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Thyroid (Expert Forum)
Just Diagnosed - RAI and Stress!?
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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Just Diagnosed - RAI and Stress!?
by Blumer, Jan 06, 2006 12:00AM
I was diagnosed with hyperthyroid and most likely Graves yesterday. My TSH was 0.1, T4 was 19.4 (normal 4.5-12) and T3 was unmeasurable - over 2000 (normal was 230-420). (Still fuzzy on what these even are!!) My main symptoms were extreme shortness of breath with physical exercise and racing heart and daily diarrhea (lovely). I have no family history so this was likely brought on by stress. Looking back, this probably started about 5 months ago? I have a million questions, but the two that are at the forefront now are:
1)Is RAI as dangerous as I have been reading?? My GP made it sound like a quick fix and is sending me to an endocrinologist on Monday to discuss it. I've only been seeing negative posts - does ANYONE recommend it?? I live in Colorado in the States - any suggestions on Drs here?
2)If my stress level is such that it can cause something like this, has anyone found stress-reduction techniques that WORK?! Finding out that I have this has raised my stress level above what it was!!! I'm snapping at people at work and at my parents who are trying to help me. At least now I have something to blame it on!?
Finally, thanks for this - I started reading it last night trying to get info on what's going on with my body and kept hearing myself in other's words. Could be worse, right?!
1)Is RAI as dangerous as I have been reading?? My GP made it sound like a quick fix and is sending me to an endocrinologist on Monday to discuss it. I've only been seeing negative posts - does ANYONE recommend it?? I live in Colorado in the States - any suggestions on Drs here?
2)If my stress level is such that it can cause something like this, has anyone found stress-reduction techniques that WORK?! Finding out that I have this has raised my stress level above what it was!!! I'm snapping at people at work and at my parents who are trying to help me. At least now I have something to blame it on!?
Finally, thanks for this - I started reading it last night trying to get info on what's going on with my body and kept hearing myself in other's words. Could be worse, right?!
Doctor's Answer
by Mark Lupo, M.D., Jan 07, 2006 12:00AM
, Jan 07, 2006 12:00AM
Stress reduction can be helpful as stress can aggravate hyperthyroidism. Read the below - it should help you make decisions about RAI vs other treatments.
There are three ways to treat hyperthyroidism - PTU/Tapazole (anti-thyroid drugs (ATDs)), I-131 treatment (RAI) and surgery.
Usually surgery is a last resort for Graves Disease but is sometimes suggested with over-functioning nodules or with hyperthyroidism in the setting of suspicious nodules.
If you have an over-active (toxic) thyroid nodule, the RAI is preferred over ATDs b/c the ATDs will only work while you are taking them and once stopped you will become hyper-thyroid again due to the toxic nodule. The problem with long-term ATDs is the potential side effects of liver damage, vasculitis and immune system suppression. RAI treatment for an over active nodule directs the radiation to the problem area and decreases the size and function of the nodule(s). The probability of permanent hypothyroidism in this case is roughly 25% depending on the situation -- but I tell patients to expect to become hypo and then if they don't need lifelong thyroid hormone treatment, that's great.
Graves disease can initially be treated with either ATDs or RAI. Graves disease is hyperthyroidism due to an immune system attack stimulating the thyroid to make excessive thyroid hormone. ATDs can be used for 12-18 months and the dose titrated to keep the T4 and T3 in the normal range. Then, if the patient is on a low ATD dose and has normal levels) the medication is stopped - at that point up to 30-50% of patients may stay in remission (ie normal thyroid levels for at least one year). The rate of remission depends on the severity of the hyperthyroidism, the levels of TSH-receptor Antibodies, size of the thyroid and a few other issues (perhaps including smoking status - Graves patients are at particularly high risk if they smoke).
RAI can be used either as the initial treatment of after a trial of ATDs have failed to achieve control or remission. RAI is a single pill taken one time -- it cures Graves Disease 85% of the time after one dose and has very few side effects. The most important side effect is permanent hypothyroidism requiring a daily dose of thyroid hormone replacement for the rest of your life. This is a much easier situation to control however than using ATDs for hyperthyroidism - and without the toxicity to the immune system, liver, and other organ systems that we sometimes encounter with ATDs. There is no increased risk of cancer in Graves patients treated with RAI vs other treatments. There may be some mild nausea or heartburn, but this is transient. In rare cases (< 1%) there may be a painful inflammation of the thyroid after RAI which is sometimes associated with severe hyperthyroidism -- this is transient and can be treated medically. WOMEN WHO MAY BE PREGNANT MAY NOT TAKE RAI AND WOMEN SHOULD NOT BECOME PREGNANT FOR 6 MONTHS AFTER RAI.
An important issue to consider with Graves and RAI is EYE disease. If there is any evidence of Graves eye disease (double vision, eye-aching, swelling, tearing, dryness, inflammation, "bug eyed look", etc) then steroids need to be used in conjunction with the RAI to avoid an increse in the eye disease -- RAI when used in this way is an excellent way to treat the graves hyperthyroidism and the graves eye disease. If there is severe eye disease - this must be aggressively controlled before RAI is considered. SMOKING significantly increases the risk of eye disease.
