: 0.20% x 60mg = 120µg Iodine

Assessment of Iodine Status

•Thyroid Size•Thyroid Serology•Random Urinary Iodine•Topical Iodine•24 hour Urinary Iodine•24 hour Urinary Iodine Post Iodine Challenge•Serum/Blood spot Thyroglobulin - poor w/ TG Ab



Thyroid Volume

Via Ultrasound or skilled examiner. Volume inversely correlates with iodine status.

Accurate only in the absence of autoimmune disease, thyroiditis or thyroid cancer.

Not practical as screening method.


Thyroid Serology

Helpful to measure as part of routine assessment.

Does predict iodine status in the absence of: •Autoimmune thyroid disease•Anemia's•Environmental toxins•Infections


From Preedy V, Burrow G, et al. Comprehensive Handbook of Iodine. Elsevier. 2009. pg 51.

At risk for Iodine Insufficiency - Vegans

Main sources of iodine: Seafood, Dairy, Iodine fortified salt.

Along with avoiding animal foods, many vegetarians and vegans use specialty sea salts which are predominately non-iodized.

Those with over 33% of their calories from raw foods are especially at risk due to low iodine intake and concomitant high intake of goitrogens and phytates.

Iodine Toxicity

Iodine toxicity occurs in three different ways:

• Simple chronic overexposure in excess of 1100 mcg.

• From an increase of iodine in a population with a previously stable but low intake. This can be a change as little as 150 mcg. Most pathology occurs in those with latent thyroid antibodies.

• A single bolus dose, usually in excess of 10,000 mcg.Merck Manual Last full review/revision August 2008 by Larry E. Johnson, MD, PhDContent last modified August 2008

Iodine Toxicity

Natural products with unsafe levels of iodine:

• Kelp: AKA Fucus vesiculosus, Kombu

• Iodoral: 12,500, 25,000 and 50,000 mcg tablets

• Potassium Iodine, AKA SSKI, NoRad

Iodine Toxicity - the Japan Question

Don’t the Japanese consume much more iodine than us and do fine with it?

It has been specifically claimed that the Japanese safely consume 13,800 mcg daily and enjoy less thyroid disease.

. . . They don’t consume close to this much, but they do consume more iodine than we do, and they have proportionately higher rates of all types of thyroid disease.


Source of the 13800 mcg intake was a 1967 paper stating average Japanese consumed 4.6 grams of seaweed daily. This number was used with a 0.3% iodine content of seaweed from another source to get the 13,800 mcg.

Yet the 4.6 grams daily was wet weight of seaweed. While the 0.3% iodine was for dry seaweed.

J Clin Endocrinol Metab 1967; 27:638-47Alan Gaby, MD, lecture notes, AANP 2011.


The average Japanese adult consumes 1200 mcg of iodine per day based on 2008 data.

Over four times the typical American intake.

Large amounts of seaweed is considered to be the largest reason.

Shigenobu Nagataki. Thyroid. June 2008, 18(6): 667-668. doi:10.1089/thy.2007.0379.

Iodine Toxicity - the Japan QuestionAfter controlling for radiation exposure, the Japanese experience higher rates of all types of thyroid disease including:

•Hypothyroidism•Hyperthyroidism•Subclinical hypothyroidism•Subclinical hyperthyroidism•Goiter•Nodules•Thyroid cancer.

Koike, A. and Naruse, T. (1991), Incidence of thyroid cancer in Japan. Seminars in Surgical Oncology, 7: 107-111. Kanji Kasagi, Norihiro Takahashi, Gen Inoue, Toyohiko Honda, Yasunori Kawachi and Yoichiro Izumi. Thyroid. September 2009, 19(9): 937-944. doi:10.1089/thy.2009.0205.

Iodine Guidelines For All Adult Patients

•Consume primarily iodized salt in the form of iodized sea salt or iodized Lite Salt (Potassium chloride/Sodium Chloride blend)•Minimize salt from packaged and restaurant foods•Maintain Iron status•Consume 200 - 400 mcg selenium daily•Avoid iodine supplements

Iodine Guidelines For Patients with Thyroid Disease

•Avoid daily iodine intake above 600 mcg combined from all sources.

•Avoid kelp products

•If taking desiccated thyroid, consider iodine-free multi vitamins and avoiding all sea vegetables

Referenced peer reviewed article on Iodoral:

Iodine, not too much, not too little.

Published in NDNR July 2009

http://alturl.com/7usy3

Optimal NutritionTHYROID SPECIFIC TOPICS

Goitrogens

•Goitrogens are chemicals that can block thyroidal iodine utilization or impair hormone production.

•These occur through distinct mechanisms, not all of which have clinical significance

Goitrogens

•This is most pronounced in indole compounds as found in cruciferous vegetables (cabbage, broccoli, cauliflower, and Brussels sprouts).

