Thyroid Updates: Treating Hypothyroidism and Interpreting Labs

Intro:

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Dr Ruscio:

Hi everyone. This is Dr. Michael Ruscio and welcome back. Let’s go into some research updates on thyroid health. And just as a quick reminder, we have dedicated a lot of resources toward monitoring new research in a myriad of areas. One of course is thyroid and we filter these studies for those that are applicable. We throw out most animal data because I’m sure it doesn’t have a lot of carryover translation into humans, and we try to consolidate toward items that our audience would be concerned with—some obscure thyroid condition that may affect one in 500,000 people we will filter out—and focus mostly on Hashimotos, thyroid, auto-immunity, hypothyroidism, dietary nutritional lifestyle solutions, the optimum way to interpret lab work, the optimum use of medication, etc. So that is what we will focus on today.

Dr Ruscio, DC:

The first study that we’ll look at was entitled “Benefits and Harms of Levothyroxine/L-Triiodothyronine Versus Levothyroxine Monotherapy for Adult Patients with Hypothyroidism: Systematic Review and Meta-Analysis.” So it said simply comparing combination T4 plus T3 versus just T4 monotherapy—18 clinical trials were examined comparing these two different therapies—no difference between monotherapy (just T4) versus combination therapy (T4 plus T3) was found in thyroid function, depressive symptoms, fatigue, quality of life, or adverse effects.

Dr Ruscio, DC:

However, and this is important to highlight, patients did have a higher preference for the combined T4 plus T3— 43% compared to 23%. So a 20% favorability toward combination therapy. And this is why we’ve made the recommendation of considering combination therapy. Yes, but not attempting to fine tune thyroid hormone until you have gone through the dietary, lifestyle, and gut-health foundation’s therapies that we recommend first. And my thinking is that this preference would likely be even more attenuated, maybe 10% favorability, toward that combination therapy, which is exactly the percentage of people who genetically are poor converters.

Dr Ruscio, DC:

But important to mention and important for me to parse just because we’ve been critical of incorrectly diagnosing hypothyroidism—which is certainly a problem, both in conventional and more so in functional health—and we’ve been critical of the over utilization of combination therapy or these egregiously high doses of T3, it doesn’t mean that there’s no time or no place for combination therapy. And I want to make sure to flag for you that this meta-analysis (18 clinical trials) did find a 20% preference.

Dr Ruscio, DC:

So the sequence here is what helps reconcile this. Start with first determining, are you hypothyroid? Yes or no? Not as easy as it may seem. If you’re hypothyroid, get on a medication. My recommendation would be start with T4, then go through the dietary, lifestyle, gut-health foundations that we harp on. And then if you’re still exhibiting symptoms, this is the best time to consider a combination therapy and/or any more fine tuning. And one of the main reasons for that is the same symptoms that the thyroid hormone may help can be addressed by the dietary, lifestyle, and especially gut-health therapies. And then two, it is, in many cases, easier to find a suitable dose when absorption is consistent. And this has been shown now in a growing number of trials that TSH will become lower and more stable if a problem in the gut is present and then addressed.

Dr Ruscio, DC:

Okay. So coming on to the next study, “Excess Use of Thyroid Hormone Treatment Among Patients with Fibromyalgia: a Cross-Sectional Study in Primary Healthcare.” And this study examined 16 fibromyalgia patients taking Levothyroxine (or T4). The initial TSH and T4 values were assessed prior to beginning Levothyroxine. This is what we do at the clinic or attempt to do as best we can. When someone comes in hypothyroid, we go back to the labs before they started hormone to double check. And you’d be surprised how often their initial labs showed them to be normal thyroid or Euthyroid. And now it’s a year, 2, 3, 4 or five later, and they’re still on medication. And this is good news, because it tells exactly what we’ll see in this study.

