EPISODE 2
Conventional Symptom Management for Hyperthyroidism & Graves’ Disease
Although some people with hyperthyroidism want to do everything they can to avoid antithyroid medication, the truth is that sometimes medication is necessary to manage the hyperthyroid symptoms. Methimazole is the most common antithyroid medication prescribed, although some people take PTU. Others will be prescribed beta blockers such as Propranolol or Atenolol, while some people will take both antithyroid meds and beta blockers.
Some people have no problem taking medication to manage their symptoms, but they experience side effects. While natural symptom management options for hyperthyroidism will be discussed in the next episode, there are other hyperthyroid symptom management options besides antithyroid medication and beta blockers, which will be discussed during this episode.
During this episode you’ll learn:
- The different types of antithyroid medications
- The different types of beta blockers, and the reason why they are sometimes recommended for hyperthyroid patients
- Common side effects of antithyroid medication and beta blockers
- Whether low dose naltrexone (LDN) can be an option to manage the symptoms of Graves’ disease
- How cholestyramine can be an alternative to antithyroid medication
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Here is the transcript for this episode:
Welcome to the Save My Thyroid podcast. Over the next two episodes, I will be discussing both conventional and natural symptom management tips for those with hyperthyroidism. In this episode, I will be focusing on conventional symptom management options, including anti-thyroid medication, beta blockers, and a few other methods. In the next episode, I will focus on natural symptom management options, including taking herbs such as bugleweed and motherwort and other natural agents such as L-Carnitine.
You might wonder why I am discussing symptom management in the first place. After all, the goal is to save your thyroid. Whether you are taking anti-thyroid medication or bugleweed, these are just masking the symptoms, correct?
Yes, that is true, but you also want to be safe while addressing the cause of the problem. If a patient of mine chooses to take anti-thyroid medication or a beta blocker, I’m fine with that. If someone is going to take a natural treatment approach completely and just take bugleweed or motherwort, of course, that’s fine, too. But I want you to be safe while addressing the cause of your condition. That is why we’re dedicating some episodes to symptom management.
Let’s dive into conventional symptom management tips for hyperthyroidism. We will start off by talking about anti-thyroid medication. This includes methimazole, brand name Tapazole, PTU, carbimazole. Typically, carbimazole is used in other countries. It converts into methimazole. Other countries use methimazole and PTU. Anti-thyroid medication blocks the formation of thyroid hormone.
The dosage varies with the person of course. Some people might start with a high dose such as 40-60mg. Other people will start out sometimes with a lower dose. Frequently, it will be a higher dose. Some people start with only 5-10 mg. What happens is sometimes a person will start with a real high dose such as 40mg, and they will become hypo. The doctor might panic and reduce the dosage dramatically to 5mg. It varies.
Methimazole works by inhibiting the enzyme thyroid peroxidase. This plays an important role in thyroid hormone formation. PTU is also a popular option although not nearly as popular as methimazole because it puts more stress on the liver. PTU not only inhibits the thyroid peroxidase enzyme but also inhibits the enzyme deiodinase, which is involved in the conversion of T4 into T3. The PTU dosage varies between typically 100mg and 300mg per day.
Carbimazole is more commonly recommended in other countries. It converts into methimazole. The dosage can range from 5mg-40mg. Of course, 40mg would be for more severe cases.
As far as anti-thyroid medication side effects, there could be numerous side effects. Unfortunately, it is common to have side effects when taking anti-thyroid medication. A number of people experience elevated liver enzymes. Sometimes it will cause depression of white blood cells. Some people experience skin rashes, itching, nausea, joint and muscle pain, dizziness. Some people experience hair loss. That can vary. Some people can experience hair loss by being hyperthyroid. When taking anti-thyroid medication, the hair loss might improve. Some people don’t experience hair loss until they take the anti-thyroid medication. Headaches are a potential symptom of taking anti-thyroid medication.
Let’s talk about beta blockers. They mainly help with the cardiovascular symptoms associated with hyperthyroidism, although some beta blockers can also inhibit the conversion of T4 to T3. Beta blockers work by binding to beta adrenergic receptors. Beta adrenergic receptors bind both epinephrine and norepinephrine, which in turn play a role in myocardial metabolism, heart rate, and systolic and diastolic function. While healthy levels of epinephrine and norepinephrine are important, in hyperthyroidism, these levels are increased, which is what causes the elevation in heart rate and sometimes blood pressure. Not everybody experiences an increase in blood pressure. When I dealt with Graves’ Disease, my blood pressure was fine. But I definitely experienced an elevation in my resting heart rate, which is how I first learned I had hyperthyroidism.
Most beta blockers reduce resting heart rate by approximately 25-30 beats per minute, which can make a big difference, especially if someone has a resting heat rate in triple heart digits. With propranolol, doses can vary from 40-160mg per day. It is the most common beta blocker I see given to people with hyperthyroidism. Propranolol is usually taken in divided doses. An example would be 40mg every six hours.
As far as other types of beta blockers besides propranolol, there is atenolol, metoprolol, butanol, timolol. The beta blockers that can block the conversion of T4 to T3 include propranolol, atenolol, metoprolol. There is also one called alprenolol.
