Wednesday, February 29, 2012

Low Energy, Fatigue, A Sign of Hypothyroidism

I was working in the hepatitis clinic when I saw a patient of mine who was currently on therapy for her chronic hepatitis C infection.  She had been doing well, minimal to no side effects to her medications with her taking the nutritional supplements I put all of my patients on who were taking the FDA approved medications, pegylated interferon and ribavirin. 
I knocked on the door of the exam room and walked in.  Delores was about 3 months into her therapy program and had acquired her labs that morning, so I had the results in hand. 
“Hi, Delores, how are you?”
“Tired, I just don’t have any energy.  It’s hard for me to ‘get up and go.’  I noticed I started having problems about 10 days or so ago and it’s slowly become worse.”
“Well, I can explain that to you.  Your blood draw that you had done this morning shows that the interferon medication you’re on has affected your thyroid gland it is now having problems with producing enough thyroid hormone for you.  If you remember correctly, that was one of the side effects I discussed with you that could happen with your being on this medication.  It’s easy to treat, I’ll start you on a thyroid replacement medication that you will need to take once a day.  The medication is called Synthroid.”
“My thyroid, isn’t that a small gland in my neck, right here?” (she pointed to the front center of her neck)
“Yes, that’s where your thyroid is located.”
“Wow.  How long will it take for the new medicine you want me to start to begin working?” 
“You should notice a change in a couple of days.”
“Okay.”

Many patients have problems with their thyroid gland.  It is quite common, with up to 4-5% of the American population having it.  Problems with the thyroid can arise from an auto-immune disease (your own immune system begins to attack the thyroid), side effects from medications, such as amiodarone, or a medication used for tuberculosis, lithium (used for bipolar disease), interferon (used in cancer patients, hepatitis), or problems with too much iodine or too little iodine, anti-seizure medications or radiation.  Problems with the thyroid can also be caused by an infiltrative disease process which can be due to sarcoidosis, amyloidosis or leukemia for instance. 

There are many symptoms of a low functioning thyroid.  They can include: fatigue, dry skin, cool/pale skin, decreased sweating, coarse hair, brittle nails, non-pitting edema, swelling around the eyes, a decrease in the red blood cell counts (anemia), decreased pulse, decreased heart contractility, shortness of breath, high blood pressure, increased blood pressure, constipation, weight gain, changes in menstrual cycle, joint pains as well as decreased lipid clearance. 
  
“Well, I do have some good news for you.  Your liver function tests are normal, your blood counts are still normal and from the looks of it, you should be in viral remission, which we’ll know in a few days.”
“So, who do I call in a few days to find out the results of my viral load?”
“You can call my nurse, Jenny, and she should know those results in about 4-5 days, so you can call her then.”
“Great.”
I gave Delores her new prescription for Synthroid and gave her a lab slip to have her blood drawn in 2 months, which would give her enough time to show a response to the Synthroid.  If her thyroid was still off at that point, I could adjust the medication as needed up or down.  I would see her after those labs were drawn. 
Delores came in 2 months later and her thyroid studies were back to normal, so I kept her on her current dose of Synthroid.  She was so happy that she had shown she was in viral remission for the past two months. 
Delores finished her medication treatment program after being on them for 11 months.  She came back into the clinic 6 months later and had her viral load re-drawn, which showed that she was in permanent remission from her chronic hepatitis C infection.  Her thyroid studies showed that they had remained normal.  Delores would have to stay on the Synthroid for the rest of her life. 

An appropriate work-up for thyroid problems is easy.  Generally you just need to draw blood and order a TSH test (thyroid stimulating hormone), along with a free T4 level.  If the TSH comes back high (normals being from .9 to 5.0 usually), and the free T4 is low then you can start the patient on replacement thyroid,  i.e. Synthroid. You have to follow-up on the replacement and make sure about 6-8 weeks later that the patient’s TSH/T4 is now in the normal range.  If the TSH is now very low (below .9) then you need to cut back on the patient’s Synthroid dose.