In summary, RAI works very well in most patients - if after 6 months the T4/T3 levels are still high then the dose may need to be repeated. The hypothyroidism after RAI may occur as soon as 6 weeks - therefore I recommend testing T4 and T3 levels every 6 weeks after RAI to document a trend and intervene early if hypothyroidism develops. The TSH level may take several months to normalize and initially is NOT a reliable way to follow treatment of hyperthyroidism.
The question of weight usually comes up about now -- hyperthyroidism falsely elevates metabolic rate so a patient sometimes can eat a significant amount and still lose weight. Once the hyperthyroidism is corrected the metabolic rate (ie, daily calorie burn at rest) goes back to what it should be for you (as we all know, this rate does not seem to be created equal from person to person!). Therefore it is essential to decrease calorie intake as you are treated and a 10-20 pound weight gain is sometimes encountered -- no matter how the hyperthyroidism is treated.
There are three ways to treat hyperthyroidism - PTU/Tapazole (anti-thyroid drugs (ATDs)), I-131 treatment (RAI) and surgery.
Usually surgery is a last resort for Graves Disease but is sometimes suggested with over-functioning nodules or with hyperthyroidism in the setting of suspicious nodules.
If you have an over-active (toxic) thyroid nodule, the RAI is preferred over ATDs b/c the ATDs will only work while you are taking them and once stopped you will become hyper-thyroid again due to the toxic nodule. The problem with long-term ATDs is the potential side effects of liver damage, vasculitis and immune system suppression. RAI treatment for an over active nodule directs the radiation to the problem area and decreases the size and function of the nodule(s). The probability of permanent hypothyroidism in this case is roughly 25% depending on the situation -- but I tell patients to expect to become hypo and then if they don't need lifelong thyroid hormone treatment, that's great.
Graves disease can initially be treated with either ATDs or RAI. Graves disease is hyperthyroidism due to an immune system attack stimulating the thyroid to make excessive thyroid hormone. ATDs can be used for 12-18 months and the dose titrated to keep the T4 and T3 in the normal range. Then, if the patient is on a low ATD dose and has normal levels) the medication is stopped - at that point up to 30-50% of patients may stay in remission (ie normal thyroid levels for at least one year). The rate of remission depends on the severity of the hyperthyroidism, the levels of TSH-receptor Antibodies, size of the thyroid and a few other issues (perhaps including smoking status - Graves patients are at particularly high risk if they smoke).
RAI can be used either as the initial treatment of after a trial of ATDs have failed to achieve control or remission. RAI is a single pill taken one time -- it cures Graves Disease 85% of the time after one dose and has very few side effects. The most important side effect is permanent hypothyroidism requiring a daily dose of thyroid hormone replacement for the rest of your life. This is a much easier situation to control however than using ATDs for hyperthyroidism - and without the toxicity to the immune system, liver, and other organ systems that we sometimes encounter with ATDs. There is no increased risk of cancer in Graves patients treated with RAI vs other treatments. There may be some mild nausea or heartburn, but this is transient. In rare cases (< 1%) there may be a painful inflammation of the thyroid after RAI which is sometimes associated with severe hyperthyroidism -- this is transient and can be treated medically. WOMEN WHO MAY BE PREGNANT MAY NOT TAKE RAI AND WOMEN SHOULD NOT BECOME PREGNANT FOR 6 MONTHS AFTER RAI.
An important issue to consider with Graves and RAI is EYE disease. If there is any evidence of Graves eye disease (double vision, eye-aching, swelling, tearing, dryness, inflammation, "bug eyed look", etc) then steroids need to be used in conjunction with the RAI to avoid an increse in the eye disease -- RAI when used in this way is an excellent way to treat the graves hyperthyroidism and the graves eye disease. If there is severe eye disease - this must be aggressively controlled before RAI is considered. SMOKING significantly increases the risk of eye disease.
In summary, RAI works very well in most patients - if after 6 months the T4/T3 levels are still high then the dose may need to be repeated. The hypothyroidism after RAI may occur as soon as 6 weeks - therefore I recommend testing T4 and T3 levels every 6 weeks after RAI to document a trend and intervene early if hypothyroidism develops. The TSH level may take several months to normalize and initially is NOT a reliable way to follow treatment of hyperthyroidism.
The question of weight usually comes up about now -- hyperthyroidism falsely elevates metabolic rate so a patient sometimes can eat a significant amount and still lose weight. Once the hyperthyroidism is corrected the metabolic rate (ie, daily calorie burn at rest) goes back to what it should be for you (as we all know, this rate does not seem to be created equal from person to person!). Therefore it is essential to decrease calorie intake as you are treated and a 10-20 pound weight gain is sometimes encountered -- no matter how the hyperthyroidism is treated.
I did not have the thyroid eye disease (TED) but I have seen/read that RAI will make that worse. I believe Dr. Mark has mentioned that here, too.
The best "advice" I can give you is to research it as much as you can, and don't let yourself be pushed into a choice you really don't want to make. Also, ask your doctor to test for antibodies if that hasn't already been done - you may have Hashimoto's disease, not Graves, and the treatments are very different.
Just curious, is this the only forum you belong to? I personally belong to six other forums - LOTS more information than just here, and I want to learn as much as I possibly can, including alternative treatments. Unfortunately, every time I see my doctor, I feel that I have to be "armed" with information, guess that's just how it goes. It seems to me that thyroid