Dr Ruscio, DC:

74% of patients taking Levothyroxine had either normal thyroid function (meaning [they] don’t need this hormone) or subclinical hypothyroidism (meaning there’s a, roughly said, 50-70ish percent chance that you don’t need hormone). Because it’s roughly that number who have subclinical hypothyroidism (a mild elevation of TSH—5, 6, 7) that will go back to normal spontaneously with time with no other treatment. You can enhance that effect by using selenium and Myo-inositol. But okay, so this shows us that only 25% of those with fibromyalgia were truly hypothyroid. Now in the doctor’s defense, you have a patient in front of you [who’s] tired, [whose] muscles hurt, maybe they’re depressed. Okay, you want to help [them]. And I totally understand the other side of this. So I want to always try to countervail my pointing out that we are too indiscriminately giving out thyroid hormone on the one hand, with on the other hand the fact that if someone doesn’t need a medication and we give that to them, that is a disservice to the patient because now they’re starting on lifelong hormone replacement therapy thyroid that they don’t need.

Dr Ruscio, DC:

And what you’ll see in some cases, even more sadly, especially if they’re working with an integrated provider, there seems to be this situation that occurs in admittedly, a smaller subset of patients, but the more hormone they take, the more aberrant or off their thyroid hormone looks. And they end up with these wacky sort of suppressed TSHs with low normal T4s and their clinician can’t figure out why. And it’s like, well, you don’t need this hormone. So maybe the reason why it’s doing funky things in your body is your poor system is trying to figure out why all this hormone is being dumped in and it doesn’t need, it’s trying to offset as best it can, but this is a reason why your thyroid hormone levels never look normal.

Dr Ruscio, DC:

And these same people will oftentimes say, “I’m anxious, I’m fatigued” because overdose can lead to fatigue. Just like in patients with Graves, you’ll see fatigue and they may have a hard time sleeping or heart palpitations. So [it is] important to want to help patients on the one hand, and maybe even run a trial—I still hesitate to run a trial on thyroid hormone in someone with normal blood levels, I think that’s generally a bad idea, but okay, I’ll see your case—but qualify that it helps them and if it doesn’t, get them off the hormone. So in this case, for these fibromyalgia patients, 74% were unneeding of the medication, were found to have normal thyroid hormone levels, even though they were on hormone when their initial diagnosis was checked, they were normal thyroid. And what that means is there’s extremely high likelihood that these patients will be able to come off the hormone. And for a subset of them, they’ll probably feel better because, like I said a moment ago, there are some patients who are on thyroid who it’s actually exacerbating their symptoms.

Dr Ruscio, DC:

Okay. The next study, “Clinical Effect of Methimazole (antithyroid drug, anti iodine, essentially) Combined with Selenium in the Treatment of Toxic Diffuse Goiter in Children.” So this is kind of a Grave-associated goiter. 103 kids with Graves were randomized to Methimazole alone or Methimazole combined with 50 micrograms of selenium. The combination of Methimazole plus selenium had a lower thyroid volume. This is a good thing. You don’t want to have a voluminous goiter causing your thyroid to be larger. So this is good. They had lower Interlukin-6 and 8. Also good, less inflammation. They had lower thyroid receptor antibodies, also good, and lower TPO, also good. And it took less time for their free T4 to return to normal 90 days versus 120 days.

Dr Ruscio, DC:

Now, [there is] one thing here I want to flag also. And that is, it took 90 days as compared to 120 days, but it wasn’t instantaneous. So there are times when we want to be a little bit patient and give therapies time to take effect. And this would be a good case of that. So good evidence here. And I’ve written an article about this many, many years ago on how effective natural therapies can be for Graves. And also that it doesn’t have to be either/or, you can use these adjunctively. And selenium is a great example of that. So selenium with Methimazole was more effective in quelling or normalizing the hyperthyroidism of Graves than was Methimazole alone.