Why are beta blockers recommended to some hyperthyroid patients? Isn’t taking anti-thyroid medication enough since anti-thyroid medication lowers thyroid hormone levels? You figure that most people would just need to take anti-thyroid medication.
One scenario is when someone has a very high resting heart rate, which again, the anti-thyroid medication can help, but also blood pressure. Sometimes if it’s caused by the elevation in thyroid hormone, if someone had high blood pressure prior to developing hyperthyroidism, then one might conclude that it’s not being caused by the elevated thyroid hormone levels. A beta blocker might be given in this case. Sometimes it will be given regardless especially if the resting heart rate is extremely high, then they might be given both anti-thyroid medication and beta blockers.
Another scenario is when someone is unable to tolerate anti-thyroid medication. Maybe the person was given methimazole, and they didn’t do well on it. They experienced some of the side effects I mentioned earlier, so they were told to take a beta blocker. Sometimes in this situation, a person might do okay on a different type of anti-thyroid medication. If someone doesn’t do well on methimazole, they might do okay with PTU. But it’s a flip of the coin. Many of those people will take PTU, and they won’t do well. It might be worth giving a tryin some situations.
If someone is unable to tolerate any anti-thyroid medication, typically the endocrinologist will be talking to the patient about radioactive iodine or thyroid surgery if they haven’t done so already. If the person doesn’t want to receive radioactive iodine or thyroid surgery, then the endocrinologist may say, “Okay, let’s just take a beta blocker.”
Scenario #3 is when someone is planning on receiving radioactive iodine, they will typically be given a beta blocker.
Also, when someone has subacute thyroiditis, that is usually caused by avirus, sometimes a bacteria. This is a transient or temporary state of hyperthyroidism. Most doctors, if they diagnose someone with subacute thyroiditis, they won’t want to give anti-thyroid medication not only because it’s temporary but also because it’s quite common for people with subacute thyroiditis to eventually become hypothyroid. The last thing they want is for someone to be on anti-thyroid medication, and then a month or two down the road, they become hypothyroid. At the same time, they are taking anti-thyroid medication. They might give a beta blocker instead.
As for side effects of beta blockers, some of the common side effects include drowsiness, fatigue, dizziness, and weakness. There are other less common side effects, which include dry mouth, dry eyes, dry skin, diarrhea, nausea, vomiting, cold hands and feet. Some people have also reported decreased sex drives, shortness of breath as well as sleep disturbances.
Also, it’s important to mention that certain beta blockers can inhibit the production of coenzyme Q10 or CoQ10. This includes propranolol and metoprolol. If you are taking one of these beta blockers, you might want to consider supplementing with CoQ10. It has many important functions, but it’s probably most well-known for its role in mitochondrial health. Mitochondria are the energy powerhouses in our cells. As a result, if anyone is taking propranolol or metoprolol, you might want to consider taking 100-200mg of CoQ10 in the form of ubiquinone. Or you could take ubiquinol. If you take that, you won’t need as high of a dose.
Now I’d like to discuss low-dose naltrexone or LDN. Naltrexone is an FDA-approved medication. In 1985, Dr. Bernard Bihari realized it can modulate the immune system. LDN can benefit autoimmunity as well as other health conditions such as cancer. As far as the LDN and research, research shows that LDN might act as an anti-inflammatory agent and can also help with chronic pain. LDN can also help with those dealing with the pain associated with fibromyalgia and gastrointestinal disorders such as SIBO (small intestinal bacterial overgrowth). It is commonly recommended as a prokinetic for people with SIBO. LDN might also help some people with active Crohn’s disease.
It’s also worth mentioning that if low-dose naltrexone is effective in someone with hyperthyroidism that is taking anti-thyroid medication, then the person might not need to take anti-thyroidmedication any longer, or maybe they will need to take a lower dose of it because what it’s doing is calming down the immune system. This is specifically for Graves’ Disease. In the case of Graves’ Disease, which is an autoimmune condition, if LDN works, it doesn’t always work, but if it does work, and calms down the immune system, the person might not need to take anti-thyroid medication, or at least require a lower dosage.
I mentioned earlier that not everyone does well when taking anti-thyroid medication, so this could be a great benefit for someone who is allergic to methimazole or has certain side effects or elevated liver enzymes or a decreased white blood cell count. Or maybe they switched to PTU and had similar side effects. LDN is something that is worth considering.
In some cases, LDN might help someone to avoid radioactive iodine and thyroid surgery who is unable to take anti-thyroid medication. You might be wondering if there are risks in taking LDN. One risk is that LDN doesn’t do anything to address the cause of the problem. Of course, neither does anti-thyroid medication.
Another risk is that LDN doesn’t always work. Methimazole, PTU, and anti-thyroid medication almost always work. The problem is that side effects are common, but they usually do their job. LDN is hit or miss.
It’s important to mention that LDN can have a negative side effecton sleep. Most people take LDN at night, and sometimes it can cause sleep disturbances. Many times, this can be helped by taking LDN during the day, earlier in the day.
