Monday, June 30, 2008

Why a General Endocrinologist Should Not be your Thyroid Doctor

10-15 years ago, a referral for thyroid second opinion from an internist, and from a general endocrinologist would show that the endocrinologist knew more about the thyroid condition than the internist. Sadly, it is not the case today. With diabetes and general medicine taking up the majority of the waking hours for the endocrinologist, there is now a loss of thyroid specific expertise by the endocrinologist. He is little better than a general internal medicine physician. He is still the king of diabetes, but not thyroid.

Case History

51 Y/O female seeks my opinion on the thyroid condition she is not sure she has, or the therapy that is needed.2 years ago the endocrinologist, while treating her type one diabetes, noted an upper normal TSH, 5.61 and commented on her enlarged thyroid on his physical. He did nothing to evaluate the goiter, and told her to return in a year.
He did not offer therapy. She had a family with autoimmune disease of the thyroid.
Aunts with Graves' disease, and papillary thyroid cancer. No antibodies were drawn or was an ultrasound done to evaluate the goiter.Next year the TSH was 6.32 and he offered her thyroid hormone, but no work up. This resulted in her getting a second opinion with me. The thyroid was visible from across the room.There was a large 2 cm nodule on the right. The ultrasound found 6 nodules of which two were > 1.5 cm.
One was 3 cm.It had an irregular border, and 3 deep penetrating blood vessels on power Doppler. There was a papillary thyroid cancer in the larger nodule by USGFNA, and she was studied for abnormal nodes,which was negative. She had surgery, and is disease free with undetectable Cancer marker 6 weeks post surgery. She is lucky to have sought another opinion on her very excellent endocrinologist taking care of her type one diabetes, but learned that his knowledge was less that needed to care for her thyroid diease.

Good Luck


Monday, June 16, 2008

Calcitonin Measurement in All New Thyroid Nodules

Is Calcitonin screening of all thyroid nodules cost Effective? A recent study by Cheung and associates in the JCEM 93:2173-2180,2008, suggests it is worth the expense. They found it was comparable to screening with TSH,colonoscopy,and mammography. Two groups were studied. One following the guidelines for nodule evaluation by the American thyroid Association ATA, and the other the same ATA except a calcitonin was added to the work up.The results of the added calcitonin to the ATA guidelines were:
The main outcome measures C/E, or dollars per life years saved LYS. $11,793 per LYS for the a calcitonin group. US screening with calcitonin would yield an additional 113,000 life years saved. at a cost increase above current ATA guidelines of 5.3 %. The calcitonin screening is most cost effective in young males with larger nodules, but is still cost effective in screening of the whole thyroid nodule population. The lack of studies on the cost effective nature of screening was the reason the ATA guidelines did not include calcitonin. Now this recent study would suggest it should be added to the nodule work up.

Calcitonin is a marker for Medullary thyroid cancer. It is a rare thyroid cancer that can occur in families. Family screening is done with DNA studies, not calcitonin.



Alarms Go Off in Restrooms When Radiated Thyroid Patients Urinate.

A 30 Y/O female with Graves' hyperthyroidism was treated with 15 Millicuries of radioiodine. The next day she entered the restroom at her workplace, and an alarm of a flame sensor sounded. This happened everyday for 6 days, whenever she went to the restroom to urinate,the sensor went off and stopped when the toilet was flushed, and the radiation in the toilet was washed away. The sensor was 10 feet away from the toilet in the ceiling. The flame sensors are usually installed in restrooms in department stores, airports, shopping centers and movie theaters. Another Graves' patient activated the flame sensor in a department store restroom 2 days after treatment with 30 Millicuries of I/131. A flame sensor was studied. A patient was with Graves' set off the alarm 3 days after treatment when she passed urine. Also the flame sensor could sense I/131 gamma rays, even when a I/131 capsule was covered by a UV light interception seal. Airport radiation detectors are known to go off when a patient is treated with RAI/131. The fact that alarms can go off in restrooms all over the world when a thyroid patient urinates gamma rays into the toilet water has not been reported before. Any physician using Radioiodine to treat thyroid patients should inform them about this malfunction of restroom sensors after they are treated.

Wow, one more thing to tell my patients after radioiodine therapy. The best thing to do is flush the toilet, and the alarm will stop! Don't panic and run out without flushing.

Good Luck,


Tajiri et al
Radioiodine and Flame sensors

abstract Endocrine Society Annual meeting San Francisco Ca 6-15-2008.

Friday, June 13, 2008

Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors

I do not use compounding pharmacy thyroid hormone for my patients. There are pure thyroid hormones made by companies such as Abbott, that makes Synthroid. Errors have been found with other medications from these pharmacies. Recently, errors have occurred when they have compounded thyroid hormone.
Case History:

46 Y/O male admitted the hospital with 22 pound weight loss,palpitations, but he did not have thyroid enlargement on physical exmination. He had a history of hypothyroidism, and had been taking thyroid hormone replacement therapy with Synthroid for 10 years. However, recently he changed physicians and the new PMD, switched him to compounded T4/T3 combination. Prior to the switch he had complained of fatique, but the first physician told him the thyroid tests were normal on his Synthroid. TSH was 1.5 N0.3-3.0. He sought a second opinion and that is when the new physician told him that he needed T3 along with the T4. 6 weeks later he was admitted. The thyroid tests were off the chart, T4 75 N 4-12, T3 1541 N 70-170. The pills were made in error, and had 11 times the dose per pill. The patient was treated in the hospital until the pulse rate was normal and discharged on beta blockers. He was clinically improved , had gained weight, and felt better by 3 weeks. Off thyroid he became hypothyroid. He was switched back on his old dose of Synthroid and the TSH was returned to normal. The pharmacy denied using that dose on any other patient. Well, why use them at all, when, safe commercially available pure thyroid hormones are available by Rx from your physician. Stay away from physicians that tout compounded hormones for treating your thyroid conditions.

Good Luck,

Beware of Compounding Pharmacy Thyroid Hormone Dispensing Errors

I do not recommend the use of compounding pharmacy