•Soy and millet are often categorized as a goitrogens but their effects are independent of iodine status.

•Goitrogens are not of clinical importance unless they are consumed raw, in large amounts or with coexisting iodine deficiency.

Goitrogens

•'Jake' was a previously healthy young man who was brought to my practice by his father who was concerned that he was getting apathetic and weak and was having difficulty swallowing. Several months earlier Jake embarked on a 100% raw produce diet. Jake went from a lean 170 pounds to an emaciated 152 pounds.

•His meals consisted mostly of blended raw vegetables with small amounts of fruit. This made it easy for him to consume 3-5 pounds of broccoli a day.

GoitrogensFindings:

• Iron and B-12 deficiencies

• Non autoimmune Hypothyroidism

• Homogenous goiter

Treatment

• Resumed low mercury fish and sea vegetables

• Avoided raw cruciferous vegetables above 6 ounces.

• Avoided soy foods and millet.

Goitrogens

3 Month Outcome

• Energy levels returning

• Difficulty Swallowing resolving

6 month outcome

• Resumed more typical healthy diet

• Regains lean mass

• Goiter resolved

Goitrogens

Goitrogens – Action StepsAvoid for all thyroid patients:

• Soy

• Fermented soy (?)

• Millet

Safe for those with Hashimoto’s

• Cruciferous

• Flax

• Lima

Celiac Thyroid Connectionsthe prevalence of celiac disease in patients with autoimmune thyroid disease is approximately 4-15 times higher than the general population, thus suggesting that patients with autoimmune thyroid disease should be routinely screened for celiac disease. However, the performance of these screening programs has never been evaluated in everyday, clinical-practice setting. We invited newly diagnosed patients with autoimmune thyroid disease, seen at our Hospital, to participate in a serological screening for celiac disease. Two-hundred and thirty-one patients, female to male ratio 8.89:1, mean age 41.3 +/- 18.1 years, range 7.1-80.5 years were included. The number of diagnosed celiac disease was 0. Our results do not support the usefulness of a screening for celiac disease in patients with autoimmune thyroid disease in daily practice, despite the favorable results obtained in Research-setting studies. Since screening is a resource-consuming activity, for both patients and clinicians, we suggest that a careful evaluation of the yield of a screening is always warranted before its adoption in the clinical practice.

Ann Ital Med Int. 2005 Jan-Mar;20(1):39-44.Screening for celiac disease in patients with autoimmune thyroid disease: from Research studies to daily clinical practice.

Celiac Thyroid ConnectionsThyroid. 2008 Nov;18(11):1171-8. doi: 10.1089/thy.2008.0110.Tissue transglutaminase antibodies in individuals with celiac disease bind to thyroid follicles and extracellular matrix and may contribute to thyroid dysfunction.

CONCLUSIONS:Anti-TGase II antibodies bind to TGase II in thyroid tissue, and titers correlate with TPO antibody titers. These findings suggest that anti-TGase II antibodies could contribute to the development of thyroid disease in celiac disease.

Celiac Thyroid ConnectionsAmong autoimmune disorders, increased prevalence of CD has been found in patients with autoimmune thyroid disease, 2% to 5% in autoimmune thyroid disorders

Celiac disease and autoimmune thyroid disease.Ch’ng CL, Jones MK, Kingham JG. Clin Med Res. 2007 Oct;5(3):184-92.

Celiac Thyroid Connections

Celiac Thyroid Summary• No one thrives on processed wheat

• No one thrives on gluten-free junk food

• Your patients capacity for change is a finite commodity

• Be strategic with it

Thyroid Nutrition–Action Steps

• Thyroid Friendly Multi (Fe, Iodine free, CCM)

• Screen for Celiac

• Screen MTHFR

• Avoid Soy

• Minimize Iodine

Thyroid imaging:Nodules and beyond

Jane Sohn, M.D.

Section 5THYROID IMMUNOLOGY

Dosing

Nutrition

Immunology

Toxicology

Other glands

Immunologic Factors Allergies

◦ Airborne◦ Dietary

Chronic Infections◦ Systemic / Viral◦ Gastrointestinal◦ Mucous membranes

Nutrient Deficiencies Toxins

Thyroid antibodies•Antibodies can cause symptoms independent of thyroid hormones

• Anxiety• Brain fog

•Antibodies can raise medical risks independent of thyroid hormones• Miscarriage• Thyroid cancer

Obstetrics and Gynecology 1997 Volume 90:364-369

Thyroid Antibodies•Antibodies can cause symptoms independent of thyroid hormones

• Anxiety• Brain fog

•Antibodies can raise medical risks independent of thyroid hormones• Miscarriage• Thyroid cancer

•Antibody tests can be falsely negative up to 40% of the time

Obstetrics and Gynecology 1997 Volume 90:364-369

Immunologic Factors TH-1 / TH-2 Dominance

•Immune dysfunction of several types can trigger Auto Immune Thyroid Disease

•Immune dysfunction can be identified by testing key cytokines including

•IL-2, IL-12, TNFα, Interferon, IL-4, IL-13, IL-10

•Natural and prescription medicines can be used to influence immune cells.

