Grave’s Disease: The Other Autoimmune Thyroid Condition

Graves disease, like Hashimoto’s, is another type of autoimmune condition that affects the thyroid gland.  And just like in Hashimoto’s, the cause of illness has to do with the immune system (the thyroid gland is just the target).

Unlike the ups and downs of thyroid hormones in Hashimoto’s, Grave’s involves mostly high levels of thyroid hormones.  Because of this, those with Grave’s are at risk for something that is rare but potentially deadly: thyroid storm.  This is part of the reason that many doctors recommend removing the thyroid gland.

Signs and symptoms of Grave’s hyperthyroidism

  • Anxiety
  • High blood pressure
  • Insomnia
  • Fatigue
  • Awareness of your heart, often due to a rapid heart beat
  • Tremor (mostly in the hands/fingers)
  • More sensitivity to heat and/or more frequent perspiration
  • Weight loss
  • Increased appetite
  • Muscle weakness
  • Enlargement of the thyroid +/- goiter (located over the mid-to-lower part of your throat)
  • Changes in bowel habits (diarrhea, more frequent bowel movements)
  • Thickening and redness of the skin on the shin or tops of the feet
  • Eye symptoms (bulging, tearing, light sensitivity, blurring)
  • Reduced libido/erectile dysfunction
  • Changes in menstrual cycles

 

How is Grave’s diagnosed?

  • Blood testing:
    • TSH <0.05
    • High free T3 and free T4
    • High TPO (thyroid peroxidase) antibodies
    • High TSI (thyroid stimulating immunoglobulin) antibodies
    • High TSH receptor antibodies (TRab)
    • Low cholesterol
    • High fasting blood sugar
  • Physical exam:
    • May have notable swelling over the front of the throat (where the thyroid gland is located)
    • May see weight loss, thickening of the skin on the front of the shins, thinning hair, moist skin.
  • Ultrasound of the thyroid:
    • May see nodules
    • May see swelling/goiter

 

Mainstream Medical Treatment

In mainstream medicine, the focus is on normalizing labs and preventing the complications (heart problems, eye problems, osteoporosis, thyroid storm).   Ideally this would be done with medications.  However, if medications don’t put someone into remission within 12-18 months, most specialists will recommend surgically removing the thyroid gland or destroying it with radioactive iodine (both which lead to the opposite of Grave’s, hypothyroidism, which does usually require life-long thyroid hormone replacement).  Please note, it is not a bad thing if this has happened or is a necessary next step!  

There are only a few drugs that are used as treatment, including methimazole, PTU, and beta blockers.  These will manage/cover up the symptoms of Grave’s.  The numbers vary, but over 50% can often go into remission within 18  months of starting a medication (to avoid surgery or radiation of the thyroid).  But unfortunately the condition can recur, and over 60% of patients can relapse.

As a conventionally trained practitioner, it is important to always address symptoms and mitigate risks as the first step in treatment.  Medications are strong and have a purpose when appropriate! 

 

Functional Medicine Approach

As with any condition or symptom that we treat via a functional medicine model, there are 2 primary goals:

  1. Symptom relief with risk reduction (i.e. in this case, prevent continued damage to the thyroid and heart)
  2. Find the trigger/cause of an over-active immune response, so that we can prevent other autoimmune conditions and potentially remove the need for ongoing medication.

As a functional medicine-trained practitioner, we can still look for immune triggers while on pharmaceuticals.  It’s not an either/or approach to care.

It is important to note that we can still treat Grave’s even if a patient already has had their thyroid gland removed or destroyed.  Remember – the problem is with the immune system, and the thyroid gland is just the target/bystander!  If the triggers/causes were not evaluated, there is more than a 25% chance of developing another autoimmune condition (such as multiple sclerosis, rheumatoid arthritis, and more).

All autoimmune diseases have 3 contributing factors:

  1. Genetics 
  2. Environment
  3. Internal imbalances, often involving gut hyper-permeability

A comprehensive functional medicine approach would evaluate all of these, but I find that the sometimes just 1-2 tests can give us enough information to identify likely triggers.  The most common triggers I find are H. pylori, poor ways of dealing with stress, and occupational exposures.  I created the image below to highlight other things that should be considered:

 

Testing per the Functional Medicine Model

As I mentioned, we don’t have to run a lot of tests to start putting an autoimmune disease into remission.  Here are 80% of the tests that could be run (but a skilled clinician shouldn’t need to run a bunch of tests – there’s a lot of overlap in treatments!):

