Hashimoto's Thyroiditis

Dr. Weyrich's Naturopathic Functional Medicine Notebook

Overview

Hashimoto's thyroiditis is an autoimmune condition in which the cells of the thyroid are destroyed. Initially the destruction of the thyroid cells causes a release of larger than normal amounts of thyroid hormone, resulting in transient acute hyperthyroidism. As destruction of the thyroid cells continues, eventually too few cells will remain to produce normal amounts of thyroid hormone and the patient will develop a hypothyroid state.

Hashimoto's thyroiditis is associated with other autoimmune conditions, such as:

• Adrenal insufficiency (Schmidt's syndrome)
• Inflammatory bowel disease
• Celiac disease
• Pernicious anemia
• Diabetes Mellitus type I
• Graves disease

Signs and Symptoms

• Chronic hypothyroid signs/symptoms: fatigue, weakness, cold intolerance, decreased memory, constipation, muscle and joint pain, hoarseness, weight gain, dry skin and sparse hair, depression, carpal tunnel syndrome, decreased sweating, swollen tongue, eyes, hands and feet, burning, prickling, itching, or tingling sensations, and hearing impairment. Slow heart rate, decreased pulse pressure, low body temperature, delayed relaxation of deep tendon reflexes.
• Acute hyperthyroid signs/symptoms: Nervousness, shortness of breath, increased sweating and heat intolerance, rapid heart rate, palpitations, fatigue, weakness, weight loss despite increased appetite, tremors, atrial fibrillation, loss of bone density, bulging eyes (exophthalmos).
• Physical Exam: Thyroid gland is usually non-tender, diffusely enlarged with fine nodularity, possibly asymmetrically.

Etiology

The exact cause of the autoimmune condition is unknown, but leaky gut syndrome, dysbiosis, and food allergies are thought to play an important role both in initiating and maintaining the autoimmune process.

Diagnosis

• Hashimoto's thyroiditis may present as either an acute hyperthyroid or chronic hypothyroid condition in the standard thyroid screening panel (TSH, free T4).
• Elevated antithyroperoxidase levels (95%).
• Elevated antithyroglobulin antibodies (60%).
• Thyroid gland nodularities upon palpation merit further evaluation (to rule out concomitant cancer) with ultrasound or fine needle biopsy, especially if isolated or unilateral, or patient has history of head/neck radiation exposure.
• Follow-up labs for associated conditions:
  • CBC (anemia).
  • Lipid panel (elevated cholesterol).
  • Chem Panel (elevated CPK, LDH, AST, Hyponatremia).
  • IgA antiendomysial antibodies and IgA tissue transglutaminase (Celiac).
  • Adrenal Stress Index (adrenal insufficiency).
  • Intestinal Permeability Test (leaky gut).
  • Food Allergy Test (autoimmune triggers).
  • Organic Acid Test (gut dysbiosis).

Differential Diagnosis

• With hyperthyroid symptoms:
  • Graves disease: Depressed TSH and elevated T4.
  • Pituitary tumor: Elevated TSH and elevated T4.
  • Pheochromocytoma: Elevated 24-hour urine VMA, catecholamines, and metanephrine.
  • Toxic multi-nodular goiter: (Iodine deprivation followed by repletion).
• With hypothyroid symptoms:
  • Iodine-deficient goiter.
  • Drug-induced: Lithium, amiodarone, propylthiouracil, methimazole, phenylbutazone, sulfonamides, interferon-alpha, iodine, aminosalicylic acid, aminoglutethimide.
  • Genetic.
  • Ablation of thyroid gland.
  • Subacute thyroiditis: Elevated Erythrocyte Sedimentation Rate (ESR) and low antithyroid antibody titer.
  • Pregnancy or post-partum.

Treatment

• Treat adrenal insufficiency first, if present (supplementing T4 or T3 in the presence of adrenal insufficiency is contraindicated).
• Hormone replacement therapy: Start with 1.6 mcg/kg/d levothyroxine (T4, Synthroid, Levothyroid) and titrate up 25 mcg/d every 4-6 weeks until TSH is normalized. Some patients get better results with a T4/T3 blend from a compounding pharmacy). Drug interactions with thyroid HRT requiring dosage adjustments: oral anticoagulants, insulin, oral hypoglycemics, estrogens and OCP, cholestyramine, iron and calcium supplements. Start with 33% lower doses in the elderly.
• Gluten-free diet if Celiac is a comorbidity.
• Treat dyslipidemia (cholesterol imbalance) if present.
• Treat dysbiosis if present.
• Heal the leaky gut if present.
• Identify and avoid problem foods.

ICD-9 Codes

ICD9-Code	Description	Comments
245.0	Acute thyroiditis
245.1	Subacute thyroiditis
245.2	Chronic thyroiditis

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References

Unless specifically noted above, references used in the construction of this web page include the following:

[FDM] Lecture notes from Functional Medicine University.

[SCNM] Lecture notes from Southwest College of Naturopathic Medicine.

[UT] Lecture notes from the University of Tennessee graduate programs in Chemistry and Biochemistry.

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