Hyper friend needs help with monitoring - Elaine, Simon, and everybody

[Guest guest]

Thanks Simon. (And Terry - you may be right. The pity is that he's so

highly recommended, by friends I trust, though the friend is hypo and

didn't have to deal with hyperT.) I have a few questions that'll come

later but first an overview for Elaine who may have missed the first

message. I have a friend with subclinical hyperT. Her initials symptoms

were itching and goiter; actually those were her only symptoms. She's

feeling pretty good on the whole. SInce she refused RAI her previous drs.

were content to monitor her yearly. When she went for a second opinion,

her new endo also wanted to do RAI but with her numbers ddin't want her

to go untreated so started her on 20 mg. Tap/day. I have some

reservations about this dr. My friend will try to get hold of the

chemical bloodwork results but apparently her hemoglobin and liver were

only tested during the initial workup. After she was started on Tap he

saw her 2 months later and only did a thyroid panel. Even my most

incompetent endo saw me after 4 weeks on ATDs to do those tests to make

sure I was ok on the ATDs. Also, there's my first question but Simon says

that there may be some method to his madness.

Her TSH started off undetectable and now that she's been on Tap for 4

months it started to move, as the testing shows. Her FT4 was 1.44 in

August, 0.96 in Oct. and is now on the low end of normal.

> 12.17.02 (same ranges)

> TSH 0.1

> FT4 0.89 (0.7-1.48)

> Dr. wants her to increase the Tap to 15 in morning and 10 in evening.

> Yes, increase to 25. She is trying to contact him to find out why since

> logic dictates a reduction might be in order, to say 15 mg./day.

1) Simon says: It doesn't sound too unreasonable from what you have said

so far

(from 20mg daily to 25 mg daily), it seems likely she is still

hyperthyroid, unless there are contary symptoms.

I wonder if this is so even if she has no symptoms. I would hate to see

her go hypo since the T4 is already so low

2) It seems the hyperT is not due to Graves but mildly toxic

multinodular. As far as antibodies go, all she has to work with so far is

this sentence from the letter she was sent with her initial bloodwork in

August. " Antithyroglobulin antibodies and thyroid peroxidase antibodies

were undetectable. " Are these all the antibody tests she needs and do

they conclusively show that there are no Graves antibodies? Should they

be repeated and if so when?

3) Simon says*:I plead ignorance of non-autoimmune thyroid disease, but

diagnosis may affect treatment. RAI if used is normally used

more aggressively against toxic multinodular goiter, and is

presumably less likely to affect the eyes adversely, whereas if

cancer is a possible alternative diagnosis

subtotal-thyroidectomy can be used in place of a normal biopsy.

My question: So, if the antibodies that cause Graves aren't present, the

risk of thyroid eye disease is dramatically reduced. Which is why proper

antibody testing is so important. Still, since she's feeling so well, why

undergo it and have to deal with hypothyroidism?

4) Simon: Also it is likely to affect long term antithyroid drug

treatment, I think Graves' goiter tends to diminish with

treatment, and lead to remission or quite low maintenance doses,

where as not all other causes of hyperthyroidism respond the

same. Meanwhile monitoring fT3 may be desired as T3-toxicosis is

common in these complaints.

My question: What is this based on? Should she have FT3 done every 2

months, less often, at all? My understanding is that the FT3 is more

expensive so she would need some science to back up her request.

Thanks for any input and a happy, healthy, productive new year, Fay

*Sorry Simon. I do have an idea of how you feel about that; as I like to

say, at my wedding 500 people told me that I would always be young, and

there were less than 200 people there.

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