  • Blood Tests
    • Through commercial labs (i.e. those that contract with insurance companies), we can check for:
      • Certain viruses (e.g. EBV)
      • Certain bacteria (e.g. H. pylori)
      • Nutrient imbalances (especially CoQ10 levels, vitamin D)
      • Immune markers (e.g. patterns in the CBC, immunoglobulin levels)
      • Other hormones (e.g. testosterone).
    • Functional lab testing:
      • Cyrex immune reactivity tests (many options)
      • Food intolerances
      • Glutathione levels
      • Genetic testing
  • Stool Testing
    • Evaluates sIgA levels, looks for dysbiosis/parasites, ensure good enzyme/bile function, and more
  • Urine Testing
    • Organic acids testing (OAT) to look for mitochondrial dysfunction
    • 8-OH-dG to look for oxidative stress
    • Hormone metabolites (DUTCH test)
    • Heavy metals
    • Pesticide/man-made-chemical levels

 

Treatments Used in Functional Medicine

As I noted before, nothing really does a better job that pharmaceuticals (I have direct personal experience with this!).  Thus, a good functional medicine practitioner will always start with methimazole, PTU, and/or beta blockers to improve symptoms.  Depending on the severity of the symptoms/thyroid levels, this can take a few weeks to notice improvement!

For natural approaches to address the symptoms, various nutraceuticals have been studied (but not extensively – there’s no profit for those that would fund such studies!):

  • Bugleweed and lemon balm.  These are for more mild cases, and appear to be safe.  (reference)
  • Selenium 200mcg (with methimazole) (reference)
  • Motherwort (acts like a beta blocker)
  • Higher doses of anti-oxidants like resveratrol (“anti-thyroid” activities when in higher doses, e.g. 500mg or more), mixed tocopherols, NAC, quercetin, etc. (reference)
  • L-carnitine (2-4 grams with food): Prevent thyroid hormones from entering cell nucleus; may be safe in pregnancy (reference)
  • Cordyceps (2 grams 3x/day) (reference)

Other treatments that have shown benefit at addressing the cause/triggers include:

  1. Eradicating H. Pylori (with pharmaceuticals and/or nutraceuticals) (references: 1, 2)
  2. Eliminating gluten (due to higher prevalence of the CTLA-4 gene in those with thyroid autoimmunity) (references: 1, 2)
  3. Increase diversity of the microbiome with more fruit/vegetable fiber (aka the food for the microbiome); option to take probiotics but these only stay around for a short period of time
  4. Avoid iodine (sneaky culprits = lotions, bread, dairy) (great article on this by one of my colleagues)
  5. Low Dose Naltrexone (LDN)

Summary

Grave’s Hyperthyroidism is an autoimmune condition that is not nearly as prevalent as Hashimotos’, but just like Hashimoto’s, it is a problem with the immune system. 

Many with this diagnosis have to use pharmaceuticals to manage symptoms and risks, and it is common for remission to occur.  However, recurrence can occur (especially with stress), and removal or destruction of the thyroid gland may be the best approach in order to prevent damage to the heart, eyes, and bones.

If there is any single test I recommend, it is to get a comprehensive blood test and look for infections.  If your healthcare practitioner who takes insurance is willing and knowledgeable about this, start with him/her.  If not, I am accepting new patients and would be happy to be your partnering “health detective”!  Schedule a free curiosity call to learn more.

The information contained in this article is for educational purposes only.  It does not constitute a diagnosis or prescription for treatment.

 

REFERENCES

  1. Is there a methimazole dose effect on remission rate in Graves’ disease? Results from a long-term prospective study. The European Multicentre Trial Group of the Treatment of Hyperthyroidism with Antithyroid Drugs (1998)
  2. Autoimmune thyroid diseases and nonorgan‑specific autoimmunity (2012)
  3. The role of Epstein-Barr virus infection in the development of autoimmune thyroid diseases (2015). 
  4. Use of Bugleweed in Grave’s: Extracts and auto-oxidized constituents of certain plants inhibit the receptor-binding and the biological activity of Graves’ immunoglobulins (1985) 
  5. A pilot study on the beneficial effects of additional selenium supplementation to methimazole for treating patients with Graves’ disease (2019)
  6. Usefulness of L-carnitine, a naturally occurring peripheral antagonist of thyroid hormone action, in iatrogenic hyperthyroidism: a randomized, double-blind, placebo-controlled clinical trial (2001)
  7. Effects of carnitine on thyroid hormone action (2004)
  8. Associations of Helicobacter pylori infection and cytotoxin-associated gene A status with autoimmune thyroid diseases: a meta-analysis (2013)
  9. Decrease in thyroid autoantibodies after eradication of Helicobacter pylori infection (2004)
  10. CTLA-4 gene polymorphisms and their influence on predisposition to autoimmune thyroid diseases (Graves’ disease and Hashimoto’s thyroiditis) (2012)
  11. Association between CTLA-4 polymorphisms and susceptibility to Celiac disease: a meta-analysis (2013)
  12. The Role of Oxidative Stress on the Pathogenesis of Graves’ Disease (2012)