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Dx Hypothyroidism Treatments: Read more...


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Observations:
Hypothyroidism

The Merck Manual Home Edition
states:
"Hypothyroidism is underactivity of the thyroid gland that leads to inadequate production of thyroid hormones and a slowing of vital body functions.

*Facial expressions become dull, the voice is hoarse, speech is slow, eyelids droop, and the eyes and face become puffy.
*Usually only one blood test is needed to confirm the diagnosis.
*People with hypothyroidism need to take thyroid hormone for the rest of their life.
*Hypothyroidism is common, especially among older people, particularly women. It affects about 10% of older women. It can, however, occur at any age.
*Very severe hypothyroidism is called myxedema.

Causes
Hypothyroidism has several causes.
*Primary hypothyroidism results from a disorder of the thyroid gland itself. The most common cause is Hashimoto's thyroiditis (see Hashimoto's Thyroiditis). As the thyroid is gradually destroyed, hypothyroidism develops.
*Subacute thyroiditis and silent lymphocytic thyroiditis can both cause transient hypothyroidism. The hypothyroidism is transient because the thyroid is not destroyed.
*Hypothyroidism can develop after treatment of hyperthyroidism or thyroid cancer because use of radioactive iodine or drugs that interfere with the body's ability to make thyroid hormones or surgical removal of the thyroid gland leads to a lack of thyroid hormone production.
*A chronic lack of iodine in the diet is the most common cause of hypothyroidism in many developing countries. However, iodine deficiency is a rare cause of hypothyroidism in the United States because iodine is added to table salt and is also used to sterilize the udders of dairy cattle and thus is present in dairy products. Rarer causes of hypothyroidism include some inherited disorders in which an abnormality of the enzymes in thyroid cells prevents the gland from making or secreting enough thyroid hormones.

In secondary hypothyroidism, which is much rarer than primary, the pituitary gland fails to secrete enough thyroid-stimulating hormone (TSH), which is necessary for normal stimulation of the thyroid.

Symptoms:
Insufficient thyroid hormones cause body functions to slow. Symptoms are subtle and develop gradually. They may be mistaken for depression, especially among older people. Facial expressions become dull, the voice is hoarse and speech is slow, eyelids droop, and the eyes and face become puffy. Many people with hypothyroidism gain weight, become constipated, and are unable to tolerate cold. The hair becomes sparse, coarse, and dry, and the skin becomes coarse, dry, scaly, and thick. Some people develop carpal tunnel syndrome, which makes the hands tingle or hurt (see Carpal Tunnel Syndrome). The pulse may slow, the palms and soles may appear slightly orange (carotenemia), and the side parts of the eyebrows slowly fall out. Some people, especially older people, may appear confused, forgetful, or demented—signs that can easily be mistaken for Alzheimer's disease or other forms of dementia.

If untreated, hypothyroidism can eventually cause anemia, a low body temperature, and heart failure. This situation may progress to confusion, stupor, or coma (myxedema coma), a life-threatening complication in which breathing slows, seizures occur, and blood flow to the brain decreases. Myxedema coma can be triggered in a person with hypothyroidism by physical stresses, such as exposure to the cold, as well as by an infection, injury, surgery, and drugs such as sedatives that depress brain function."

Diagnosis:
Usually hypothyroidism can be diagnosed with one simple blood test: the measurement of TSH. Many experts suggest that the test be done at least every other year in people older than 55 because hypothyroidism is so common among older people yet so difficult, in its mild stages, for doctors to distinguish from other disorders that affect people in this age group.

In those rare cases of hypothyroidism caused by inadequate secretion of TSH, a second blood test is needed. This blood test measures the level of the thyroid hormone T4 (thyroxine) that is not bound by protein (free). A low level confirms the diagnosis of hypothyroidism.

Treatment:
Treatment involves replacing thyroid hormone using one of several oral preparations. The preferred form of hormone replacement is synthetic T4. Another form, desiccated (dried) thyroid, is obtained from the thyroid glands of animals. In general, desiccated thyroid is less satisfactory than synthetic T4 because the content of thyroid hormones in the tablets may vary. In emergencies, such as myxedema coma, doctors may give synthetic T4, T3 (triiodothyronine), or both intravenously.