•Ultimately, the cause of immune dysfunction needs to be identified and addressed.

•Prime causes include allergies, infections, toxins and deficiencies.

Immunologic Factors - Allergies Airborne•Airborne allergies involve up-regulation of antibody formation

•Antibody formation against any specific antigen heightens the antibody response against other antigens against which the host is already sensitized

•Consequently lowering ‘total antigenic load’ and reactivity to one antigen can confer greater tolerance to other antigens

Immunologic Factors - Allergies Case Study: Fredrique, 41 year old female•Over a 4 month period, Fredrique’s TSH scores ranged from 41 – 158 despite thyroid dose modifications and other steps

•Her TPO antibodies during this time were never lower than >1000

•After 4 months of SLIT, TPO antibodies lowered to 41

•TSH was able to be brought to 1.7

Immunologic Factors - Allergies Dietary•Food allergies involve up-regulation of antibody formation and alterations in bowel flora

•Food allergies can be:• Not relevant• Innate• Functional

Immunologic Factors - Allergies Dietary•Heightened antibodies from food allergies can raise thyroid antibodies and effect whole body inflammation effecting peripheral thyroid metabolism

•Food allergies can be assessed by• Testing• Elimination – Reintroduction Diets

Avoidance and Reintroduction Plan

7 Foods:• Wheat

• Dairy

• Soy

• Corn

• Peanuts

• Eggs

• Sugar

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Immunologic Factors - Allergies•Gluten can be culprit but not always

Case Study: Monique, 31 year old female

•Gluten-free for 2 years

•TPO antibodies never lower than >200

•Testing showed Dairy, Almonds to be allergenic

•After 6 months of allowing ‘healthy’ version of gluten and avoiding reactive foods, TPO antibodies became negative

EBV and ThyroidSteps to Autoimmune Thyroiditis: (1) CD8+ T-cell deficiency, (2) primary EBV infection, (3) decreased CD8+ T-cell control of EBV, (4) increased EBV load and increased anti-EBV antibodies, (5) EBV infection in the target organ, (6) expansion of EBV-infected B cells in the target organ, (7) infiltration of autoreactive T cells into the target organ, and (8) development of ectopic lymphoid follicles in the target organ.

http://www.hindawi.com/journals/ad/2012/189096/

Immune Repair for Hashimoto’s•History of known food intolerance, IBS, malabsorption, consider dietary allergies: •Key Labs: IgG panel (plan divided samples)•Treatments:

• Avoidance• NAG / Glutamine• GI Antihistamines

Immune Repair for Hashimoto’s•History of mono, HSV, recurrent lymphadenopathy, consider chronic viral infections:

•Key Labs: CBC (Lymphocytosis), EBV PCR, Herpeselect panel

•Treatments:• Sleep• Manage Cortisol• Adequate protein – no sugar• Colostrum / Arabinogalactan• Antiviral Herbs / Rx• Antiviral Infusions

Immune Repair for Hashimoto’s•History of IBS, UTI, Bloating, consider dysbiosis / SIBO

•Key Labs: Chem (BUN), Stool Culture (open), Candida, Hydrogen Breath (lactulose, glucose)

•Treatments:• Diet• Movement• Hydration• Stress reduction• Appropriate probiotics• Antimicrobial Herbs / Rx

Immune Repair for Hashimoto’s•History of URI, Allergies, Asthma, Eczema, consider Airborne allergies

•Key Labs: CBC(Eos), IgE Total, Immunocap regional panel

•Treatments:• Avoidance• Hydration• Nasal irrigation• Natural antihistamines (Quercenace – loading dose)• SLIT• Nasal steroids

Immune Repair for Hashimoto’s•History of Vaginal yeast, Sinusitis, Thrush, Tinea, consider Systemic Candidiasis

•Key Labs: Skin yeast antigen, Stool Culture (open) Chem(Uric Acid)

•Treatments:• Diet – no sugar, alcohol• Probiotic foods (yogurt, sauerkraut, Kim Chee)• Probiotic Supplements (100 billion +)• Nasal irrigation/ antifungals• Natural / Rx antifungals

Immune Repair SummaryFood intolerance

• Avoidance / Reintroduction (Virgin Diet)

• Allergy Testing

Airborne allergies – SLIT

Infections

• GI

Non-specific TPO - Moducare

Section 6THYROID TOXICOLOGY

Dosing

Nutrition

Immunology

Toxicology

Other glands

Thyroid Disruption. Patrick L. Altern Med Rev 2009;14(4):326-346.

