Treatment of Hyperthyroidism Dr Barry Durrant-Peatfield
The body has a remarkable ability to heal itself, and should be given a chance to do so. The most successful early physicians knew their subject so well that the natural cause, and eventually self-healing of the illness, was often quite predictable. So the Vital Elixir was given just before the patient showed clear signs of getting better, with, of course, miraculous results. This incidentally, is not the same as the placebo effect (often cited as the result of thyroid and adrenal therapy), which occurs for a limited time as a result of strong suggestions by the prescriber or high expectation by the patient. Sometimes, a remarkable and dramatic recovery occurs using eye of newt and toe of frog. This bedevils a balanced judgement of cause and effect.
Sorry, I digress.
So the first approach is an alert and informed assessment of progress, intervening only when necessary. Over-intervention is the curse of modern medicine in almost any illness you can imagine; we should take to heart that sometimes a policy of masterly inactivity is much better for the patient and may even spare his life.
The second line of approach is to relieve symptoms until it is clear that the illness is either going to resolve itself in time or will recall sterner measures. There are two medical weapons in most common use. First, simply anxiolytics. These are basically tranquillisers, and are acceptable for a limited time where the degree of over activity causes nervous tremor, worry, panic and palpitations.
The old fashioned and much derided Valium has a use here not a large dose, say 5 mgs twice or three times a day can make life bearable. Along with this, or possibly instead beta blockers may be used. These are a group of compounds which prevent high levels of nervous activity reaching the tissues, and have a general calming effect on anxiety, nervous shaking and rapid pulse, in addition to their other therapeutic effects like reducing blood pressure, slowing down heart action (helping angina) and preventing migraines. The one most widely used is Propranalol, often 10 to 40 mgs 2 or 3 times a day according to need. Even with extensive use, there are very few either short term or long term side effects, although asthma is sometimes a problem.
Many doctors have found that a combination of an anxiolytic and a beta-blocker, in really small doses, works better than high doses of either by themselves and may control mild hyperthyroidism for extended periods of time.
When things are getting tougher, the next approach is the use of a chemical block on the production within the thyroid of thyroxine, which prevents the iodine molecules from attaching themselves normally to the thyronine molecule. Two preparations have been in use for years; the commonest is Carbimazole (usually in multiples of 5 mgs) and the other is Propyl-thiouracil (20 mgs). They are both widely used as a bulwark against invasive surgical or medical attack, as I will discuss in a moment.
There are of course, difficulties; they have been found to cause problems with the growth of white blood cells, suddenly and unexpectedly, and the immune system may be so compromised that a major or minor infection may suddenly appear. Sometimes, of course, the patient is simply intolerant of the medication and becomes ill.
A regular daily dose is chosen; rapidly, the amount of thyroid hormone production starts to fall and the circulation of thyroid hormones starts to decline. The trick, of course, is to ensure the dose is neither too much, nor too little, remembering that thyroid production and thyroid hormone requirement may vary quite a lot. If this isnt born in mind, the result would be that the patient may be out of balance, either over or under active. Most physicians fall back upon the blood test to adjust dosage, but I think it is tiresome to have repeated tests, when the patient who after all, knows how they fell better than anybody may often have a much better idea of their requirements than any blood tests. I have always taught my patients to check their pulse rate once or twice a day and their resting temperature; and to make an overall assessment as to whether they fell well or not. If too much of the medicine is given, the thyroid activity will be low and the patient will feel tired, cold and sluggish; the pulse may be low, say 60 bpm; the resting temperature below 36.6 degrees centigrade or 97.8 degrees Fahrenheit. (Of this resting temperature, more anon). The patient should, in my view, with ordinary common sense, then adjust the dose downwards, (or have a day or so off) until things have put themselves right. And, of course, vice versa.
This treatment may be used for an extended time, certainly a year or so so long as the self-monitoring and the advice from an understanding doctor or health care practitioner provide for virtual normality. Most commonly, the over active state will, with ups and downs, tend to correct itself; and the patient may find in time the medication becomes unnecessary. A life event or illness may, however, start it all over again, but the patient by now will recognise the symptoms and be able to deal with them. Another common sequel however, is that having normalised for a while, the thyroid activity may start running below normal. This, as we noted before, occurs with Hashimotos disease. The management problem is that this running down may be slow and insidious the loss of energy and well being, the weight gain, may go more or less unnoticed, may be put down to age, over-work, worry, or bad eating, before it becomes obvious that all is not well. Informed patients will alert themselves to this and seek advice. This may or may not be helpful, and patients may have to take matters into their own hands, using available natural thyroid support, not requiring a prescription.
Popular in some quarters is the block and replace approach to treatment. A dose of Carbimozole (Neomercazole) or Propyl-thiouracil is chosen to be deliberately in excess of the actual requirements enough more or less to shut the whole thing down. Then, thyroxine is added to bring it all back to normal. Yes I know what youre thinking. However, the idea is to shut the thyroid down so thoroughly that it is sufficiently shocked by it all not to relapse when the anti-thyroid treatment is withdrawn. It is claimed that control is smoother, and there is a lower relapse rate. All I can say is that it may work like this way sometimes, but it is difficult to be convinced.
