The Thyroid Needs an Advocate
By Amer Budayr, MD
Thyroid hormone deficiency is a prevalent health condition, thyroid disease is found in up to ¼ of adults, and the most common manifestation of thyroid hormone imbalance is hypothyroidism, in either its clinically diagnosed and subclinical varieties.
The most common cause of thyroid deficiency is auto-immune thyroiditis, known as Hashimoto’s. The antibody test that defines Hashimoto’s is the anti-TPO (thyroid peroxidase) antibody. Surveys show that it is present in 90-100% of individuals with auto-immune thyroiditis. It is also found in 30-50% of relatives of patients with this diagnosis, and is present in 8-27 % of the general population. Of note is that this antibody is seen in up to 14 % of pregnant individuals.
Given the wide spectrum of health effects of thyroid deficiency and the broad spectrum of signs and symptoms that patients experience, it becomes evident this condition impacts a lot of lives.
There is no established treatment for autoimmune thyroiditis, though there are studies showing reduction in antibody levels when gluten is removed from the diet and adequate selenium levels are attained.
How common is thyroid disease?
Whickham Survey (2779 subjects), TSH >6mIU/L in 7.5% of females and 2.8% of male
NHANES III (16,353 people aged >/=12yr) – 4.3% of this population
Colorado study (>25,000 state residents attending statewide health fairs) – 9.5% with elevated TSH
Subclinical Hypothyroidism is more frequent in areas of Iodine sufficiency 23% compared with 4.2% in iodine deficient areas
Conventional treatment guidelines are as follows:
Give levothyroxine (T4) for replacement
Aim for a TSH level of 0.5 – 3 in most (possibly 5-7 in elderly)
Adding liothyronine (T3) may help a few, in low doses
Pregnancy is a special time with a critically important need for maintaining thyroid sufficiency
T4 replacement is usually life-long
Thyroid deficiency can be progressive
Once a patient is on a full dose replacement, requirements should vary very little
TSH measures adherence to therapy
Monitor TSH every 8 weeks when adjusting T4 dose
Monitor T3 and TSH if using T3 supplement
Monitor every 6-12 months on stable dose T4
Important notes for successful treatment:
T4 does not act unless it is picked up from the pharmacy, ingested and absorbed
Take T4 in morning, ½ hour before food or other meds or supplements
Calcium supplements/multivitamins should not be taken within four hours of ingestion of T4
Always make up for a missed dose
Pregnancy specific issues:
Levothyroxine requirements increase as early as the fifth week of gestation.
Given the importance of maternal euthyroidism for normal fetal cognitive development, we propose that women with hypothyroidism increase their Levothyroxine dose by approximately 30 percent as soon as pregnancy is confirmed.
Thereafter, serum thyrotropin levels should be monitored and the Levothyroxine dose adjusted accordingly.
Recommendations for thyroid hormone supplementation in subclinical hypothyroidism/ Hashimoto’s:
Use T4 or T4 and T3 combination therapy. Keep T3 dose to 5 mcg. Keep T4 dose low. Make sure TSH is NOT SUPPRESSED
Consider trial of increased Liothyronine (T3) dosage twice daily and monitor thyroid levels in one month.
Check peak T3 level for safety, usually 1-2 hours after the dose is taken
Consider a trial of stopping the T3 to check if symptomatically beneficial, repeat the lab in 4-6 weeks if stopping the T3.
Conclusion:
Thyroid disease is common and also treatable. Following appropriate medication protocols will improve symptoms and decrease long-term negative effects of a poorly functioning thyroid gland.