Dr Ruscio, DC:

The next study looked at levothyroxin supplementation in euthyroid (or normal thyroid) pregnant women who had positive antibodies. Remember, there’s generally speaking two functions to thyroid health; there is the status of the hormone production—so this is euthyroid (normal), hyperthyroid (high levels), hypothyroid (low levels)—on the other parallel track there’s autoimmunity. Graves causes hyper, Hashimoto’s causes hypo.

Dr Ruscio, DC:

So in this study, being a systematic review with meta-analysis of nine studies by the way, they wanted to see what would happen in pregnant women who had normal thyroid hormone levels but had positive TPO antibodies. And you’ll remember that we’ve discussed subclinical hypothyroidism, meaning this mild elevation of TSH, does seem to contribute to infertility. And the general trend in the data is thyroid hormone replacement in this cohort of individuals does improve pregnancy outcomes—less miscarriages, less preterm births. So what would happen if the thyroid hormones were normal, but there was Hashimotos or TPO antibodies positive? So compared to the no treatment group, treatment with Levothyroxin did not reduce the risk of adverse pregnancy outcomes—no reduction in preterm birth, preeclampsia, or spontaneous miscarriage.

Dr Ruscio, DC:

So this is important to keep in mind because we’re always trying to find where is that line of appropriate treatment versus over-treatment and at least according to this data point (which is probably the best to date being that it’s a systematic review with meta-analysis) I think we can safely conclude that in those with subclinical hypothyroidism levothyroxin [is] a good idea because it improves pregnancy outcomes. Conversely, in those with elevated TPO, thyroid hormone [is] not necessary, not helpful. And this is where cleaning up your diet, getting your vitamin D where it should be, and selenium are probably the better places to go.

Dr Ruscio, DC:

The next study looked at Prevalence and Predictors of Adequate Treatment of Overt Hypothyroidism, meaning let’s prospectively (going forward in time) follow up with 113 newly-diagnosed overt (or true) hypothyroid patients. Let’s follow them for 10 years and let’s see how well they were treated. This is kind of shocking. At 10 years, only 68% were biochemically euthyroid, meaning they had normal TSH and normal free T4. So what this means is they likely didn’t have the appropriate follow up with their doctor, kind of settled into whatever dose they were at maybe at year two, and then at year 10, that dose was no longer adequate. Now there were some risk factors that led to being under-medicated, essentially age, smoking, higher TSH at diagnosis, and higher BMI. Now you can’t do anything about your age. Hopefully you can stop smoking. The higher TSH is important to flag.

Dr Ruscio, DC:

And you’re hopefully starting to cue in on the fact that the level of TSH makes a big difference. 4.5 being the upper limit cutoff. 6 is very different than 10 is very different than 55. I had a patient consult the other day and normally we ask patients to upload, as I alluded to a moment ago, the labs from before they started thyroid hormone medication, the labs that diagnose them as hypothyroid. And she didn’t have a chance to upload them but she said, “okay, well I can find them.” And okay, what was your TSH? Because we were wondering is your hypothyroid diagnosis viable. Her TSH, 55. Okay. Very little debate there. You’re hypothyroid. And this is important to cue in on, because the higher your level of TSH at diagnosis, the more likely that you are true hypothyroid and the less likely you’ll see the spontaneous remission that is seen frequently (50, 60, 70% of the time) when you have this subclinical hypothyroidism (or an elevation of TSH between 4.5 up to a cutoff of between 7-10).

Dr Ruscio, DC:

So if your TSH is anywhere between 4.5 up to 7-10 as upper cutoff range, there’s a good likelihood you will not need thyroid hormone. So just one other thing there I want to weave into this so that you’re empowered and you understand that interpreting thyroid blood work, it’s not rocket science. It is very wrong, in my opinion, to say, “well, yeah, I mean your TSH it’s 3.8. And it’s not high but it’s suboptimal. And oh, your free T4—0.8 to 1.8 being the range—it’s 1.1. It’s also not low, but it’s sluggish. So let’s get you on hormone.” This is the wrong way of interpreting this. And I want to try to just keep spelling this out, because there is this nuance. We do want to make sure people get the appropriate care but we don’t want to overreact and put people on hormones that they don’t need.

