This is a case study. A 50-year-old female, weight gain, hair loss, feels cold, follows Paleo and quit her job to work on her health, so that gives you an idea of the intensity of her symptoms. She is on a T4 and T3 combo, but her values on recent testing are really high. This is after reducing her dose by 20 percent. TSH is basically 0, T4 12, free T3 4.6, and reverse T3 is 36. TRP was 3. Ferritin was low a year ago, but don’t know it now. Symptoms are worse after the reduction. She’s taking selenium, iodine, and a zinc supplement for thyroid support. BioHealth salivary adrenal test showed a flattened cortisol curve and overall low cortisol values with low DHEA. She was started on hydrocortisone by another functional medicine practitioner. She was feeling well until her thyroid medications were dropped because her labs were in a hyperthyroid range and she was losing a lot of hair. I treated her for bacterial and yeast overgrowth based on Genova testing, but no breath testing. Practitioner who has her on 5 mg of hydrocortisone is suggesting a Wilson’s protocol of T3 only treatment to knock her reverse T3 back in line. I’m not too familiar with that program. Regarding next steps, (1) Check diet and make sure she’s not too low carb. (2) Recheck inflammation, autoimmune markers, ferritin, iodine, and zinc. (3) Check breath tests for SIBO, and (4) Consider low-dose naltrexone (LDN).

Chris Kresser:  Great study. A lot of stuff to talk about here. So the first thing is that her thyroid numbers are definitely too high. This is a condition called facetious hyperthyroidism and it’s iatrogenically induced hyperthyroid state where the dose of thyroid medication is too high. Her TSH is almost 0 and that can cause osteopenia or osteoporosis down the line and puts her at greater risk for stroke and other cardiovascular events. It’s more serious than a lot of practitioners like to let on, so when I see this I really urge the patient to have that discussion with their prescribing physician and sometimes there isn’t much of a discussion. The prescribing physician just says, this is what we’re doing, or you know, it’s safe, don’t worry about it. But I am always ready to provide studies and information that show that it’s not safe.

This is a pretty classic presentation for someone who has autoimmune thyroid disease. What happens here is their immune system is attacking the thyroid gland so their thyroid gland is not functioning properly and they lose the capacity to produce hormone. They start on thyroid hormone. They feel a little bit better, but the underlying cause of the problem is not addressed and so they get continued destruction of the thyroid gland and they have to take more and more thyroid hormone in order to get the same symptomatic benefit and the dose just keeps going up and up and up and up. Once they get on the treadmill it can be really hard to get off, and that’s where this patient is now probably.  

So what you have to do in this situation is you have to address all the possible underlying causes of thyroid dysfunction. We will talk a little bit more about that when we get to the blood chemistry section on thyroid, but you’re certainly on the right track. You want to look at the gut. You want to look at blood sugar. You want to look at heavy metal toxicity and mold as biotoxins. You want to look at HPA axis dysregulation which you already have. I’m not sure where we are in that unit, but cortisol is an anti-inflammatory hormone. So if she has low cortisol, low DHEA, and a flattened cortisol curve, that means she’s not able to mount an anti-inflammatory response. So that is probably contributing to the attack against her thyroid gland and that is one of the things that is triggering her immune dysfunction.

So you’ve got to address all these underlying causes that we’ve talked about in this program and maybe also metals and other potential triggers for immune dysfunction, food intolerances, Cyrex Array 3 and Array 4, and you’ve got to look at nutrient deficiencies which can provoke immune dysregulation and also thyroid issues, which you mentioned in your number (2).

So I would do all of that first and then if you’re still not where you want to be, then that certainly would be a time to consider low-dose naltrexone which promotes T regulatory cell function and differentiation and can really help in situations like this. So I hope that helps.