Many Points of Thyroid Disruption from Exotoxins

Thyroid Disruption. Patrick L. Altern Med Rev 2009;14(4):326-346.

Environmental Factors Metals

◦ Iodine◦ Mercury◦ Lead

Other Toxins◦ Thiocyanate◦ PCB’s◦ BpA

Are Your Patients Toxic?Some Things You Just Won’t Know Unless You Look!

Mercury – TG AntibodiesAbstract

. . . associations between total blood mercury and thyroglobulin autoantibody antibody positivity and thyroid peroxidase autoantibody positivity in . . . Women . . . (n=2047). Relative to women with the lowest mercury levels (≤0.40 μg/L), women with mercury >1.81 μg/L (upper quintile) showed 2.24 (95% CI=1.22, 4.12) greater odds for thyroglobulin autoantibody positivity (p(trend)=0.032);

this relationship was not evident for thyroid peroxidase autoantibody positivity. Results suggest an association between mercury and thyroglobulin autoantibody positivity.

http://www.ncbi.nlm.nih.gov/pubmed/22280926

Environmental FactorsPCB’s Suppress T4 and raise TSH METHODS:

The sample consists of youth from the Akwesasne Mohawk Nation (n=232) who reside in proximity to several industries that have contaminated the local environment. We used multiple regression analysis to examine the effect of PCB groupings, p,p'-DDE, HCB, lead, and mercury on thyroid hormones after adjusting for sociodemographic covariates and controlling for all other toxicants.

RESULTS:

Exposure to PCBs affects the thyroid hormone profile in adolescents. The group of persistent PCBs was positively associated with TSH but inversely related to FT(4). Nonpersistent PCBs were significantly and negatively related to FT(4) only. http://www.ncbi.nlm.nih.gov/pubmed/18560538

Environmental Factors

Thiocyanate Abstract

Thiocyanate [SCN-] is a complex anion which is a potent inhibitor of iodide transport. It is the detoxification product of cyanide and can easily be measured in body fluids. Consumption of naturally occurring goitrogens, certain environmental toxins and cigarette smoke can significantly increase SCN- concentrations to levels potentially capable of affecting the thyroid gland.. Iodine supplementation completely reverses the goitrogenic influence of SCN-. SCN- is also generated from cigarette smoking as a detoxifying product of cyanide. During the past two decades many reports dealt with the possible effects of cigarette smoking on thyroid hormone synthesis, thyroid gland size and thyroid autoimmunity including infiltrative ophtalmopathy of Graves' disease.


Environmental Factors

Thiocyanate – Don’t smoke and minimize (unless you have sickle-cell anemia?)

◦ Sources:◦ Tobacco◦ Plantain◦ Yucca◦ Lentil◦ Garbanzos◦ Millet◦ Buckwheat

Environmental FactorsBisphenol A Abstract

The globally escalating thyroid nodule incidence rates may be only partially ascribed to better diagnostics, allowing for the assessment of environmental risk factors on thyroid disease. Endocrine disruptors or thyroid-disrupting chemicals (TDC) like bisphenol A, phthalates, and polybrominated diphenyl ethers are widely used as plastic additives in consumer products. This comprehensive review studied the magnitude and uncertainty of TDC exposures and their effects on thyroid hormones for sensitive subpopulation groups like pregnant women, infants, and children. Our findings qualitatively suggest the mixed, significant (α = 0.05) TDC associations with natural thyroid hormones


Environmental Factors – Specific Steps

•UTM post challenge – treat specifically

•Repeat results can be non-linear

•Mineral replacement

Environmental Repair for Hashimoto’s•History of chemical sensitivity (detergent aisle), neurologic symptoms, high exposure, consider Toxicology

•Key Labs: • UTM• Chem (low Uric Acid, ALT)• RBC elements• PCBs• Bowel Transit Time• Urine specific gravity (hydration)

Environmental Repair for Hashimoto’s•Treatments:

• Avoidance• General Detox

• Cleansing diet / Medical Food• Sauna• Maintain elimination• Spinach + Brown Rice• Cholestyramine

• Targeted Chelation Therapy

Section 7ENDOCRINE CONNECTIONS

Dosing

Nutrition

Immunology

Toxicology

Other

glands

Thyroid / Endocrine InteractionsKey Hormones with thyroid Interactions:

