Posters in the 88th Meeting of the American Thyroid Association: Malabsorption, T4 and GI problems

[diogenes]

These posters in the upcoming meeting of the ATA indicate the increased need for T4 for patients with GI problems.

Poster 1

Main Causes of Thyroxine Malabsorption The Systematic Study

C Virili et al.

Despite the increasing attempt to individualize the levothyroxine (T4) treatment, a significant fraction of the treated patients does not reach the target TSH. Previous studies showed that several gastro- intestinal (GI) disorders may increase the need for T4. This study was aimed at analyzing, in a large cohort of consecutively examined patients, the prevalence of the more relevant causes of increased need for T4 and at quantifying the impact of these disorders on the T4 requirement. A total of 2808 patients with hypothyroidism, due to inflammatory or autoimmune thyroiditis, were prospectively treated with a tight schedule and were followed up for at least 24 months. All patients agreed to take thyroxine in fasting conditions, waiting at least one hour before eating or drinking. Some 499 (17,7%) patients in pregnancy, lactating, obese, using foods and/or cosmetics and drugs known to affect T4 bioavailability, were positively excluded. The dose has been increased until the desired serum TSH (0.5- 2.5mU/l) had been obtained. Patients have been divided in re- sponders and non-responders based on the threshold dose (1.21 lg/ Kg BW/day) obtained as median requirement in 208 hypothyroid patients in whom interferences with T4 treatment, including GI disorders, had been excluded. After all, 295/2309 (12.8%) patients (268W/27M; median age=50 years; median BMI=25.37) failed to reach the target TSH and were classified as non responders. The median dose to attain target TSH in these patients was higher than in reference group (1.52 vs 1.21 lg/Kg BW/day; p < 0.0001). They underwent diagnostic workup for gastrointestinal disorders which revealed lactose intolerance in 38 patients (12,8%), H pilory infec- tion and related nonatrophic gastritis in 123 patients (42%), a celiac disease in 10 patients (3.4%), a gastric atrophy in 48 patients (16.3%) and other causes in 27 patients. A definite diagnosis was not reached in 49 patients (16.6%). The median need for T4 ranged from 1.45 lg/ Kg BW/day in H pylori related disorders to 1.76 lg/Kg BW/day in celiac patients. These data clearly indicate that GI disorders, mostly occult, account for a significant fraction of T4-treated patients with refractory hypothyroidism.

Poster 2

Ulcerative Colitis in Thyroid Disorders: Evidence for an increased need for thyroxine

C Virilli et al

Data on the association of ulceratie colitis (UC), a chronic inflam- matory disorder of the large bowel, and thyroid disorders are scarce and whether the presence of UC may interfere with thyroxine (T4) treatment efficacy is not known. The aim of this study has been to examine, in a large cohort of consecutively examined patients with thyroid disorders, the presence of UC and its role in the pharmaco- logic thyroid homeostasis. A total of 8537 patients were retrospec- tively analyzed and 43 patients bearing an inflammatory bowel disease were recruited (0.005%). Among them, 32 patients had UC (28F/4M; median age = 59 years), and 15 of them (F/M; median age = 60 years) were in need for T4 treatment. All patients have pledged to take thyroxine in fasting conditions, abstaining from eating or drinking for at least one hour. T4 was prescribed in an increasing fashion until the target TSH (<0.8-2.5> mU/l) has been attained and maintained in at least 2 controls. To calculate the pos- sible excess of T4 required in UC patients, the requirement of T4 has been compared to the one observed in 115, similarly treated, age- and BMI-matched patients, clearly devoid from gastrointestinal and/or pharmacological interference. The median thyroxine dose required was 1.72 lg/kg/day, significantly higher than in the reference group (+22%). An higher dose was needed in 13 out of 15 UC patients (87%). Since half of these were senior patients, we divided the sample in two groups: under 60 years (7 patients; median age = 53 years) and over 60 years (8 patients; median age = 73 years). In younger patients a dose excess has been detected in 5 out of 7 patients (median T4 increase = +26%) being the median T4 requirement 1.78lg/kg/day, significantly increased as compared to reference patients (1.31 lg/kg/day; p = 0.003). In the elderly group an increased T4 dose was seen in all 8 patients (median T4 increase = +21%), again significantly higher than the one required by the age-matched reference group (p = 0.019). The increased need for thyroxine was therefore similar independently from the age of patients. Our findings support the hypothesis that ulcerative colitis may represent a novel cause of increased need for thyroxine.