What should be the final solution is, in my view, all too rapidly turned to by doctors and surgeons, who may consider their solution the treatment of choice right from the start. It has the merit of usually having an immediate effect, but may bring in its train other problems, and simply exchange one therapeutic master for another, with no hope of a normal thyroid function without continuous and long-term medication. This final solution is thyroid ablation, which means the thyroid is knocked out finally and forever.
Two approaches are chosen; the first is radioactive iodine. Here the iodine is given to the patient as a drink. The radioactive iodine concentrates in the thyroid tissue and nukes it. The second is surgery, where a proportion of thyroid tissue is removed. The problem with these two solutions lies in their permanence; they cannot be undone, and getting it right that is nuking or removing the right amount, can only be a matter of guess work. More often than not, the amount destroyed or removed is not right to begin with; furthermore, it obviously cannot allow for changes in thyroid function, which will occur within the passage of time.
With radioactive iodine ablation there is the merit of simplicity. A solution is prepared of the radioactive isotope of iodine, which is swallowed in one draught. The thyroid uses iodine as its main raw material, and so this radioactive form concentrates in the colloid (hormone forming) tissue in the thyroid gland. (Of course, it goes elsewhere in the body, especially the breast, but you may not be told this). We all know that radioactivity destroys cell and Chernobyl showed us how terrible its uncontrolled effects are. Radioactive iodine concentrates itself in the cells and this radioactivity destroys them. The severity of cellular damage depends, of course, on how much is initially given. This amount is calculated by body weight and the presumed severity of the over activity of the thyroid forming cells. You hope it is about rightYou have undergone all the blood tests after all. And we know blood tests are wonderful and rightOr do we?
There are 3 possible scenarios. One is that the calculation is right it does happen. The amount of thyroid tissue left is just right to produce the right level of hormones in the blood stream. (Of course, the cells may later partly recover, and then it may have to be done all over again, or further damage and loss of function may occur and the thyroid as a whole may become under active).
The second scenario is that the patient continues to have an over active thyroid in spite of treatment, and a further dose of radioactive iodine or doses may have to be given at once. In this circumstance, getting it right becomes more and more unlikely.
The third scenario is a good deal more common. Overkill becomes evident in a few days, and thyroid hormone in the blood stream falls pretty quickly. Very soon, thyroid replacement (usually thyroxine) becomes necessary. So long as the physician is convinced that this is what has happened admits it, in spite of blood tests, which may or may not confirm the situation and prescribes thyroxine, the resulting hypothyroidism can be sorted out. However, as we shall see later, diagnosis is most likely to be based on blood levels, and not on what the patient is saying. So the hapless patient, bewildered by this perfect high-tech wonder treatment, repeatedly assured how much better they must be, but feeling more or less terrible, exchanged one sort of pill for another, this time for the rest of his or her life.
As I have found with many hundreds of patients, it may now be very difficult to get the balance of replacement therapy right, since for reasons not entirely clear, problems arise with the uptake of the synthetic thyroxine (we know the other thyroid hormones will assuredly not be given) and the conversion T4 to T3 doesnt work as it should, and tissue uptake doesnt take place as it should. It would seem logical, having wrecked thyroid function, that if replacement is required it should be provided as close to natural thyroid hormone as possible.
What seems to happen, however, is that our unfortunate patient, having repeated blood tests finds blood levels swinging about from one extreme to another, as the physician constantly tries to get it right by altering the thyroxine doses. The patient, of course, never feels really well, sometimes ever again.
The second ablative approach we saw is thyroid surgery. Let it be said at once that growths or cysts in the thyroid must be treated by surgical removal or a draining procedure, and a much-enlarged thyroid which interferes with breathing or swallowing leaves no option. But partial thyroidectomy to reduce the amount of thyroid hormone forming tissue is a popular, if in some eyes, barbaric procedure. It is popular with surgeons, if only because, their job done, they may then refer the patient back to the physician for subsequent management.
My view is that as a procedure, it should be the last resort only; and not as is so often and regrettably the case, almost the first option. Apart from all the normal objections to surgery, and a lasting reminder from the scar that one has had ones throat cut, the objection has to be the same as with nuking; however, can one make a good enough guess to get it right? Well, usually it isnt possible. Too little means the surgery may have to be done again or suppressant drugs continued with; too much and one falls back on thyroxine replacement. Sometimes, the abused thyroid tissue may recover some function, so that the result of an over enthusiastic surgical removal may, in time, largely correct itself. But many patients, who have passed through my surgery doors, have found themselves under active sooner or later. Once again, the patient is obliged to join the seesaw of more or less replacement therapy ever after, being told that they are perfectly well whatever they say since the blood tests show they are.
Inevitably, I have seen many patients who are hypothyroid in consequence of this treatment. They are told that thyroxine will solve all their problems, resulting in now being hypothyroid. Sometimes, sometimes, it does. But it doesnt do any such thing for a very large number of people. The thyroid produces T4, T3, T2, T1 and calcitonin (and possibly another hormone suspected by Broda Barnes) this is how it works. Perhaps someone can tell me how one of the hormones, a synthetic precursor hormone, can do as well as the natural product. Well, largely I find it cant, and doesnt.
I find many people never recapture their original health, in spite of the constant adjustment of dose; and more over, they often turn out to be suffering from symptoms and signs of low adrenal function. Getting them right can be very difficult but a combination of adrenal support, often natural, together with thyroid support, can go a very long way to restoring normal health.