Thyroid conditions are often difficult to diagnose early. It is common for patient and provider to not engage in any discussion about thyroid issues. A patient could be asymptomatic or feel normal despite having telltale symptoms. Unfortunately, this can lead to late diagnoses and treatment.
As part of Thyroid Awareness Month this January, and to better understand thyroid conditions, we spoke with Claudia Mano, Sr. Medical Director—Medical Affairs. Claudia has been with PRA for over 19 years. She is an endocrinologist by training, has a Master’s degree in thyroid disease and has worked in the field for over 25 years. Read her insights on thyroid conditions, treatments, and research below.
Can you describe the specific types of thyroid disorders that exist?
The most common types are hyperthyroidism, hypothyroidism, goiter, thyroid nodules, thyroid cancer, and Hashimoto thyroiditis.
What is the difference between hyper/hypothyroidism?
Hypothyroidism leads to a decrease in the thyroid hormone. Someone with hyperthyroidism will generally have a slow metabolism, tiredness, and slower body functions. The thyroid gland is under-reactive—this means that the thyroid gland will not produce enough thyroid hormone to keep the body functioning normally.
For hyperthyroidism, this leads to the opposite—your body will function in a more accelerated way instead. With hyperthyroidism, more of the hormone is produced in your body, so the gland is overreactive.
What causes these conditions? Are there any current treatments that provide lasting remission?
These are often autoimmune diseases. Treatment can involve the surgical removal of the full or partial gland. This removal could result in hypothyroidism. You can also have hypothyroidism because of a radiation treatment. You can have congenital hypothyroidism, where a baby is born with the condition. Some medications may affect the thyroid and result in hypothyroidism.
You can also have damage to the pituitary gland, which affects the production of those hormones, as well as some rare disorders that can infiltrate the thyroid gland.
The most common cause for hyperthyroidism is overproduction of the thyroid hormone. This is known as Graves' disease. This is caused by antibodies that affect the thyroid. They cause the thyroid to grow and secrete too much of the thyroid hormone. It’s often hereditary and it's more common in young women.
Another type of hyperthyroidism is characterized by one or more nodules in the thyroid that may gradually grow and increase their activity so that the total output of thyroid hormone into the blood is greater than normal. This condition is known as toxic nodular or multinodular goiter.
The most common treatment that we have in terms of antithyroid agents is the methimazole or in rare instances propylthiouracil (PTU). We can also use the radioactive iodine as an alternative way to treat hyperthyroidism. We usually start using the antithyroid agents, but there are situations when we may consider using iodine. Radioiodine is the first therapeutic choice for patients in whom ATDs and/or surgery are contraindicated, as well as in cases of hyperthyroidism relapse following treatment with ATDs.
A final option for treatment is surgery. Surgery in the treatment of GD is not well established in literature; some authors classify them as absolute and relative. Absolute indications include:
- A large goiter causing compressive symptoms
- Suspected or confirmed malignant thyroid nodule
- Pregnant women who fail to achieve disease control through anti-thyroid drugs
- Refusal of iodine treatment
- Women planning to become pregnant within a period of four to six months
- Intolerance to anti- thyroid drugs
Relative indications include:
- Large goiter
- Severe ophthalmopathy
- Poor adherence
- Lack of response to anti-thyroid drugs treatment
How are these conditions diagnosed? What types of biomarkers we can use to detect thyroid complaints?
For hyperthyroidism it takes a while for to be effective—we follow those patients for 12 to 24 months to check the remission of disease. It's not so easy—the remission rate is around 30 to 50%. It also depends, for instance, if there is large goiter or a high level of T3. Those are situations where there is a higher probability that this patient will not respond well to anti-thyroid drugs.
We must take all of these scenarios into consideration when we treat patients. Sometimes patients may relapse, which leads to evaluating next steps. Sometimes you need to use iodine because the drug treatment is not working.
