Thyroid hormone, diseases, and treatment

There are three components of thyroid hormone - TSH, T3 (fT3) and T4 (fT4)

If TSH is high this means hypothyroidism while a low TSH means hyperthyroisim provided it is not due to pituitary disorder. The treatment of hypothyroidism is by thyroid hormone replacement while for hyperthyroidism is either surgery, Iodine131 or antithyroid drugs. These will normalise the TSH with dose titration as advised by a physician or endocrinologist.

For patients resources, please have a look at:

Hypothyroidism: http://www.thyroid.org/wp-content/uploads/patients/brochures/Hypo_brochure.pdf

Hyperthyroidism:

https://www.thyroid.org/wp-content/uploads/patients/brochures/ata-hyperthyroidism-brochure.pdf

Enough amount Oral L-Thyroxine Oral that can bring TSH within normal ranges.

A high TSH with normal freeT3&T4 is subclinical hypothyroidism, treatment is indicated if TSH is>10, or during pregnancy, and if a goiter is present or those with a family history. Otherwise, a close follow-up is needed.

Thank you for your nice discussion Muhammad Yousuf

Thank you for your nice answer Sinan Ibaguner

Thank you for your nice answer Hyder Mirghani

I Am in Accordance to give thyroid hormone therapy if the patient has a TSH level of 10IU or more or if he has a level between 4.2 and 10IU and symptoms (it is not subclinical).

In the case of patients, less than 65 years old a metanalysis (JCE) demonstrated a good cardiovascular outcome in patients with subclinical hypothyroidism, but not in those over 65 (in some way somehow similar to the controversy with the intensive glucose control in aged people). In that study, they conclude that it is necessary a prospective study to demonstrate the results they are showing in their metanalysis. Moreover, several studies demonstrate a good effect of thyroid hormone substitution in subclinical hypothyroidism in some patients with high cholesterol levels and cardiac function.

Fernando Bolaños thank you so much for sharing your experience.

Thank you very much, Dr. Fernando, for the valuable comment, also, if the thyroid autoantibodies are positive, the treatment may be justifiable.

Yes if the have goiter. and the controversy is in case of women who want to become pregnant. There are studies  showing good and no difference between the two arms..

My T3 is 0.93ng/ml, T4 is 6.07 ug/dl and TSH 5.11 ulU/ml (Hight 5.2 inch, weight 74.6kg and age 29 ). Do i need to take medicine to overcome thyroid problem ? Or it can be possible by losing body weight? Would you like to give me some suggestion Fernando Bolaños ?

You are young and you should be checked about your thyroid glan status (?do you have goiter¿). Since you have TSH levels slightly increased you should be tested for antiperoxidase antiboides and have a thyroid ultrasound to see if your thyroid gland is hypoechoic which is suggestive of thyroiditis. .

I think you may hve subclinical hypothyroidism and that case it it is useful to be treated with a mixture of T4 and T3 (Although it ia still a controversy). because of the more calorigenic action of T3. Of course you need to get a diet by a dietitian and to do exercise..

I do not like to use apetite suppreeants like phentermine due to its stimulant effects and I am trying liraglutide en some patients.

I hope these ideas will be useful to you.

?Do you mean 5 feet¿

Thank you very much Fernando Bolaños for the valuable suggestion.

Hello. Dr Farhana. about your question.I think,

People with hypothyroidism is suffer from low metabolism, Therefore for increasing their metabolism, it is better to increasing their protein intake which increasing the metabolism.

Sometimes a high or normal TSH with slightly elevated T4 may point to TSH secreting pituitary adenoma

Thank you very much Hyder Mirghani Murwan khalid Sabahelkhier for the valuable suggestion.

TSH heterophile antibodies may be a source of interference

Yes after increasing , it is better to go back to doctor, for checking all hormones related to thyroid hormone. Doctor will give you treatments to put hormone level in normal situation i.e. treatment method is very important for normal thyroid hormone

IN case of secondary hypothyroidism, starting thyroxine before hydrocortisone may precipitate adrenal crisis

Enough dosage of once daily L-Thyroxine to bring down TSH to normal range.

Of course, however, in certain circumstances, you can give a one week dose of thyroxine as a single dose.

Farhana Najnine : this statement isn't accurate. ( Nutritional deficiencies are the sole cause of an underactive thyroid problem. )

can check this out for the condition of subclinical hypothyroidism based on your thyroid function test results.

Article 2013 ETA Guideline: Management of Subclinical Hypothyroidism

Nutritional deficiency may affect hypothalamo-pituitary axis

Thank you very much Cheah Sin Dee for the valuable suggestion.

TSH levels could be affected by emotional states, fullness, FSH and LH levels etc. That's why preanalytical changes should investigate. The variation of TSH within the day is 50%. In this regard, we should take blood from patients in the early morning. I strongly advise you to consider these situations before treatment.

In the case of a patient with autoinmune thyroiditis and goiter we have prescribe him  levothyroxine even if  the TSH leves is normal. In the case of subclinical hypothyroidism (TSH between 4.5 y 10uU/ml without sympotms), the article in the JCE (metanalisys) showed good results in those less than 65 years old, but not in those above that age. A prospetive controlled study is being done to confirm these results. According to some guidelines it si advised to mesure TSH in the first trimester of pregnancy as a screening test, only  if there are risk factors of thyroid disease. It the TSH os above 2.5uU/ml it is advised to give levothyroxine.

Thank you very much for the valuable suggestion Fernando Bolaños Tahir A.M Omer Durmuş Ayan

Also, in 65 yers old or older patients, the TSH upper limit is around 7uU/ml, and many authors do not advise to initiate levothyroxine  treatment until the TSH value is 10uU/ml or more.  Besides, you have to take in account that iron, antiacids, omeprazol and calcium decrease thyroid hormone absorption, so you have to wait about four hours to have them.

@Farhana Najnine - Dietary changes are first step as said...Even excess iodine can cause hypothyroidism as we have going in our study... Indiscriminate use of fortified iodized salt irrespective of environmental iodine status can be a major concern for homeostasis of the thyroid. This should also taken into consideration

Yes, but if a patient is taking a levothyroxine dose enough to substitute the amount produced by the thyroid (1.6ug/kg/day),, like in the case of hypothyroidism, , you do not have to worry about the effect of iodine on the thyroid  since the gland is not working (due to inhibition caused by  the subtitutive  dose of the hormone)..

In the case of severe undernutrition like anorexia nervosa you may see a a great diysfunction of the hypothalamus and pituitary axis , with hypercortisolism, amenorrea, increase of GH and decrease of IGF-1. 

Yes Sir...however prolonged dose of exogenous levothyroxine has been shown to effect adversely in many thyroid hormone sensitive organs including reproductive systems. It is thus plausible to conclude that dietary factors combined with adequate endocrine supplements may be a solution to this problem.

Yes, the dose must be graduated according to the physiologic production by the thyroid gland, which has no drawbacks in the human tissues..

The question is what to do if the thyroid hormones are elevated.

The best thing to do is search for a good endocrinologist. If the patient is not taking thyroid hormones, for whatever reason, it probably is due to hyperthyroidism (an overactive thyroid). There may be a few causes, and an endocrinologist is the best choice for an adequate treatment.