Dr Ruscio, DC:

And this, again, is disturbing how much of this we end up having to triage at the clinic. Like I mentioned a moment ago, the person who was put on thyroid hormone that they didn’t need now, years later, their doctor is never able to get their levels where they want them to be and they’re still having symptoms. And in these cases, not to say this is an absolute rule, but twofold interventions helps to resolve the symptoms. One, get them off the thyroid hormone they don’t need. And in some cases it’s pretty instantaneous improvement in sleep fatigue [and] anxiety. And then oftentimes going to work on their gut health. Or they’re either under-eating or under-eating carbs, as another example. So anyway, just a few thoughts there in terms of wanting to get this balance right, wanting to be progressive and proactive and seek out the therapies that can help, but not going beyond that sweet spot where you end up having worse outcomes because you’re doing interventions that are not going to be helpful.

Dr Ruscio, DC:

Okay. The next study looked at the “Effect of selenium on thyroid autoimmunity and regulatory T cells in patients with Hashimoto’s [thyroiditis]”. And this was a prospective randomized control trial. 90 patients with Hashimoto’s were randomized to 200 micrograms of selenium versus no treatment. And at six months, the selenium group had significantly reduced TPO, thyroglobulin, and TSH. Now the difference in TSH [was] somewhat minimal, 0.02. Now, if it was 0.2, that’d be significant. The thyroglobulins reduced by 48. Also pretty small. And the TPO reduced by 28. So important here to mention that selenium does have [the] majority [of] data trending in the direction of being able to lower thyroid antibodies. But from what I’ve seen, maybe 200 points of TPO is the maximum that you’ll see regarding reduction in TPO. So this is something and it can be helpful. But if you’re an unmanaged Hashimoto’s case, you’ll oftentimes see antibodies at thousand or above.

Dr Ruscio, DC:

So just to clarify, selenium can be helpful. In this case, 28 points. If you’re unmanaged [it is] not going to be huge. And this is where we want to hit all of the things—improve your diet, improve your sleep, vitamin D, selenium—just as the foundational pillars. And we want to have that nuanced read of [when we have] hit a point of satisfaction. And the best data here— as I’ve remarked before, although this is not conclusive, however it is the best data point that we have—found that a cutoff of 500 for TPO is probably when we can say, okay, we’re happy. And now you can eat out and not have to live in fear.

Dr Ruscio, DC:

And this is important because you’d be surprised how many people have gotten on the gluten dogma train. While I’m fully supportive of a gluten elimination and reintroduction, it doesn’t mean that if your thyroid antibodies are hovering at 225, you can never go out to eat or have any fun or ever eat grains or gluten. You want to be careful to listen to your body. And if you notice a fairly marked aversion to gluten, then avoid it. But the point I’m trying to make here is someone could have antibodies in the low 200s, their TPO feel fairly well overall, not notice an aversion of gluten when they have it, but be avoiding it based upon faith or fear. And this is the food freedom we want to try to give people back.

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Hi, everyone. If you are in need of help, we have a number of resources for you. “Healthy Gut, Healthy You”, my book and your complete self-help guide to healing your gut. If you’re not a do-it-yourselfer there is the clinic—the Ruscio Institute for Functional Health—and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and help them along their path, health coaching support calls every other week, and also we offer health coaching independent of the clinic for those perhaps reading the book and/or looking for guidance with diet, supplementation, etc. There’s also the store that has our Elemental Diet line, our probiotics, and other gut health and health-supportive supplements. And for clinicians, there is our FFHR—the Future of Functional Health Review—database which contains case studies from our clinic, research reviews, and practice guidelines. Visit DrRuscio.com/resources to learn more.