•Cortisol

•DHEA

•Estradiol

•Pregnenolone

•Progesterone

•Testosterone

Physiological Cortisol Range

Cortisol

Cel

lula

r T

hyro

id F

unct

ion

Functional Hypometabolism

Functional Hypometabolism

Optimal Thyroid Function

Thyroid / Adrenal Interactions – Paradox of Cortisol

Thyroid / Adrenal Interactions Excess cortisol

◦ Inhibits T4 to T3 conversion ◦ Suppresses TSH ◦ Decreases thyroid receptor responsiveness

Low cortisol ◦ Decreases thyroid receptor responsiveness◦ May inhibit T4 to T3 conversion ◦ Transport across the membrane is energy dependent & modified by

cortisol◦ Cortisol regulates T3 receptor density◦ May have to give cortisol to make thyroid supplementation work

properly

Thyroid / Endocrine - Cortisol

•Excess cortisol: inhibits actions of T2 and T3 on mitochondria

•Low cortisol: cell membranes become inconsistently permeable to T3

•Hypoadrenalism = absolute contraindication to thyroid replacement therapy

Thyroid / Endocrine - Cortisol•Suspect when: Fatigue, hypotension, salt craving•Test via: Combination of blood and saliva (confirmation)•Ideal Levels: Serum AM Fasting before 9 AM = 12-20 ng/dl

Thyroid / Endocrine - Cortisol Salivary Cortisol is now done by major regional labs

(Quest Diagnostics and Lab Corp) Measurement of salivary cortisol in 2012 - laboratory techniques and clinical indications.

. . . Several studies have shown diagnostic sensitivities and specificities of over 90%, . . .

. . . There are emerging roles for the use of salivary cortisol in diagnosing adrenal insufficiency, particularly in conditions associated with low cortisol-binding globulin levels, and in the monitoring of glucocorticoid replacement

. . . salivary cortisol has been used extensively as a biomarker of stress in a research setting, especially in studies examining psychological stress with repeated measurements.


Thyroid / Endocrine - Cortisol

The Journal of Clinical Endocrinology & Metabolism May 1, 2011 vol. 96 no. 5 1478-1485

Thyroid / Endocrine - Cortisol Action steps when abnormal:

•Meditation – 10 minutes: http://alturl.com/g9tsm

•Hourly Movement Breaks: http://alturl.com/5p6mu

•Acupuncture

•Glycemic Control

•Avoidance of stimulants (Slow clearance with Hashimoto’s)

•Sleep Hygiene

•Cortisol replacement rarely conducive to long-term health in non-Addison’s population

http://alturl.com/g9tsm

http://alturl.com/g9tsm

http://alturl.com/5p6mu

http://alturl.com/5p6mu

Thyroid / Endocrine - DHEA•Thyroid Interactions: Can weakly potentiate thyroid hormones – may need dose modification

•Suspect when: Adrenal dysfunction, fatigue, hypoglycemia, thinning of body hair, poor libido, female androgenic symptoms (excessive)

•Test via: Serum

•Ideal Levels:◦ Female Adult – 80 – 260 mg/dl◦ Male Adult – 220 – 515 mg/dl

Thyroid / Endocrine - DHEA Action steps when abnormal:

Gender High Low

Female Glycemic management, weight loss, ovarian function management

Stress reduction, Dietary protein increase, Replacement therapy (2.5 – 10 mg)

Male Rare – Cushing's, Stress reduction, Dietary protein increase, Replacement Therapy (5 – 50 mg)

Thyroid / Endocrine - Pregnenolone•Thyroid Interactions: Lack of can weekly inhibit utilization of thyroid hormones

•Suspect when: Adrenal symptoms + short term memory issues

•Test via: Serum

•Ideal Levels:• Female Adult – 30 – 180 ng/dl• Male Adult – 45 – 280 ng/dl

Thyroid / Endocrine - Pregnenolone

Action steps when abnormal:

Gender High Low

Female Rare - Cushing's Stress reduction, Dietary protein increase, Replacement therapy (10 – 50 mg)

Male Rare – Cushing's, Stress reduction, Dietary protein increase, Replacement Therapy (50 – 200 mg)

Thyroid / Endocrine - Progesterone

•Thyroid Interactions: Progesterone potentiates uptake and conversion of thyroid hormones

•Suspect when: Insomnia, anxiety, irregular cycles• PMS• PCOS• Peri-menopause• Menopause

•Test via: Serum days 17-23 for menstruating women

•Ideal Levels: 8 – 20 ng / dl (~1/10 Estradiol)

•Action steps when abnormal:• Low: Replacement oral micronized or topical (lack of endometrial effect topical)• High: Liver function, DIM, Bowel flora regulation

Thyroid / Endocrine - Testosterone

•Thyroid Interactions:• Lack of can weaken efficacy of endogenous and exogenous thyroid hormones• Replacement can increase efficacy of endogenous and exogenous thyroid hormones

