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  • Lab interpretation/Counterintuitive treatment?

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    Old 05-19-2013, 08:19 AM   #1
    thobuon
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    Lab interpretation/Counterintuitive treatment?

    Please help with my medical dilemma. I went from hyper to normal without meds, but my doctor put me on antithyroid meds.

    February lab:

    T4, Free (Direct) 2.90 ng/dL (range 0.82-1.77)
    TSH 0.006 uIU/mL (range 0.450-4.500)
    Triiodothyronine, Free, Serum 7.5 pg/mL (2.0-44)

    April lab:

    TSH <0.1 uIL/mL (0.5-4.7)
    Free T4 1.15 nG/dL (0.73-1.95)
    Free T3 3.1 pG/mL (2.3-4.2)
    Thyroglobulin AB 1 iU/mL (<4)
    Thyroid Peroxidase AB 16 iU/mL (<9)

    I was put on 10 mg MMI and propanolol after the April tests, but it seems that my FT4 and FT3 improve on their own (no action between Feb and April labs). I did not see my April test until last week. I asked my doctor why am I on methamizaloe if my FT4 and FT3 are ok. He first diagnosed me with Grave's in February after a thyroid scan and iodine uptake. Then he said that the April test concluded that it is Graves'. But, if my FT4/FT3 are fine, I did not think that meds are necessary. When I asked him that, he said "Progression from Graves' hyperthyroidism to chronic autoimmune thyroiditis and hypothyroidism is well-recognized. Some folks can go from hyper to hypo in a year. You are on a very minimal dose of MMI and before stopping it I would like you to get your labs drawn first. After you draw your labs you can decrease to 5mg in the morning until we get the results back."

    What I did was gave the lab tests as he requested (this past Friday), but I
    decided to stop the MMI starting today. This past week I am experiencing
    persistent lightheadedness and I am concerned that the meds are unnecessary and harmful. I plan to ask him for a referral to an endocrinologist as I want a second opinion. Plus, I am thinking that my doctor is making me hypo.

    I am confused and freaked out. Your advice and help are greatly appreciated.

    Thank you.

     
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    Old 05-19-2013, 01:21 PM   #2
    ladybud
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    Re: Lab interpretation/Counterintuitive treatment?

    Your doc is right in that hyper can go to hypo, especially with your TPO antibodies elevated. In April, your TSH was still too low (hyper) and T3 and 4 normal. I agree you probably do not need the MMI now, but do need to be monitored as to labs going forward, and will probably need to be on thyroid replacement at some point in next year or two. The MMI suppresses the thyroid function of producing the hormones. The propranolol treats the symptoms of tachycardia, anxiety, jitters, etc. I don't think the meds have hurt you, but your hyperthyroidism seems to be correcting on its own and they are probably not needed. Obviously, this needs to be a decision between you and your Dr., whomever you choose to work with, your PCP or an endo.

     
    Old 05-19-2013, 02:16 PM   #3
    thobuon
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    Re: Lab interpretation/Counterintuitive treatment?

    Dear Ladybud,

    Why will I need thyroid replacement? Would stopping MMI prevent that?

    Thank you for your advice. After some thinking, I decided to stay with the MMI but at the 5mg instead of 10mg. This is until after I get the last labs from my GP and meet with him. I neglected to say that in March I had a thyroid ultrasound (normal) and uptake scan (scan and uptake findings, in the clinical settings of hyperthyroidism, are comparable with diffused toxic goiter (Graves disease)). I wonder if the uptake is what compel my doctor to diagnosed me with Graves even though my FT3 and FT4 returned to normal on their own. This is the only reason I can think for his prescription for methimazole.

    I trust my doctor but research on the net show too many are not treating thyroid optimally.

    I really do not know how to proceed except to seek a second opinion.

    Thank you.

     
    Old 05-19-2013, 07:05 PM   #4
    ladybud
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    Re: Lab interpretation/Counterintuitive treatment?

    I think your Dr treated you based on scan and very low TSH. If your antibody levels remain elevated, the antibodies will eventually destroy your thyroid gland and you will become hypothyroid, requiring replacement. This is the natural progression of this disease (Hashimoto's-autoimmune thryoid inflammation with Graves)- hyper initially, then a period of normal (euthyroid) then hypothyroidism. This progression takes place over years typically- Hyper 1-2 years, then eu 1-2 years, then hypo. During this time, treatment is based on the stage you are in, as evidenced by your symptoms and your labs. I think your Dr is doing what is reasonable, but a second opinion may reassure you (or confuse you if there is disagreement). I personally would wait for next labs and see if your Dr takes you off the meds and just monitors you if you are now euthyroid (normal phase).

     
    Old 05-20-2013, 06:35 AM   #5
    thobuon
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    Re: Lab interpretation/Counterintuitive treatment?

    Thank you, ladybud, for your advice. It makes me feel better. It makes sense, too, because I may have been hyper for a while but not diagnosed because of no symptoms, until a couple of months ago. I will wait until the lab results, which is some time this week, and will post backk for your thoughts.

    Thank you for holding my hands. Take care.

     
    Old 05-23-2013, 09:53 AM   #6
    thobuon
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    Re: Lab interpretation/Counterintuitive treatment?

