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How to Thwart a Thyroid Problem

An Untreated Condition of the Butterfly-Shaped Thyroid Gland Can Have a Significant Impact on Your Body and Daily Life. Find Out How to Spot the Signs and What You Can Do About It.

Winter 2014

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Who Gets Thyroid Disease

Anybody can develop a thyroid problem, but women are much more likely than men and older adults are more likely than young people to develop one. People with HIV may also have somewhat higher rates of thyroid abnormalities than the general population, due to changes to the immune system caused by HIV or due to certain infections and cancers. Antiretrovirals and medications used to treat certain illnesses that are more common among people living with HIV, such as hepatitis C and tuberculosis, can also affect a person's thyroid function (see "Medications that Can Affect the Thyroid" for a list of some meds to watch for).

Infectious diseases specialist Dr. Stephen Shafran, from Edmonton's University of Alberta Hospital, says, "Overall, thyroid disease is not very common in people living with HIV, perhaps because thyroid disease is much more common in women than men, and in Canada the ratio of HIV infection for males to females is approximately 3:1." He also notes that in his HIV practice, he sees more hypothyroidism than hyperthyroidism.

Cause and Effect

The most common cause of hypothyroidism is called Hashimoto's thyroiditis, an autoimmune disease that involves the body's own immune cells damaging the thyroid. Iodine deficiency, thyroid surgery, radiation therapy to treat cancers of the head and neck, and other endocrine disorders are usually considered in the diagnosis of hypothyroidism. For people who have more advanced HIV, doctors might also check for infections or cancers that can invade the thyroid.

Although uncommon, people with HIV can develop a form of hyperthyroidism called Graves' disease one to three years after starting ART due to a strong immune response. As a result of starting HIV treatment, Patrick's immune system improved, but because his response to the medication was so strong, he also produced antibodies that caused his thyroid to become overactive and produce too much thyroid hormone.

A number of medications can also affect the thyroid, which is yet one more reason for people to talk to their doctors and pharmacists about all the drugs they're taking.

Pinpointing the Problem

Diagnosing a thyroid problem is key to feeling better and preventing other problems from ensuing. Had Selena's hypothyroidism gone undiagnosed, her lack of energy and weight gain would have likely continued to take a toll on her quality of life and sense of well-being. As for Patrick, if his Graves' disease had gone undiagnosed and untreated, he could have developed more serious complications, such as heart disease and bone loss, down the road.

Luckily for both of them, the diagnosis of thyroid disease is generally based simply on symptoms, a physical exam and blood tests. Blood tests that reveal a low level of thyroxine and a high level of TSH indicate hypothyroidism. And blood tests that reveal high levels of thyroxine and low levels of TSH indicate an overactive thyroid. (To sort out more complex cases, other tests such as a thyroid scan or a thyroid biopsy may be ordered.)

Offsetting the Imbalance

Dr. Shafran notes that treating an underactive thyroid tends to be more straightforward than treating an overactive one: "Hypothyroidism is easy to manage with the drug levothyroxine [Synthroid, Eltroxin], which is available in many strengths." On the other hand, he says, "managing hyperthyroidism tends to be more complex and patients should be treated by an endocrinologist -- a doctor who specializes in treating hormone problems." In cases of hyperthyroidism, two types of medicine are usually prescribed: an anti-thyroid drug and a heart drug called a beta-blocker, to control uncomfortable symptoms like a rapid or irregular heartbeat and shakiness. Sometimes, radioactive iodine is prescribed to destroy the overactive thyroid gland. Most patients who receive radioactive iodine subsequently become hypothyroid and then require levothyroxine therapy.

To treat hypothyroidism, levothyroxine is the most commonly prescribed medication (see "Tips for Levothyroxine Users"). To ensure that your treatment is working well, your healthcare team will monitor its effects to make sure your symptoms improve and your hormone levels return to normal. A person's TSH level will usually normalize after several weeks of treatment. If it remains elevated, this indicates that the dose of levothyroxine is too low. The dose may then need to be increased gradually until the TSH normalizes. Patience is needed as it can take several weeks or months to get you on the right dose and for your symptoms to resolve. After your treatment is stabilized, your doctor will probably recommend that you continue taking this dose and that your levels be monitored regularly.

The good news is that thyroid disease is a manageable condition that is fairly simple to diagnose and treat. In terms of prevention, the best thing a person can do to stay healthy is report any unusual symptoms to their healthcare team. For people on ART, there is only a small chance that the thyroid will be affected -- most people do just fine. If you have suspicious symptoms or several risk factors, your doctor may screen you for thyroid disease to detect it early.

Tips for Levothyroxine Users

Take your dose daily: Take your dose as prescribed every day and avoid missing any. If you do miss one, let your healthcare team know. If you are not taking enough medication, your symptoms may not fully improve; however, if you take too much, this can swing the balance and lead to an overactive thyroid.

How to take your medication: Try to take levothyroxine at around the same time each day. Unless your doctor or pharmacist suggests otherwise, it is best to take it first thing in the morning with a full glass of water on an empty stomach (about 30 to 60 minutes before eating). If a morning dose is not convenient, try taking it at bedtime instead. Discuss the best way to take all of your medicines with your doctor and pharmacist to avoid any interactions with foods or other medicines.

Keep an eye out for side effects and drug interactions: Levothyroxine usually causes few or no side effects provided you are on the correct dose and your healthcare team is monitoring you regularly. If you experience any symptoms -- such as heart palpitations, excessive sweating, rapid weight loss or restlessness -- be sure to let your healthcare team know, as this may indicate that your dose is too high.

To prevent drug interactions, make sure your healthcare team has a complete list of all of the medicines you take, including vitamins, herbs and complementary therapies as well as other prescription and over-the-counter medicines.

Levothyroxine should be taken at least four hours before or four hours after taking other drugs that interfere with how well it gets into the bloodstream. These include cholestyramine, calcium, magnesium and aluminum salts (found in antacids and supplements), iron supplements, sucralfate (Sulcrate) and dietary fibre supplements.

The scoop on ritonavir: The HIV medication ritonavir (Norvir) -- used to boost other protease inhibitors and also found in Kaletra -- can speed up the clearance of levothyroxine from your body. To offset this interaction, higher doses of levothyroxine may be required. Your doctor and pharmacist can ensure that you are on the correct dose of levothyroxine based on the way you respond to thyroid treatment.

Pregnancy planning: If you are planning to become pregnant or you are pregnant, your doctor should monitor your thyroid hormone levels more closely. He or she may recommend adjusting your dosage.

A word of caution: Although there is a lot of hype about the use of levothyroxine to speed up metabolism and help you lose weight, this is not recommended and can be dangerous. Too much thyroid hormone can cause heart palpitations and lead to bone loss.

Michelle Foisy, Pharm.D., is a clinical pharmacist with the Northern Alberta Program in Edmonton and a clinical consultant in HIV.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication The Positive Side. Visit CATIE's Web site to find out more about their activities, publications and services.
See Also
An HIVer's Guide to Metabolic Complications's Lipoatrophy Resource Center
More on Lipodystrophy & Metabolic Complications

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