•Suspect when: Fatigue, Poor Libido, Low exercise recovery, Tendonitis, Lack of enthusiasm

•Test via: Serum (consider free and bioavailable)

•Ideal Levels:• Female Adult: 40 – 90 ng/dl• Male Adult: 450 – 850 ng/dl

Thyroid / Endocrine - Testosterone

Action steps when abnormal:

Gender High Low Replacement

Female Glycemic management, weight loss, ovarian function management

Stress reduction, Dietary protein increase, Strength Training

IM / Subdermal – 16 – 50 mg / Month

Male Rare – Cushing's, Stress reduction, Sleep Hygiene, Strength Training, Dietary protein increase

IM / Subdermal – 200 – 400 mg / Month

Thyroid / Endocrine – Estradiol•Thyroid Interactions

• Exogenous and Endogenous Estradiol increases thyroid binding globulin, lowering the effects of thyroid hormones

• Decrease of Estradiol potentiates thyroid hormones. Consider when discontinuing NHRT or OCP

•Suspect when: • PMS• Perimenopause• Menopause• Male on Testosterone replacement therapy

•Test via: Serum

Thyroid / Endocrine - Estradiol Action steps when abnormal:

Gender Blood levels High Low ReplacementFemale Menstruating

(day 17-23)65 – 200 pg/ml

NHRT: 45-130 pg/ml

Hepatic Function, lower sugar

Stress reduction, Dietary protein increase, Strength Training

w/o uterus: IM / Subdermal – 3 – 8 mg / Month, w/ uterus consider testosterone

Male 10 – 35 pg/ml Generally complication of TRT – dose modification

Stress reduction, Sleep Hygiene, Strength Training, Dietary protein increase

n/a

Thyroid / Endocrine – IGF-1•Thyroid Interactions: Lack of may slow T4 to T3 conversion in liver.

•Can be cancer risk factor when elevated

•Suspect when: • Poor immunity• Poor skin repair• Poor exercise recovery• Fatigue• Low cognitive function• Unexpected osteoporosis

•Test via: Serum AM Fasting

Thyroid / Endocrine – IGF-1 Action steps when abnormal:

Gender Blood levels High LowFemale 100 – 250 pg/ml Glycemic control Sleep Hygiene, HIIT,

Testosterone, secretogogues

Male 110 – 295 pg/ml Glycemic control Sleep Hygiene, HIIT, Testosterone, secretogogues

Section 8 CASE REVIEW – Q AND A

39yo femaleHistory: trip abroad in 07-unwittingly contracted multiple microbes. Within a few months of return home became pregnant. Family history of Hashimoto's.

09 finally diagnosed w/microbes after multiple visits to multiple doctors. After treatment of microbes by natural means she was rid of all but one microbe which she still has; Blastocysts Hominus-even after hi dose Flagyl for 2wks population didn't budge but liver enzymes went out of range.

Fatigue was still very present and she knew her family history and requested TPO and TSH-TPO was off charts and remains so to this day. TSH was at 32 for years with other practitioner.

Participant Case Review #1

Participant Case Review #1con’tShe's finally medicated but not leveled yet. Last TSH 3wks ago was 8 and TPO remains at <1,000. Dosed up from Levothyroxine 125mcg to 137mcgOn Levothyroxine 137 x 3wks. Retest in 5wks.She observes a gluten free dairy free organic diet. Low grain high veg medium amount of meat protein. We are working at building gut/immune system and slow steady detox-liver function normal again.Recent investigations into heavy metal shows mercury and she is seeing a biological dentist for amalgam removal by Huggins protocol. Then we will begin heavy metal detox slowly. Also one root canal tooth on thyroid meridian and she will have that extracted prior to amalgam removal.

Participant Case Review #239 year old female Diagnosed with Hashimoto's age 26.

Age 26-31 gained 80 lbs. and was on Levothyroxine. 5-10 mcg cytomel was added for a year or two . Was suffering from fatigue and depression since diagnosis and was given Citalopram, then Wellbutrin. Stopped Wellbutrin on her own and fatigue returned. Tried blood type diet and eliminating gluten in 2005, no change noticed.

Went to see Dr. XXXX in 05/06. Dr. XXXX put her on Naturethroid, titrated dose using ThyroFlex and RMR, and optimal dose was between 3.5-4g QD in divided doses. Also treated adrenals. Initially lost 25 lbs. after the change of meds. Did well for a long time on this dose but weight continued to creep back up.