Dr Ruscio, DC:

The next study, [Are ethnic differences, urinary iodine status, lead and cadmium exposure associated with thyroid autoimmunity and hypothyroid status? A cross-sectional study] looked at ethnic differences in urinary iodine status, lead, and cadmium and how they were associated to thyroid, autoimmune, and hypothyroidism. This was a cross-sectional study in just under 3000 patients. And the following associations were noted between various toxins and thyroid on immunity—elevations of lead, elevations of iodine, and elevations of cadmium. Now, the lead and the cadmium, probably not surprising.

Dr Ruscio, DC:

What might be surprising is the iodine. And this is why—and it’s been years since we’ve really drilled down into this—but as more and more research comes in, it is clear that excessive intake of iodine is harmful to the thyroid. Now, it is true that in an area where iodine intake is endemically low, then iodine repletion or iodine supplementation is helpful. But what seems to have happened is there’s this bifurcation in thyroid care where some people are thyroid agnostic, I guess you could say, regarding iodine, that they don’t have strong views, and there’s a couple gurus who just feel that everyone needs to be on iodine and a rather aggressive dose. And that needs to be reexamined. However, there is one small nuance in that the US food supply does have iodine fortification in dairy and grains.

Dr Ruscio, DC:

However, if you’re an ardent, let’s say, paleo dieter or elimination dieter and you’re not having any dairy, any grains, nor are you using iodized salt, meaning you’re using sea salt (which does have iodine, has a very, very small amount) then you run the risk of becoming iodine insufficient. And this was found in one, I believe it was, a two year follow-up study looking at paleo dieters and found an increased level of iodine insufficiency in that population. Now a 24 hour urinary iodine with creatinine ratio can help ferret that out. It’s not very hard to sort. I would not recommend the now-seemingly-less-popular iodine patch skin test because it just has not been validated. But said simply, if you haven’t reintroduced dairy, I would consider reintroducing dairy. If you haven’t reintroduced some grains, consider it. Although I don’t think people need to be eating grains.

Dr Ruscio, DC:

If you’re using a sea salt, look for a sea salt that is also iodized. And maybe the most simply do a internet search for foods that are rich in iodine and try to incorporate these into your diet. And shouldn’t take much for you just to fill a few gaps of where you may be avoiding, let’s say most or every iodine rich food, and you make a practice of getting in the RDA on a roughly daily basis. And that should hedge your bets pretty well.

Dr Ruscio, DC:

Okay. The next study looked at the effect of TPO antibodies and thyroglobulin antibodies on maternal neonatal outcomes. And essentially what they found was of those who had postpartum thyroiditis (so after the pregnancy they had thyroid auto immunity) they also had lower rates of normal thyroid function at a 2-3 year follow up.

Dr Ruscio, DC:

So what this means is if you have thyroid autoimmunity that starts postpartum, but your thyroid hormone levels are normal, continue to have your antibodies monitored, use some of the therapies that are known to lower thyroid antibodies, and be proactive and preventative. Clean up your diet, exercise, vitamin D, selenium, some simple factors here. I would also recommend tuning up your gut health. This is yet to really be demonstrated, that gut therapies can lower antibodies, but there’s been some association, as I’m sure you’ve heard me discuss in the podcast before, between SIBO and thyroid auto immunity. So certainly it seems reasonable to clean up your gut health as an additional attempt to improve your prognosis.

Dr Ruscio, DC:

Now, also remember that if you have Hashimoto’s, the odds are in your favor that you will not become hypothyroid. The best data point here found a 9-19% conversion to true hypothyroidism. So this is important to mention. And as I’ve said before in the podcast, but I think this is worth repeating, Hashimoto’s autoimmunity is the most common cause of hypothyroidism. Now if we tell you that and nothing else, you’re kind of left to assume that the majority of people who have Hashimoto’s will become hypothyroid—70%, 80% maybe. But in actuality, only 9-19% of these people seem to progress to and convert to overt hypothyroidism. So important just to contextualize that and be able to quantify risk.