How about getting a prescription for LDN? You do need a prescription. You can’t order it online on your own or go into a health food store. It is a medication. It is just one that has fewer side effects, especially when compared to anti-thyroid medication. Many medical doctors unfortunately are not open to prescribing LDN although more are open now than a number of years ago. It’s worth asking your primary care doctor.
What you might want to do if you can’t get a prescription from your primary care doctor is perhaps you can contact a local pharmacist. Even local pharmacists like a CVS or Walgreens or a mom-and-pop pharmacist. See if they know doctors who prescribe LDN. The pharmacists are the ones who fill the prescriptions. You would think that they would know who is writing the prescriptions. They could refer you to one or more doctors.
But there are other options. You might want to check out the website LDNScience.org. You could do a search for doctors in your area who might prescribe LDN.
Another option is to set up a remote consultation with a doctor who is willing to prescribe LDN. There is LDNDirect.com and LDNDoctor.com. They are both websites you can visit. You pay a fee to speak with a practitioner. They will almost always write a prescription for LDN.
Next, I want to talk about cholestyramine. LDN is something to consider if you are unable to tolerate anti-thyroid medication although I will also be talking about in the next episode natural agents such as bugleweed. To me, the bugleweed might be a better option before resorting to other types of medications. But bugleweed doesn’t work for everyone. If someone is taking anti-thyroid medication and they are experiencing side effects, and they take the bugleweed and that doesn’t work, then LDN is something to consider taking.
There is also cholestyramine. Cholestyramine is actually a bile acid sequestrant, so it’s not primarily used for hyperthyroidism. What it does is binds to certain components of bile, which in turn disrupts the enterohepatic circulation of bile acids. Bile acid sequestrants are commonly used for lowering cholesterol or for the treatment of chronic diarrhea, especially when the cause is due to bile acid malabsorption. Cholestyramine also could be used in cases of toxic mold to bind to mycotoxins. Cholestyramine also has been shown to interfere with enterohepatic circulation of endogenous thyroid hormones, which is increased in hyperthyroidism. Simply put, it binds to thyroid hormones, and then the hormones are excreted by the body.
In most cases, a dosage of cholestyramine used in studies was 4g, 3x per day. As far as side effects of cholestyramine, the main side effects include constipation and abdominal discomfort. Although I am not aware of evidence that shows that cholestyramine causes significant liver damage, mild elevation in the liver enzymes sometimes will occur.
As far as getting a prescription for cholestyramine, you do need a prescription from a medical doctor, just like with anti-thyroid medication, beta blockers, or LDN. So it might be challenging getting a prescription for cholestyramine. I can’t say I’ve had a lot of patients get this prescription. Just a couple up until this point. What they did was spoke with a doctor and showed the doctor the research.
There is research on my website related to Cholestyramine, as I have written an article on this. It’s probably not a good idea to show them my article because they would probably not want to know that you are getting that advice from me. If you show them the journal articles that discuss cholestyramine for hyperthyroidism, they would probably be more open to writing a prescription. Not that you can’t tell them that you are looking to take a natural approach. That of course is up to you. But they usually don’t want to take orders from other doctors. Most endocrinologists, assuming you are working with an endocrinologist. Make sure you let them know that the research is from published journal articles.
That’s all I want to discuss with regards to conventional symptom management. Most people will start off by taking anti-thyroid medication. For those who choose to take medication, as of course some people won’t, and we will talk more about natural options in the next episode. Usually, antithyroid medication will be the first option. Some people will be given beta blockers. If someone doesn’t do well on the antithyroid medication, they will be put on the beta blocker. The thing with that is some beta blockers affect conversion of T4 to T3, which is good because it lowers T3. Still, it’s not the same as anti-thyroid medication. Beta blockers are really more for the cardiovascular symptoms.
There are other risks with having elevated thyroid hormone levels such as decreased bone density. LDN can lower thyroid hormone levels indirectly by affecting the immune system. Cholestyramine directly affects the thyroid hormone level. If someone is unable to take anti-thyroid medication, and let’s say the natural agents that we will discuss in the next episode aren’t too effective, they may want to consider taking either LDN or cholestyramine.
Let’s go ahead and summarize what I just discussed. Antithyroid medication is commonly given to lower thyroid hormone levels. Side effects are common, but everything comes down to risk versus benefits.
Beta blockers help with cardiovascular symptoms. However, certain beta blockers can affect the conversion of T4 to T3. Essentially, they are indirectly lowering T3 levels by affecting that conversion process.
Low dose naltrexone and cholestyramine are options to consider for those with hyperthyroidism who can’t tolerate antithyroid medication. I will mention that some people will take LDN and antithyroid medication at the same time because the antithyroid medication will lower the thyroid hormone levels, and they still might take LDN to modulate the immune system. On the other hand, if someone is on antithyroid medication and it’s working fine and they are not having any side effects, then there is really no sense to add cholestyramine. Both LDN and cholestyramine require prescriptions. Everything I just mentioned requires prescriptions.
I’ll be discussing natural agents in the next episode. Thank you so much for tuning in. I look forward to hopefully catching you on the next episode.