TSH must be kept suppressed to feel normal. When TSH approaches normal range is not functional- has depression and apathy, fatigue, brain fog, and sleeps all the time. Adrenals tested, were within normal range with a dip around noon that was treated. Stopped doing thyroid labs, feels best with Free T3 above normal range, TSH stays around .02, TPO stays around 3-400 and TG stays around 50. Docs always try to reduce her thyroid dose, so she self- treats

Participant Case Review #2 cont.Difficulty losing weight, and when she has hypo symptoms, her weight can increase by up to 6 lbs. overnight. Did hCG diet and successfully lost 75 lbs. over a year, after which she developed cholecystitis. After this, she stopped gluten, dairy, eggs and notices edema on eating gluten and other grains. Re-gained about 50% of weight.

Irregular menses X 10+ years, more recently cycles last from 10- 45 days, often has a “double period” about 9-10 days apart. Hormones, when tested, showed low normal progesterone and estradiol.Chronic fatigue, chronic tonsillitis, chronic BV, acne, extensive dental work, and gums bleed around crowns.

Chronic tonsillitis treated + prevented successfully by daily lymphatic tincture. Menses improving with biphasic botanical formula, but continues to be erratic. Skips menses when hypo symptoms return. Currently planning to do food sensitivity testing.March 2012 started T3SR only therapy. Went to a max dose of 70 mcg BID and stayed there for a year. Initially lost about 10 lbs. and energy/mood improved significantly. After about 9 months, hypo symptoms began returning, weight went up 10 lbs., bowel movements slowed, and depression had been returning since 12/12. FT3 in 01/14/13 was 4.5. She didn’t respond to an increase in T3 at this time.

Participant Case Review #2 cont.In 03/13 switched back to NT 3g in divided doses, depression lifting and energy returning. Notices worsening of fatigue and depression in winter, October-May. ANA done about 10 years ago was +, homogenous, RF negative+ MTHFR Mutation : heterozygous for C677T+ COMT Mutation : Heterozygous+ TNF-a heterozygousHomozygous negative for Interleukin-6

Recently hypo symptoms accompanied by arthralgia's (fibromyalgia-type symptoms), diminished with switch of medication.

Participant Case Review #2 cont.

No change on Thyrosol or Thyrocsin, had some initial improvement on iodine and took for a few months before stopping. Restarted and had no results. Some improvement with Beta-carotene/Vitamin A supplementation. Considerable improvement on Xymogen’s Mitochondrial Renewal Kit (especially the L-Arginine) in energy and exercise tolerance. Considerable difficulty with detoxification protocols (fatigue, irritability, headaches). Does best on Paleo-type diet.Meds: NatureThroid 2g QAM, 1g QPMProgesterone: 25 mg daily

Supplements: Flax oil 2 Tbsp. QDNutrient IV monthly (50g Vitamin C, high dose Bs, and minerals)5-MTHF 1-2g QD100b CFU probioticMetagenics Kaprex AIBiphasic botanical formula with daily phytolacca, iris, and ocimum sanctumVitamin D3: 10K IU daily

Participant Case Review #344 Year old female with symptoms of anxiety, racing heart, insomnia and weight gain.Labs confusing:TSH 0.2 (low)Free T4 1.2 (normal)Free T3 3.3 (normal)Anti TPO Antibodies: 97 (elevated)Endocrinologist says she may have Hashimoto’s but can’t be treated until her thyroid slows down enoughSupplements:Thyroid supportFish OilWomen’s multivitaminL-CarnitinePassofloria tincture

Participant Case Review #432 Year old male Fatigue, depression weight gainTSH 1.9Thyroid antibodies negativeFree T4 1.1 (normal)Free T3 3.5 (normal)

Endocrinologist says she may have Hashimoto’s but can’t be treated until her thyroid slows down enoughSupplements:Thyroid supportFish OilWomen’s multivitaminL-CarnitinePassofloria tincture

Participant Case Review #554 year old female12 year history of hypothyroidism without Hashimoto'sOn Armour thyroid 120 mg and cytomel 5 mg to help low t3 levelsLabs all over the boardTsh 0.001Free t3 3.9Tsh 0.1Free t3 2.9

Tsh 0.02Free T3 2.8Why won't her t3 levels go up, why are her labs so inconsistent?

Participant Case Review #6* I directly responded instantly on this case28 year old woman, pregnant for last 6 weeksOn synthroid 112 mcgIodoral 12.5 mgPrenatal vitaminsShe is always tired and anxiousHer tsh goes too low without IodoralWith it she can take a higher dose of synthroid and feels better(Reference iodine w preg cases)

Iodoral in Pregnancy Leads to Congenital Hypothyroidism - 3 Recent cases

Endocr Rev, Vol. 33 (03_MeetingAbstracts): MON-593Copyright © 2012 by The Endocrine Society

Congenital Hypothyroidism Caused by Excess Prenatal Maternal Iodine Ingestion: A Case Series

Kara Connelly, MD1, Bruce Boston, MD1, Elizabeth Pearce, MD2, David Sesser, BA3, Sam Pino, BS2, Lewis Braverman, MD2, David Snyder, MD4 and Stephen LaFranchi, MD1

Case 1 is a term infant with CH; TSH = 102.8 mU/L

CH confirmed with serum free T4 = 0.47 μg/dL (n 0.9-2.3 μg/dL) and TSH >100. The infant's mother took Iodoral tablets containing 12.5 mg of iodine daily throughout pregnancy.