    Hi,

    My labs came back. Here is my thyroid history so far. My doctor says that I have Graves'. He is not consistent in lab orders. What tests should he order each time? I see him next week. What is the next treatment step? I am not sure if I need an endo, but I decided to get an endo opinion. That appointment is a month from now. I plan to continue the methamizole and propanolol, go to the endo, and ask him for labs. Is this reasonable or what is my best option?

    My doctor agreed to decrease my MMI because I was worried about going hypo. According to my doctor, my liver is inflamed. What can I do? Should I worry? Thank you for your help.

    5/17/2013 MMI 5 mg
    5/17/2013 T3 75 ng/dl (90-200 ng/dl)
    FT3 2.5 pg/ml (2.3-4.2 pg/ml)
    T4 6.6 ug/dl (4.4-12.4 ug/dl)
    FT4 1.11 ng/dl (0.73-1.95 ng/dl)
    SGOT (AST) 184 u/l (5-35 u/l)
    SGPT (ALT) 365 u/l (7-56 u/l)
    4/16/2013 MMI 10 mg
    Propanolol 10 mg
    4/10/2013 TSH <0.1 uiu/ml (0.5-4.7 uiu/ml)
    FT3 3.1 pg/ml (2.3-4.2 pg/ml)
    FT4 1.15 ng/dl (0.73-1.95 ng/dl)
    Thyroglobulin AB 1 iu/ml (< 4 iu/ml)
    TPOAB 16 iu/ml (<9 iu/ml)
    SGOT (AST) 23 u/l (5-35 u/l)
    SGPT (ALT) 37 u/l (7-56 u/l)
    3/13/2013 Thyroid ultrasound Normal
    Uptake and scan Diffuse toxic goiter (Graves)
    2/22/2013 TSH 0.006 uiu/ml (0.45-4.5 uiu/ml)
    FT3 7.5 pg/ml (2.0-4.4 pg/ml)
    FT4 2.9 ng/dl (0.82-1.77 ng/dl)
    SGOT (AST) 15 iu/l (0-40 iu/l)
    SGPT (ALT) 12 iu/l (0-32 iu/l)

     
    Old 05-23-2013, 11:34 AM   #7
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    Re: Lab interpretation/Counterintuitive treatment?

    Your liver enzymes went up after starting the MMI, and the drug is probably causing that. In addition, your T3 and T4 levels are near low end of range. Did your Dr not question why your liver enzymes were so high, and notice that they were perfectly normal before you started this drug? Did he not advise you to stop the MMI? You may have gotten your lab results before consulting with him. I would call him TODAY, and see what he says, but in my opinion, the MMI needs to be stopped now, and liver enzymes rechecked in a month when you see the endo or sooner to see if they are coming down at least. Is there any other reason your liver enzymes could be elevated, like exposure to hepatitis? I would report this to FDA on their website as a serious adverse drug reaction if enzymes return to normal and no other explanation for enzyme elevation is found. In the meantime, avoid any alcohol and acetameniphen (Tylenol) as they are hard on liver.

     
    Old 05-23-2013, 01:17 PM   #8
    thobuon
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    Re: Lab interpretation/Counterintuitive treatment?

    Dear ladybud,

    Thank you for your advice. My doctor's response to my labs: "your thyroid is great and you are on the right dose- we will wean it off at our visit. You liver is slightly inflammed- this is commonly seen in the first months of taking this med or can even be related to the graves. We will recheck this at your visit."

    His answer re the inflammed liver: "THis is common with the medicine and the disease- you should not be overly concerned but we will follow these."

    My appointment with him is next week. I suppose that I could stop the MMI and when I see the endo, ask him for a new set of labs to see about the liver. This stopping of the MMI would be against my doctor's advice, though. So, I am hesitant and confused, but concerned. Would continuing the MMI for another month be truly bad? I am currently on 5 mg of MMI, and he did say weaning it off, so it might be a lower dosage. That might help, right?

    Thanks for your hand holding.

     
    Old 05-23-2013, 07:36 PM   #9
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    Re: Lab interpretation/Counterintuitive treatment?

    Since you are seeing him next week and he is checking liver function again and beginning to wean you off, I think that would be ok. One week is not going to make a huge difference, and by the time you see the endo you'll probably be off it, and he can check liver enzymes again. So I would just do what your Dr suggests, then you can decide after you meet the endo who you want to manage this problem. I think you'll be fine. Medicine is not an exact science, and a lot of it are judgment calls. There can be many ways to accomplish the end, so as long as it is reasonable, it's ok. Two different Drs are rarely going to do exactly the same thing to solve a problem.

     
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    Old 05-23-2013, 08:03 PM   #10
    thobuon
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    Re: Lab interpretation/Counterintuitive treatment?

    Dear ladybud,

    I asked my doctor and he said to stop the methimazole. He is fine with me going to an endo. He says that we will check my liver enzymes. From my research, it seems that my doctor is pretty decent. He tries and is open to my questions, suggestions. I just hope that The endo is as receptive and knowledgeable.

    Ladybud, I thank you for helping me through this time of worry and confusion. I will most likely check in again for your advice. Thank you.

     
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