Treatment begins with small doses of thyroid hormone, because too large a dose can cause serious side effects, although large doses may be necessary. The starting dose and the rate of increase are especially small in older people, who are often most at risk of side effects. The dose is gradually increased until the levels of TSH in the person's blood return to normal. During pregnancy, doses usually need to be increased.

Spotlight on Aging:
*More than 10% of older people have some degree of hypothyroidism.
*Women are affected about twice as often as men.
*Typical symptoms, such as weight gain, muscle cramps, tingling, and the inability to tolerate cold, are less common among older people. When such symptoms do occur among older people, they are less obvious.
*Older people may also have less typical symptoms. For example, they may lose weight, become confused, and have a decreased appetite, joint stiffness, joint and muscle pains, weakness, and a tendency to fall.
*Because symptoms in older people can be different, are often subtle and vague, and are common among older people who do not have hypothyroidism, doctors may not recognize these symptoms as being caused by hypothyroidism. A screening test, in which blood levels of thyroid-stimulating hormone are measured, is important. The test should be done every year in people over 65."

Medications Used in Treatment:
1. Thyroxines: Synthroid® Unitroid® Levoxyl® Tirosint®/ levothyroxine
2. Triodothyronines: Cytomel®/liothyronine
3. Natural Thyroids: Armour® thyroid, N-P® thyroid, Nature-Throid®/ dessicated thyroid
4. Thyroxine/Triodothyronine Combination: Thyrolar®/thryoxine/triiodothyronine

Suggested Links:
*N.H.S. Choices
*Medscape


*[Editor] Subclinical hypothyroidism is associated with poor outcome of pregnancy, dyslipidemia, atherogenesis, and increased mortality in the long-term. Thyroxine has no activity on TAFI, Thrombin-activatable fibrinolysis inhibitor in thyroid disease. Yet, Wilson reported that replacement of adequate compounded T3 will reduce thyroid antibodies from nearly 1000 to normal range in 6- 9 months. The literature documents that the presence of thyroid antibodies are associated with a host of other inflammatory conditions including diabetes, osteoarthritis, and GI disease.

*[Editor] Selelenium and the thyroid gland: more good news for clinicians reports that selemium supplementation decreases anti-thyroid peroxidase (TPO) antibodies in pregnant women and post-partum thyroiditis. Selenium also reduces anti-thyroid antibodies in both sexes. Whether selenium increases risk of diabetes long term has not bee proven.

*[Editor] KL Wilson in AJOG 2014 documented that low T4 in pregnancy is associated with prematurity and incerased incidence of abruptio placenta (P>.007). Attention must be given to accurate diagnosis and treatment of pregnant women.

*[Editor] The discovery in the 2007-2008 NHAMES study that phthalates falsely suppress TSH and elevate free T4 makes the laboratory diagnosis of hypothyroidisim and subclincial hypothyroidism more difficult. Phthalates are present in greater than 92% of all mankind. The significance is that the HPT (hypothalamic-Pituitary-Thyroid Axis "do not completely compensate for small changes in thyroid hormone levels associated with percholorate and phthalate ester exposure." Therefore, patients are undertreated.

*[Editor] TSH increases with age, yet there is a clear age dependent feature between subclinical hypothyroidism and ischemic heart disease. Based on the work of Gaby, normal clinical replacement thyroid could be up to 5 grains per day [Gaby AR, Alternative Medicine Review 2002].

*[Editor] It is the opinion of J Paoletti in the International Journal of Pharmacology Compounding states that "individualization of thyroid therapy will often require the use of compounded T3 or T4/T3 combination therapy." The development of thyroid antibodies is diagnostic of Hashimoto's thyroitis. Yet, this immunological condition does not completely respond to levothyroxine/ selenium. The literature and the Editor's experience is that additional replacement with compounded T3 daily can lower the measurable TPO and thyroid antibodies even to normal range.

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