Dr Ruscio, DC:

Okay. Another study here was a narrative review on hypothyroidism in older individuals, and they wanted to look at mainly subclinical hypothyroidism in those who are over 65. And these studies found there was no increased risk of poor outcomes if you had subclinical hypothyroidism, mildly elevated TSH, and you were over 65. There was no negative outcomes for cardiovascular or cognitive health if your TSH was between 4.5 and 7. In older individuals with subclinical hypothyroidism, symptoms of hypothyroidism, cardiac, and bone health did not improve after Levothyroxine treatment.

Dr Ruscio, DC:

So this narrative review concluded that if the TSH concentration is at or below seven, do not initiate treatment. And it looks like the line here is really being drawn between 7 and 10. And why this is relevant is [that] the line for when we treat subclinical hypothyroidism was 10. Now it’s being potentially drawn at 7. But another way of reconciling this is monitoring your TSH over time.

Dr Ruscio, DC:

And remember, you don’t have to decide [to] go on lifelong Levothyroxine treatment based upon one test. You can, let’s say, find a 7.8 and then say, “okay, I’m going to clean up my diet a bit, make sure my vitamin D is where it should be, use selenium, use myo-inositol, and then retest two to three months later and reevaluate.” And if you’re holding at that 7.8 and you feel well, maybe you do nothing. If you are symptomatic [that is] more of an indication to use hormone. And if you’re going up, then [that is] even more [of an] indication that you should use hormone. But remember the odds are in your favor that upon that retest, you will be lower. Likely below 4.5. Or perhaps lower yet still, where it’s easy to decide not to go on hormone, perhaps 5.5—just as one arbitrary numeric example.

Dr Ruscio, DC:

Okay. And [the] last study I wanted to cover here looked at weekly versus daily dosing of Levothyroxine in adults with hypothyroidism. And this was a meta-analysis of two randomized control trials looking at 109 patients comparing a weekly dose versus a daily dose. And after 12 weeks, the weekly dose group had a 1.7 higher TSH. So this is not great. But there was no difference in symptoms and there was no difference in adverse events. Now, what population might this be favorable for? For those whom they find it a pain in the butt taking their daily morning medication and then not having to eat or drink anything for that window afterwards. So not saying this is something that should necessarily be done across the board, but if you’re someone who (due to your schedule, what have you, it’s annoying) then you could speak with your doctor about trying this weekly dosing at a higher dose. And, consider that.

Dr Ruscio, DC:

Now, there’s also another way around this if the short fast post-medication is annoying to you, and that is using the liquid version—the liquid gel tab, essentially, tirosint is one example—that has been shown not to require the post-administration fast. So it’s more expensive. That’s a downside, but you don’t have to fast. And if you have issues with GI malabsorption, the Tirosint or equivalents have actually been shown to get around that due to it being a liquid gel tab [that] is easier to absorb in that first section of the small intestine where most of the Levothyroxine (or whatever you’re taking) absorbs.

Dr Ruscio, DC:

And this is another reason why gut health is so important. And as I discuss in “Healthy Gut, Healthy You,” it really seems to be the small intestine is where the party’s at because this is where the majority of absorption occurs. Now, you can do all these fancy dancy analyses on your levels of short-chain fatty acids and microbiome analyses, and they have some merit, but they’re not really quantifying for the most part what’s going on in the small intestine. And just to tie it back to thyroid, the initial section of the small intestine (the duodenum) is where you’re going to absorb your thyroid hormone medication.

Dr Ruscio, DC:

And the small intestine, in general, is where you’re going to absorb 90% of your calories and most of your nutrients. So [that is] part of the reason that we’re seeing some of these exciting probiotic trials showing the ability to lower TSH, and in some cases even reduce the dose needed of a thyroid hormone medication, from a simple intervention of a probiotic. And there’s other data showing that if people have H Pylori or ulcers and they can’t get their TSH consistent and they’re on Levothyroxine, it’s likely because they’re mal absorbing, they give them Tirosint instead, and all of a sudden everything normalizes.