Levothyroxine should remain the standard of care for treating hypothyroidism. Levothyroxine replacement therapy has three main goals. One is to provide resolution of the patients' symptoms and hypothyroid signs, including biological and physiologic markers of hypothyroidism. The second goal is to achieve normalization of serum thyrotropin with improvement in thyroid hormone concentrations. The third goal is to avoid overtreatment (iatrogenic thyrotoxicosis), especially in the elderly.
How are these conditions diagnosed? What types of biomarkers can we use to detect thyroid symptoms?
The classic symptoms for hypothyroidism are that patients gain weight and feel slow and fatigued. It’s important to discuss this with your general practitioner (GP) as soon as possible in order to catch the symptoms in their initial phase and avoid a later diagnosis, and a worse situation.
For hyperthyroidism, symptoms are often the opposite. Those patients can feel very agitated and have an accelerated heartbeat. They may lose weight or have ophthalmological problems. Again, it’s important to alert patients to these symptoms early so they can seek appropriate treatment immediately.
We always ask patients to be aware of their medical and family history, if possible. Other family members may have the disease. Because hypothyroidism, for instance, is an autoimmune disease, you may have other autoimmune diseases that run in your family, such as type 1 diabetes.
During your yearly physical exam, the thyroid gland is examined to check for any increase in size or nodules. To look at this in more detail, there’s a blood test –TSH and free T4 to analyze the hormones.
For hypothyroidism or autoimmune diseases such as Hashimoto, a disorder that can cause hypothyroidism, we test presence of antibodies against thyroid peroxidase (TPO) antibodies.
Many people actually have those antibiotics present, but they don't have any thyroid problems. When you are looking for antibodies, you need to correlate this with the patient’s medical history to diagnose any conditions.
For hyperthyroidism we can measure levels of thyrotropin receptor antibodies (TRAbs), which when elevated confirm the diagnosis of Grave’s disease.
Thyroid scans will find out if the entire thyroid gland is overactive or whether a toxic nodular goiter or thyroiditis (thyroid inflammation). Thyroid update tests, which measure the ability of the gland to collect iodine, may be done at the same time.
How can we increase awareness and prevent late diagnosis?
We must empower people to talk to their doctors about any concerns with their thyroid gland. Because the thyroid is a gland in your neck, you can sometimes see when it looks abnormal. Healthcare providers can also show patients how to perform self-exams.
We can ask patients to keep an eye out for subtle symptoms that may be related to these conditions. The more we have those conversations, the more we can talk about the possible symptoms and treatments. Unlike diabetes, these conditions are not as commonly discussed. Any awareness campaign is good awareness, as with any disease.
What patient communities and resources exist for thyroid disorders? How can patients navigate diagnosis?
There is a lot of good material from the American Thyroid Association, The American Association of Clinical Endocrinology, and the Thyroid Cancer Survivors Association, which has a page where patients can share their stories.
Thyroid Change allows you to see patient stories and patients talking about how they discovered the disease. This is so interesting not only for the patient, so they don’t feel alone, but to feel that there is a way forward. Sometimes patients don't know about these conditions—they just think they might be obese if they have hypothyroidism. That isn’t always the case. That’s why it’s so crucial to have those stories and continue studying how patients seek help and connections.
What are some of the recent developments in therapeutics for thyroid issues? Any recent break throughs in research?
I’ve been in this field for almost 25 years and I am happy to see some new approaches for the treatment of Graves’ disease. This involves biologics, small molecules, and peptide immunomodulation. These drugs are in in different stages of development and will probably be approved in the next few years. Still, they could work now for patients who aren’t finding success with conventional treatment.
This is a graphic included in a recent publication summarizing new therapeutic options for Graves’ Disease:
What are you excited about when it comes to future of treatment and research for these conditions?
These new approaches have some limitations, mostly due to cost implications. We don't know if they will fully recover patients or improve treatment long-term. For instance, it is unclear if they will improve the long-term risk of hypothyroidism or reduce goiter. Those are questions that remain unanswered, but new drugs will absolutely shed light on the physiopathology of the disease and its involvement with the immune system.
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