Infant's urine iodine was normal (70 μg/dL, n 42-350 μg/L) after mother discontinued supplemental iodine, but breast milk iodine was elevated (3,228 µg/L, n 5-180 μg/L).

Cases 2 and 3 are twins whose mother took Iodoral 12.5 mg daily throughout pregnancy. TSH >200 mU/L [n 1.7-9.1 mU/L]; case 3: T4 = 4.64 [n 7.2-15.7], TSH >200 mU/L [n 1.7-9.1 mU/L]) and confirmed by serum sample (case 2: free T4 = 0.5 μg/dL [n 0.9-2.3 μg/dL], TSH 420 [n 1.7-9.1 mU/L]; case 3: free T4 = QNS, TSH 217 [n 1.7-9.1 mU/L]).

Mother had elevated serum and urine iodine levels. These infants also had elevated urinary iodine (case 2: 10,474 μg/L; case 3: 693 μg/L, n 42-350 μg/L).

Iodoral in Pregnancy Leads to Congenital Hypothyroidism - 3 Recent cases


Patient is a 60 year old male.Dx with OCD at age 29, at about the same time he was DX with Hashimoto’s. Hashimoto’s had been monitored by his PCP over the years and treated with Synthroid. In the last 5-6 months, patient reports: extreme fatigue, brittle nails, sinus drainage in back of throat making him hoarse (he is a drama teacher) and extreme cold hands (though this appears to be “settling down”). After a while he went in to see PCP and labs showed elevated TSH. PCP increased Synthroid to 175mcg and then to 200mcg and included Sildenafil 25mg.

Participant Case Review #7As of today, blood tests “leveled out” (according to PCP) but all symptoms continue. Patient is convinced issue is Hashimoto’s and sleep-related. Sleep is where this case gets complicated: with OCD he has a reversed sleep schedule: he is up all night and sleeps during day until 2-3:30.This is largely due to rituals & associated anxiety related to preparing for bed. He is working on changing this with his psychiatrist. But it is a very slow process. His OCD also worsened 3 years ago when his Mom passed. Working with two therapists. His sleep is further disturbed by GERD and pain due to rotator cuff injury!

Participant Case Review #712/12TSH 6.25 uIU/mlfT4 1.51 ng/dL 01/13TSH 2.25 uIU/mlfT4 1.66 ng/dLT4 total 11.7 ug/dLT3 total 0.71 ng/dLTG antibodies WNLTPO antibodies 176.0 IU/mL T3 total 157 ng/dL


02/13TSH 0.11 mIU/L – his PCP is keeping him here which seems too low to me?fT4 1.9 ng/dLFTI 3.5T3 uptake 37T4 9.4 mcg/dL


54 yo femaleOct 31/12 Jan 28/13Oct 31/212 TSH 4.12 TPO 300, thyroglobin antibody 326Jan 28/13 TSH 3.94 TPO 241 thyroglobulin antibody 327

Allergies: sulpha 1988, clindamycin 2011 post dental implant

Participant Case Review #8Treatment/medication:Nessman lycopus drainage for thyroid, cactus for heart palpitationsAllergy research Thyroid plus 1pill/day 5 days/week (Non-Rx Thyroid Glandular)Pure north Vit, multivit, fish oil, digestive enz, probiotic, vit D 6,00 IU, selenium MB 150ug/dayALA, glutathione, magnesium citrate, NAC 200 mg/daySymptoms (4 minimum):Afternoon fatigue better with thyroid plusMemory lossConstipation, Eczema when eating dairy, food sensitivity test negative for glutein and dairy 2012 and 2013

How do I lower the thyroid antibodies?

Post Event Quiz

Which of the following can justify thyroid replacement in a symptomatic patient with a TSH between 2.5 to 4.5?

A. Ultrasonographic signs of autoimmunityB. AM Axillary body temperature below 97.2C. Delayed Achilles reflexD. Positive prior response to thyroid replacement

Post Event Quiz

Most hypothyroidism in the US is caused by:

A. ObesityB. Bromide toxicityC. Iodine deficiencyD. Autoimmune disease

Post Event Quiz

Thyroid dosing can be safely increased until

A. Free T3 elevates above 4.8 pg/mLB. TSH is suppressed below 0.4 mIU/LC. Symptoms have resolvedD. AM Axillary body temperature rises above 98.9

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