Dr Ruscio, DC:

So just a few, I guess, closing remarks that tie in the importance of gut health as it pertains to your thyroid in a few different facets, but especially as it pertains to absorption of your thyroid hormone medication. In close, let me just remark that if you are in need of kind of a second opinion on your thyroid health, please reach out to the office. This is something that, gosh, like I said, we’re probably seeing a case that’s been mishandled per day. And I don’t mean to be overly contrarian or I guess negative, but it is frustrating when people come in and they’ve been told they have a disease that requires lifelong hormone medication when they actually don’t. And the more people we can save from this fate, while helping them to find the root cause of their symptoms, address those, and feel better, obviously the better for us and the better for the patients. And it’s a true win-win.

Dr Ruscio, DC:

Alright, guys, I hope that helps. And I will look forward to speaking with you next time.

Outro:

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• Benefits and Harms of Levothyroxine/L-Triiodothyronine Versus Levothyroxine Monotherapy for Adult Patients with Hypothyroidism: Systematic Review and Meta-Analysis
  • 18 RCTs comparing combined therapy (LT4/LT3) versus monotherapy (LT4) for adult patients with hypothyroidism
  • NO difference for:
    • Thyroid function
    • Depressive symptoms
    • Fatigue
    • Quality of life
    • Adverse effects 
  • Patients had a higher preference for combined therapy (43% vs 23% monotherapy)
  • Commentary: This meta-analysis showed no benefit of combined therapy for those w/ hypothyroidism. 

 

• Excess use of thyroid hormone treatment among patients with fibromyalgia: a cross-sectional study in primary health care
  • 16 fibromyalgia patients taking levothyroxine 
  • Initial TSH and T4 values were assessed prior to beginning levothyroxine
  • 74% of patients taking levothyroxine initially had either:
    • Normal thyroid function
    • Subclinical hypothyroidism
  • Only 25% had overt or central hypothyroidism 
  • Commentary: A significant number of fibromyalgia patients are inappropriately prescribed levothyroxine despite NO true hypothyroid diagnosis. 

 

• Clinical effect of methimazole combined with selenium in the treatment of toxic diffuse goiter in children
  • 103 kids w/ Graves’ disease (GD), randomized to:
    • Methimazole alone
    • Combined methimazole + selenium (50 mcg/d)
  • The combined methimazole + selenium group had:
    • Lower thyroid volume
    • Lower IL-6 and IL-8 
    • Lower TRAb (-411 vs -105 μ/mL)
    • Lower  TPO Ab levels (-191 vs -97 μ/mL)
    • Took less time for fT4 to return to normal level (90 vs 120 days)
  • Commentary: Combined methimazole and selenium (even at a lower dose) is more effective than methimazole alone in managing GD, even in a pediatric population. 

 

• Levothyroxine Supplementation in Euthyroid Pregnant Women With Positive Autoantibodies: A Systematic Review and Meta-Analysis
  • 9 studies on pregnant euthyroid women w/ positive TPO antibodies 
  • Compared to no treatment, treatment w/ levothyroxine did NOT reduce the risk of adverse pregnancy outcomes (preterm birth, preeclampsia, placental abruption etc). 
  • Commentary: Treating euthyroid pregnant women w/ levothyroxine was NOT associated w/ a reduced risk of adverse pregnancy outcomes, despite having positive TPO antibodies. 

 

• Prevalence and predictors of adequate treatment of overt hypothyroidism – a population-based study
  • Prospective study of 113 newly diagnosed overt hypothyroid patients
  • Followed x10 years
  • After 10 years, only 68% were biochemically euthyroid
  • Risk factors for remaining hypothyroid include:
    • Age
    • Smoking
    • Higher TSH at diagnosis
    • Higher BMI
  • Commentary: This study showed that a substantial amount of overt hypothyroid patients are inadequately treated at a long-term followup. Those who are older, have history of smoking, higher BMI, or had higher TSH at diagnosis may need more attention to their thyroid labs after starting treatment. 

