Episode - Graves’ Disease vs. Hashitoxicosis


Graves’ Disease vs. Hashitoxicosis

A small percentage of people with hyperthyroidism are diagnosed with Graves’ disease when they actually have Hashitoxicosis. And while both Graves’ disease and Hashitoxicosis are autoimmune conditions, the approach to manage the hyperthyroidism differs.

During this episode you’ll learn:

  • How Graves’ disease is diagnosed
  • How Hashitoxicosis is diagnosed
  • Whether you can have false negative thyroid antibodies
  • How Hashitoxicosis is treated

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Here is the transcript for this episode:

Welcome back to the Save My Thyroid podcast. This is Dr. Eric Osansky. In this episode, I’m going to discuss how to differentiate between Graves’ Disease and Hashitoxicosis. The reason why I decided to create this episode is because some people are diagnosed with Graves’ Disease when they actually have Hashitoxicosis.

Let’s go ahead and start by discussing how Graves’ Disease is diagnosed. With Graves’, usually you will have a depressed and undetectable TSH (thyroid stimulating hormone). Remember, this is a pituitary hormone, not a thyroid hormone. Speaking of the thyroid hormones, not only do you have the depressed TSH, but you usually have elevated thyroid hormone levels. The two main thyroid hormones are T3 and T4. You usually will have elevated thyroid stimulating immunoglobulins, which is a type of TSH receptor antibody. With Graves’, you will have depressed TSH levels, elevated thyroid hormone levels, and elevated thyroid stimulating immunoglobulins. Some doctors will test the TSH receptor antibodies, or TRAB, instead of the TSI. Either one of those, if you have hyperthyroidism in the presence of elevated thyroid stimulating immunoglobulins or elevated TSH receptor antibodies (TSI is a type of TSH receptor antibody), either way, that is diagnostic of Graves’ disease.

Some doctors will recommend the radioactive iodine uptake test. I do have a separate episode dedicated to discussing this test. Just remember that this isn’t needed to diagnose Graves’ if the TSI or TRAB is positive. If you have elevated antibodies associated with Graves’, then you don’t need to do that uptake test in my opinion. There is an argument that you don’t need to do it even if those are negative. I would tune into that episode where I specifically talk about the radioactive iodine uptake test. I will get into greater detail during that episode.

How is Hashimoto’s diagnosed? Hashimoto’s thyroiditis is characterized by an elevated thyroid stimulating hormone, TSH. As far as the antibodies associated with Hashimoto’s, thyroid peroxidase antibodies or TPO, as well as anti-thyroglobulin antibodies, one or both of these will be elevated. With regards to the thyroid hormones, you will usually get normal or less than optimal thyroid hormone levels. Sometimes overtly depressed thyroid hormone levels. If doctors decide to do the radioactive iodine uptake test, this will typically be negative. With Graves’, the radioactive iodine test will usually be elevated. This test is not recommended when Hashimoto’s is not suspected. It’s usually reserved for those with hyperthyroidism, and they are trying to confirm or rule out Graves’.

It’s also worth mentioning that people could have all three of those antibodies I mentioned. They could have the Graves ‘antibodies, TPO, and/or anti-thyroglobulin antibodies. It is common for people to have two or three of these antibodies.

How is Hashitoxicosis diagnosed? You will have depressed thyroid stimulating hormone, low TSH. Elevated thyroid hormone levels, so elevated T3 or T4. Elevated thyroid peroxidase and/or thyroglobulin antibodies. Then normal thyroid stimulating immunoglobulins, TSI. This is also the case with Hashimoto’s. Hashitoxicosis is more in line with Hashimoto’s. With Hashitoxicosis, you also have that negative radioactive iodine uptake test if you decide to do it.

As I mentioned earlier, you can have both the antibodies for Graves’ and Hashimoto’s. A common example is having an elevated TSI as well as elevated TPO antibodies. Another scenario is where someone might have elevated TSI and elevated thyroglobulin antibodies. Then there is a situation where someone might have all three elevated.

In this situation, how can one tell if the person’s hyperthyroidism is related to Graves’ or Hashitoxicosis? Hashitoxicosis is negative TSI. If someone has elevated TSI in the presence of hyperthyroidism, that essentially means the person has Graves’ disease. If someone has hyperthyroidism with the presence of elevated TPO antibodies and/or thyroglobulin antibodies, and the TSI is negative, then that typically means the person has Hashitoxicosis.

One question you might have is can you have false negative antibodies? Graves’ is characterized by elevated TSI, and it is possible for someone to have anegative TSI. Therefore, if someone has hyperthyroidism with a negative TSI, it won’t 100% rule out Graves’. That being said, most people with Graves’ will have that positive TSI or TRAB.

How is Hashitoxicosis treated? First of all, you might be wondering: Is antithyroid medication an option? Like methimazole or PTU. That is commonly given with Graves’. The problem is Hashitoxicosis is more transient, more temporary. Usually, antithyroid medication isn’t recommended. A more likely scenario is a beta blocker being prescribed by the doctor.

What can be done to address the elevated thyroid hormone levels if antithyroid medication isn’t given? One thing to mention is that some beta blockers affect T4 to T3 conversion. One example is Propranolol. Bugleweed is also an option to consider. Like methimazole or PTU, bugleweed has antithyroid properties, but not nearly as potent. That being said, you wouldn’t want to take bugleweed if you’re not hyperthyroid. As I said, with Hashitoxicosis, it is transient, but it is a bit of a catch-22 because you don’t want to have elevated thyroid hormone levels for a prolonged period of time. Even though it’s transient, it could remain elevated for a few weeks, and sometimes longer than that. Bugleweed might be an option to consider in some cases. If someone is taking bugleweed, you would just want to monitor their symptoms, and their blood tests.

Low-dose naltrexone or LDN is also an option to consider. I’m not going to get into details on that here. I mentioned it in an earlier episode. LDN modulates the immune system, so in some cases, this might be a good option. The problem with LDN is it’s hit or miss. If it does work, it could be a good option.

Let’s go ahead and summarize everything. Graves’ is characterized by hyperthyroidism in the presence of TRAB or TSI. If someone has depressed TSH, elevated thyroid hormone levels, and elevated TSI and/or TRAB, then that is diagnostic of Graves’ disease. On the other hand, Hashimoto’s is characterized by an elevated TSH along with elevated TPO and/or anti-thyroglobulin antibodies. Hashitoxicosis is characterized by hyperthyroidism (depressed TSH, elevated thyroid hormone levels), but the difference between this and Graves’ is that it’s characterized by negative TSI or TRAB as well as positive TPO and/or antithyroid globulin antibodies.

Antithyroid medication usually isn’t given for cases of Hashitoxicosis. Beta blockers are more commonly recommended. Other options I mentioned include bugleweed and LDN.

That pretty much does it for this presentation. I hope you now understand the difference between Graves’, Hashimoto’s, and Hashitoxicosis. I look forward to catching you in the next episode.