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Thyroid (Expert Forum)
I'm full of questions: Graves, RAI, Testing
Answered by
Mark Lupo, M.D. - Thyroid Nodules, Thyroid Cancer, hyperthyroidism, hypothyroidism, Thyroid Ultrasound
Thyroid & Endocrine Center of Florida
Sarasota - FL
Questions in the Thyroid forum are answered by Dr. Mark Lupo. Topics covered include goiter, graves disease, Hashimoto's thyroiditis, hyperthyroid, hypothyroid, thyroid cancers, thyroiditis, and thyroid stimulating hormone (TSH).
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I'm full of questions: Graves, RAI, Testing
by NURSELPN, Sep 06, 2005 12:00AM
I've got quite a few questions. Even though I have been a nurse for quite some time this is a little deep for me. I had treatment for Graves disease with RAI this past Feb. My family physican is still trying to get my Free T3, Free T4, & TSH within normal limits. It has been in hypo range since May I'm currently up to 150mg of Armour & my last TSH was significantly improved but remains elevated. I asked him today how long does the radition keep ablating cells & will I always be considered to have Grave's disease? Since May I also have been suffering with Graves eye disease. He really didn't have an answer for me. In fact he said that was a good question. Not really the answer I wanted. Also I have never had thyroid antiboties done should I ask him about this too or is this an afterthought now. Does B-12 definiency have anything to do with thyroid or endrocrine problems. My B-12 was 89 & is now only 324 after 3 mos of injections, first weekly, now biweekly. I would really appreciate it if anyone could share their knowledge. Thanks.
Doctor's Answer
by Mark Lupo, M.D., Sep 07, 2005 12:00AM
, Sep 07, 2005 12:00AM
The RAI effective time is up to 6 months, so in most cases the destruction of thyroid cells is complete by now. You will always have "graves" but the hyperthyroidism due to graves is now cured and you are dependent on replacement thyroid meds for "post-ablation hypothyroidism." Armour should be titrated to keep the TSH around 1 - changing the dose every 6-8 weeks as appropriate. Some armour pts do better with bid (2x/day) dosing - ie, 75mg in am and again at 2-3pm in your case -- this tends to minimize over stimulation in the am and help with afternoon fatigue issues.
The eye disease is more concerning - this is the reason to remember that you will always have Graves - the immune system that attacked and stimulated the thyroid can cause inflammation in the orbit (eye-socket) causing the eye to protrude, dryness, increased tears, double vision, and in some cases vision loss. This sometimes gets worse after RAI but in most cases will quiet down within one year as thyroid levels are stabilized and the immune system calms down as the thyroid is destroyed by RAI. Prednisone is used to decrease inflammation if necessary - some severe cases need external radiation or surgery. Most patients need re-wetting drops, elevate head of bed, lacrilube at night to protect sclera from drying out, wear sunglasses and stop smoking (if you smoke).
Antibodies are a bit of an afterthought - may be interesting to get TSH-receptor antibodies (such as TSI and TBII) as these are more specific to Graves and if the %activity (this is the way these are measured) is really high then it may give us insight into the immune activity against the eyes. Also TPO and Tg antibodies may help.
The low b-12 is likely another auto-immune disease called pernicious anemia. This can be documented by measuring antibodies against Parietal Cell and Intrinsic Factor.
It is essential to have local evaluation by your physician and particularly with an eye doc familiar with graves.
Good luck - ML, MD
The eye disease is more concerning - this is the reason to remember that you will always have Graves - the immune system that attacked and stimulated the thyroid can cause inflammation in the orbit (eye-socket) causing the eye to protrude, dryness, increased tears, double vision, and in some cases vision loss. This sometimes gets worse after RAI but in most cases will quiet down within one year as thyroid levels are stabilized and the immune system calms down as the thyroid is destroyed by RAI. Prednisone is used to decrease inflammation if necessary - some severe cases need external radiation or surgery. Most patients need re-wetting drops, elevate head of bed, lacrilube at night to protect sclera from drying out, wear sunglasses and stop smoking (if you smoke).
Antibodies are a bit of an afterthought - may be interesting to get TSH-receptor antibodies (such as TSI and TBII) as these are more specific to Graves and if the %activity (this is the way these are measured) is really high then it may give us insight into the immune activity against the eyes. Also TPO and Tg antibodies may help.
The low b-12 is likely another auto-immune disease called pernicious anemia. This can be documented by measuring antibodies against Parietal Cell and Intrinsic Factor.
It is essential to have local evaluation by your physician and particularly with an eye doc familiar with graves.
Good luck - ML, MD
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