 

• Effect of selenium on thyroid autoimmunity and regulatory T cells in patients with Hashimoto’s thyroiditis: A prospective randomized-controlled trial
  • 90 Hashimoto’s thyroiditis patients, randomized to selenium (200 mcg/d) or no treatment
  • After 6 months, the selenium group had significantly reduced: 
    • Anti-TPO (-28.4 vs 0 IU/ml)
    • Anti-Tg (-48.8 vs +18.3 IU/ml)
    • TSH (-0.2 vs +0.5 mIU/L)
  • NO difference between groups noted for fT3 and fT4 
  • Commentary: Selenium is useful for reducing thyroid antibodies in patients with Hashimoto’s thyroiditis. 

 

• Are ethnic differences, urinary iodine status, lead and cadmium exposure associated with thyroid autoimmunity and hypothyroid status? A cross-sectional study
  • Cross-sectional study of 2,877 participants
  • The following were associated w/ thyroid autoimmunity
    • Elevated blood lead levels (OR 1.6)
    • Elevated urinary iodine levels (≥300.00 µg/g) (OR 1.5)
    • Elevated blood cadmium levels (OR 1.4)
  • Commentary: High iodine, lead, and cadmium levels may be associated w/ thyroid autoimmunity. 

 

• Effects of Thyroperoxidase Antibody and Thyroglobulin Antibody on Maternal and Neonatal Outcomes in Pregnant Women
  • 296 pregnant women, classified into 4 groups according to thyroid antibody status in first trimester:
    • 97 women: TPOAb+/TgAb-
    • 35 women: TPO-/Tg+
    • 85 women: TPO+/Tg+
    • 79 women: TPO-/Tg-
  • Followed thyroid status x2-3 years postpartum
  • TPOAb (OR 2.3) and TgAb (OR 3.1) had a higher rate of postpartum thyroiditis:
    • 6.3% TPO-/Tg-
    • 16.5% TPO+/Tg-
    • 22.9% TPb-/Tg+
    • 35.3% TPO+/Tg+
  • Of those who had postpartum thyroiditis, lower rates of euthyroidism was found in those w/ thyroid antibodies at 2-3 year followup
  • Commentary: In summary, both TPO and Tg antibodies were associated w/ a higher rate of postpartum thyroiditis. In addition, the presence of antibodies was associated w/ higher rates of thyroid dysfunction at a 2-3 year followup. Getting TgAb on top of TPOAb may add additional prognostic value to pregnancy-related outcomes than TPOAb alone. 

 

• Subclinical hypothyroidism in older individuals
  • Narrative review of subclinical hypothyroidism (SCH) in those >65 yo
  • Studies showed no increased risk of poor outcomes (e.g. cardiovascular, cognitive) if TSH between 4.5-7 
  • In older individuals with SCH, symptoms of hypothyroidism, and cardiac and bone health did not improve after levothyroxine treatment.
  • “This data suggest that treatment with levothyroxine should be considered for TSH concentration is persistently 7 mIU/L or higher and to not initiate treatment with TSH concentrations of less than 7 mIU/L.”
  • Commentary: Consider age and the degree of TSH elevation when managing SCH. 

 

• Weekly Versus Daily Levothyroxine Tablet Replacement in Adults with Hypothyroidism: A Meta-Analysis
  • 2 RCTs, 109 participants comparing weekly vs daily levothyroxine
  • After 12 weeks:
    • The weekly levothyroxine group had a 1.78 mIU/mL higher TSH
    • No difference in symptoms
    • No difference in adverse events
  • Commentary: Weekly levothyroxine led to slightly higher TSH with no difference in symptoms or side effects.

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