[humanbean]

They underwent diagnostic workup for gastrointestinal disorders which revealed lactose intolerance in 38 patients (12,8%), H pilory infec- tion and related nonatrophic gastritis in 123 patients (42%), a celiac disease in 10 patients (3.4%), a gastric atrophy in 48 patients (16.3%) and other causes in 27 patients. A definite diagnosis was not reached in 49 patients (16.6%).

It shocks me but doesn't surprise me that so many of these patients had gut problems that had previously been unidentified.

I get the impression from reading your post that it is assumed there is no connection between gut problems and hypothyroidism, and the only issue is that gut problems make treating hypothyroidism more difficult.

In my opinion the anecdotal evidence from posts on this forum is that gut problems are one of the earliest issues that occur in hypothyroidism for most patients.

In my own case I developed severe indigestion in my teens. I was diagnosed as suffering from subclinical hypothyroidism in my early 30s. I got my first prescription for levothyroxine in my 50s. I suspect that I've suffered from hypothyroidism all my life.

[Gcart]

Me to hb. Doctor called out in childhood grumbling appendits . Appendectomy at 12yrs .

weight loss , school nurse referred to hospital , anemia found.

Gut pain , tiredness throughout adult life. Thyroid cancer in my 60yrs

Hormone treatment, still not perfect, but stomach pains so much better and other symptoms better . To long to go into.

So glad of this forum , it has helped me so much. Maybe I would not have lost my thyroid to cancer had I been diagnosed sooner? Not sure about .

[helvella Administrator Thyroid UK]

They underwent diagnostic workup for gastrointestinal disorders which revealed lactose intolerance in 38 patients (12,8%)

OK - so were these patients taking a levothyroxine product that contains lactose? Or not? Or didn't anyone think to ask the obvious?

Surely simply having a lactose intolerance is not in itself proof that the lactose intolerance causes impaired absorption?

Quite possibly some of those who were found not to have impaired absorption are actually taking a lactose-free product and might also suffer impaired absorption if they switched to a lactose-containing product?

These questions/observations are so incredibly primary school level, it is hard to understand why they didn't make the poster!

[diogenes Remembering in reply to helvella]

This is a basic chicken and egg situation. What caused what? GI problems causing insufficient T4 uptake or hypothyroidism causing GI problems causing insufficient T4 uptake.

[Katepots]

In my mind my GI problems came about because I was undiagnosed for decades. T4 made matters worse. Only when I addressed gut issues by going gluten and casein free, rectified vitamin deficiencies and switched to NDT as I don’t convert adequately (well I convert to RT3) have I had any relief.

I think the GI problems stem from most of us having autoimmune thyroditis which is never addressed by our medical fraternity in the uk.

[Katepots]

These papers in fact make me quite angry.😳

[humanbean in reply to Katepots]

Yes, me too.

[rslnhwt]

No mention of SIBO. I don't think it is taken very seriously.

ncbi.nlm.nih.gov/pmc/articl...

'It has been reported that SIBO may be present in more than half of patients with hypothyroidism.'

[Gcart]

Just remembered I was diagnosed with overgrowth ages ago . Nothing done ! SIBO . . Now gluton and dairy free

post TT cancer First time in most of my life my gut is comfortable .

All down to this forum. Thanks all who have helped. 😘