The Use of 24 Hr Urine Testing for Thyroid Dysfunction
There is a large body of evidence to support the use of 24 hour urine testing for thyroid dysfunction. Excellent papers are available to point out their efficacy but have been ignored (1). Analytical and clinical validation has been shown to anyone who will read it, or listen. The 24 hour urine thyroid function test is generally to be preferred over standard serum TFT because it shows the amount of thyroid being used, not simply how much is there and perhaps not being used (2-21).
In this world of Evidence Based Medicine, this has come to mean that the evidence is narrowed down to clinical assays only. It should go without dispute that the physicians’ observations should not only be included in this evidence but, indeed, have precedence over the tests. In this connection the Barnes Basal temperature test does not deserve the implied opprobrium heaped on it by the RCP. It is a most valuable tool as a screening test and the RCP misunderstands its role when they suggest it is being used to make the diagnosis. In fact a low basal temperature points the way to a fuller clinical appraisal, and it is here that its great value lies.
However, there is much evidence to support the measurement of basal body temperature in the diagnosis of thyroid dysfunction. Dr. Broda Barnes discovered in the course of performing basal metabolism tests that patients suffering the symptoms and signs of hypothyroidism also suffered from low body temperatures (22). Upon further investigation, he learned that this simple test was an excellent, although not a totally accurate, indicator of hypothyroidism. This test is also used by others (23,24) but is also disparaged (25) by citing a study on body temperatures (26). Like the somatic studies below, this study did not screen patients with physical complaints that might lower their body temperature, including hypothyroidism. Thus, the logical error of attempting to distance the symptom from hypothyroidism, again used data tainted by hypothyroidism.(27)
Sufficiently low body temperatures are described as hypothermic. Although general concern by physicians only starts below 95 degrees Fahrenheit, the differential diagnosis for hypothermia is revealing (28). In addition to exposure, which is well down the list, it places a variety of hormone deficiencies at the top of the list, with hypothyroidism, and presumably its mimics, first. Thus, Dr. Barnes is substantially, although not always, correct a fact which he noted as well.
The stark contrast between Dr. Broda Barnes use of the low basal temperature indicator, and its rejection (25). coupled with the comparison of the inclusive differential diagnostics for hypothermia (28), with the exclusive differential diagnostics for hypothyroidism (29-36), in particular, those in the UK guidelines (37-40), suggests that instead of caring for the patient (28), the important role is selling levothyroxine sodium to the exclusion of other hormone replacements, which are potentially needed hormone replacements (37-40).
Fraser WD, Biggart E, OReilly D St J, Gray H W, McKillop JH, Thomson JA. Are biochemical tests of thyroid function of any value in monitoring patients receiving thyroxine replacement? Br Med J. 1986, 293: 808-10
Chan V, Landon J. Urinary thyroxine excretion as index of thyroid function. Lancet. 1972, (Jan 1) 7740: 4-6
Tal E , Sulman FG. Urinary thyroxine. Lancet. 1972, 1291
Chan V, Besser GM, Landon J, Ekins RP. Urinary triiodothyronine excretion as index of thyroid function. Lancet 1972, (Aug 5) 253-256
Chan V, Besser GM, Landon J. Effects of oestrogen on urinary thyroxine excretion. Br Med J. 1972, 4: 699-701
Rastogi GK, Sawhney, Sinha, Thomas, Devi. Serum and urinary levels of thyroid hormones in normal pregnancy. Obstet Gynecol. 1974, 2: 176-80
Rogowski P,Siersbaek-Nielsen K, Mlholm Hansen J. Urinary excretion of thyroxine in different thyroid states. Acta Endocrinol (Kopenh). 1978, 87: 525-3
Kolendorf K, Broch Mller B, Rogowski P. The influence of chronic renal failure on serum and urinary thyroid hormone levels. Acta Endocrinol (Kopenh). 1978, 89: 80-8
Ali Afrasiaki M, Dabir Vaziri N, Grant Gwinup, Mays M, Barton CH, Ness RL,Valenta LJ. Thyroid function in the nephrotic syndrome. Ann Int Med. 1979, 90, 335-8
Aizawa T, Yamada T, Tawata M, Shimizu T, Furuta S, Kiyosawa K, Yakata M. Thyroid hormone metabolism in patients with liver cirrhosis, as judged by urnary excretion of triiodothyronine. J Am Geriatrics Soc. 1980;28(11):485-91
Yoshida K, Sakurada T, Kaise K, Saito S, Yoshinaga K. Measurement of triiodothyronine in urine. Tohoku J Exp Med. 1980;132(4):389-95
Lopresti JS, Warren DW, Kaptein EM, Croxson MS, Nicoloff JT. Urinary immunoprecipitation method for estimation of thyroxine to triiodothyronine conversion in altered thyroid states. J Clin Endocrinol Metab. 1982;55( 4):666-70
Yoshida K, Sakurada T, Kaise K, Yamamoto M, Saito S, Yoshinaga K. Thyroid stimulation test with urinary T3 concentration as an index of thyroid response. Tohuku J Exp Med. 1983;139(3):271-7
Mirralles-Garcia JM, Mories-Alvarez MT, Reglero-Chillon A, Lanao JM, Corrales-Hernandez JJ, Garcia-Diez LC. Urinary kinetics of triiodothyronine and their modification with age. Horm Metab Res. 1985;17(7):366-9
Orden I, Pie, Juste, Marsella, Blasco. Thyroxine in unextracted urine. Acta Endocrinol (Kopenh). 1987;114:503-8
Faber J, Siersbaek-Nielsen K, Kirkegaard C. Renal handling of thyroxine, 3,5,3- and 3,3,5-triiodothyronine, 3,3-diiodothyronine in man. Acta Endocrinol (Kopenh). 1987;115:144-8
Orden I, Pie J, Juste MG, Giner A, Gomez ME, Escanero JF. Urinary triiodothyronine excretion. Rev Espan Fisiol. 1988;44 (2):179-84
Hertoghe J. The usefulness of evaluating the urinary excretion of triiodothyronine and thyroxine in the urines of 24 hours for diagnosis of thyroid dysfunction and follow-up of thyroid treatment. Conference in Antwerp, Belgium, March 1975
Baisier WV, Hertoghe J, Eeckhaut W. Thyroid insufficiency. Is TSH the only diagnostic tool? J Nutr Env Med. 2000; 10: 105-13
Baisier WV, Hertoghe J, Eeckhaut W. Thyroid insufficiency. Is thyroxine the only valuale drug? J Nutr Env Med. 2001;11:159-166
Hertoghe T. The efficacy of diagnosing borderline and overt hypothyroidism with the laboratory assessment of triiodothyronine and thyroxine excretion in the urines of 24 hours. A comparison with plasma thyroid tests. Optimal hormone therapy in the aging adult. Basic and advanced seminar, San Francisco, February, 2000
Barnes, B MD, Hypothyroidism: The Unsuspected Illness, Harper & Row, 1976
Starr, Mark MD, Hypothyroidism Type 2, Mark Starr Trust, Columbia, MO, 2005
Lowe JC, The Metabolic Treatment of Fibromyalgia, McDowell Publishing Company, 2000
Wilsons Syndrome, American Thyroid Association, Nov 1999 updated May 2005
Mackowiak, et al., A Critical Appraisal of 98.6 Degrees F, the Upper Limit of the Normal Body Temperature, and other Legacies of Carl Reinhold August Wunderlich, JAMA, 1992, 268:1578-80
Pritchard EK, The Linguistic Etiologies of Thyroxine-Resistant Hypothyroidism, Thyroid Science www.thyroidscience.com click on debate.
Differential Diagnosis of Hypothermia, http://pier.acponline.org/physicians/public/d598/tables/d598-tddx.html
Baskin HJ, MD, Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism, Am Assoc Clin Endocrinol, 2002, Rev 2006
Levy EG, Ridgway EC, Wartofsky L, Algorithms for Diagnosis and Management of Thyroid Disorders, www.thyroidtoday.com 2004.
The American Thyroid Association provides links to several hypothyroidism related guidelines: Use of Laboratory Tests in Thyroid Disorders, Treatment Guidelines for Patients with Hyperthyroidism and Hypothyroidism, and Guidelines for Detection of Thyroid Dysfunction.
Levy EG, Hypothyroidism Treatment Failure: Differential Diagnosis, www.thyroidtoday.com 2004.
Vanderpump MPJ, Ahlquist JAO, Franklyn JA, et al., Consensus Statement for Good Practice and Audit Measures in the Management of Hypothyroidism and Hyperthyroidism, BMJ, August 1996
Garber JR, Hennessey JV, Lieberman JA, Morris CM, Talbert RI, Managing the Challenges of Hypothyroidism, Supplement to J of Fam Pract, 2006, www.jponline.com
Kaplan MM, Clinical Perspectives in the Diagnosis of Thyroid Disease, Clin Chem, 1999, 45:8(B) 1377-1383
UK Guidelines for the Use of Thyroid Function Tests, The Association for Clinical Biochemistry, British Thyroid Association, British Thyroid Foundation, 2006, www.british-thyroid-association.org/guidelines.htm
Baisier, WV, Hertoghe, J., Beekhaut, W., Thyroid Insufficiency? Is Thyroxine the Only Valuable Drug?, J Nutr and Environ Med, September 2001, 11(3):159-166
Gaby AR, Sub-Laboratory Hypothyroidism and the Empirical use of Armour Thyroid, Alt Med Rev, 2004, 9(2)
Danzi S and Klein I, Potential Uses of T3 in the Treatment of Human Disease, Clin Cornerstone, 2005, 7(S2): S9-S15
Hertoghe T, Nabet JJ, The Hormone Solution, Harmony Books, 2002