Health Practices for Hashimoto Disease

Educational Objectives

The goal of this program is to improve the management of Hashimoto thyroiditis. After hearing and assimilating this program, the clinician will be better able to:

1. List adverse effects of selenium supplementation.
2. Explain the impact of low-dose naltrexone on thyroid function.

Summary

Hashimoto thyroiditis: Peterson et al (2018) surveyed >11,000 hypothyroid patients and revealed widespread dissatisfaction with current treatments; many respondents reported switching doctors or seeking complementary and alternative treatm ents

Iodine: thyrotropin (TSH) is elevated, and thyroid hormones are reduced in severe iodine deficiency; the body compensates by increasing the gland size and shifting production toward T3; thyroid supplements containing high doses (100x) of iodine are available in the market; studies have shown an association between iodine supplementation campaigns and increased rates of hypothyroidism and subclinical hypothyroidism, possibly because of increased free radicals within the thyroid, causing inflammation and an autoimmune response, or preexisting Hashimoto disease susceptible to the effects of excess iodine, eg, Wolff-Chaikoff effect

Vitamin D: the VITAL study by Manson et al (2020) showed no significant reduction in autoimmune thyroid disease with vitamin D supplementation (2000 IU/day); the D-Health trial by Neale et al (2022) found no significant difference in the rates of new levothyroxine prescriptions between the vitamin D and placebo groups

Selenium: deficiency is associated with autoimmune thyroid diseases; some studies have shown benefits of selenium supplementation, eg, reduced postpartum thyroiditis and improved mild thyroid eye disease; no benefit was observed in the treatment of Graves hyperthyroidism; cross-sectional evidence suggests that higher dietary selenium intake is associated with a 35% lower risk for developing Hashimoto thyroiditis; Wang et al (2018) found a 10% decrease in thyroid peroxidase antibody (TPO) antibody levels at 3 and 6 mo in patients taking selenium supplements; other thyroid parameters remained unchanged; a meta-analysis by Winther et al (2017) found that selenium consistently reduced TPO antibody levels, regardless of the duration of the study (3, 6, or 12 mo); this effect was more pronounced in patients with higher baseline TPO antibody levels; Huwiler et al (2024) showed a small but significant reduction in TSH levels after selenium supplementation; no significant changes were observed in T4 or T3 levels; adverse effects include alopecia, dermatitis, and increased risk for type 2 diabetes; the CATALYST trial by Winther et al (2014) showed that selenium supplementation reduced TPO antibody levels; no difference was observed in terms of thyroid hormone levels, levothyroxine dosage, or overall quality of life between the selenium and placebo groups; the selenium group reported significantly higher symptom scores at 12 mo

Ashwagandha root extract: a small study found that ashwagandha root extract lowered TSH and increased thyroid hormone levels compared with placebo; the mechanism behind this effect is unclear; potential concerns include the risk for adrenal insufficiency; there is no evidence to suggest the benefit of vitamin B₁₂, copper, magnesium, and zinc for patients with autoimmune thyroid disease

Microbiome: short-chain fatty acids have a positive impact on the immune system; a dysregulated gut microbiome may increase intestinal permeability, allowing antigens that resemble thyroid proteins to enter the bloodstream, triggering an autoimmune response against the thyroid gland; a healthy gut microbiome may promote thyroid health by recycling thyroid hormones, eg, bacterial sulfatases remove sulfate groups from T3, allowing it to be reabsorbed

Evidence: Zheng et al (2023) found that individuals with TPO antibodies had distinct oral microbiome characteristics compared with those without TPO antibodies; Zhao et al (2016) revealed that individuals with hypothyroidism had increased microbiome richness and diversity compared with those without the condition; slowed gastrointestinal transit may increase susceptibility to small intestinal bacterial growth

Diets: a gluten-free diet may alleviate symptoms and improve thyroid function in individuals with celiac disease; patients on levothyroxine with positive tissue transglutaminase antibody are less likely to meet TSH goals and be on higher doses of levothyroxine; a gluten-free diet improves medication absorption and reduces inflammation; Malandrini et al (2022) found no conclusive evidence that a gluten-free diet significantly impacts thyroid autoimmunity markers; the evidence does not suggest improvement with the Paleo diet, probiotics, and lactose-free diets; some vegetables contain negligible amounts of goitrogenic compounds, which are unlikely to have a significant impact on thyroid function, especially when cooked; the elimination of soy is associated with low iodine intake in certain populations

Other therapies: Chen et al (2020) showed that no significant difference was observed in TPO antibody levels between the acupuncture and control groups; the acupuncture group reported an improvement in quality of life; the study lacked a blinded, sham-controlled group; low-dose naltrexone (LDN) has been explored for its potential anti-inflammatory properties; Raknes et al (2020) found no significant association between LDN use and changes in thyroid hormone levels; there was a slight tendency toward increased levothyroxine use among patients taking LDN

Surgery: Guldvog et al (2019) showed that total thyroidectomy led to a significant decrease in TPO antibody levels and improvements in quality of life in patients with Hashimoto thyroiditis who experienced persistent symptoms despite medical treatment; a follow-up study by Hoff et al (2024) revealed continued improvements in quality of life regardless of TPO antibody levels; regression analysis showed that TPO antibody levels did not predict the change in symptom benefit

Readings

Arora P, Raihan M, Kubba A, et al. Lymphocutaneous sporotrichosis treated with potassium iodide with development of subclinical hypothyroidism. Indian Dermatol Online J. 2017;8(6):475-477. doi:10.4103/idoj.IDOJ_3_17. View Article; Huang H, Liu B, Qu N, et al. Research progress of opioid growth factor in immune-related diseases and cancer diseases. Int Immunopharmacol. 2021;99:107713. doi:10.1016/j.intimp.2021.107713. View Article; Kalra P, Prasanna Kumar KM. Recurrent thyroiditis. Thyroid Res Pract. 2021;18(2):45-49. doi:10.4103/trp.trp_9_21. View Article; Mahmoudi L, Mobasseri M, Ostadrahimi A, et al. Effect of selenium-enriched yeast supplementation on serum thyroid-stimulating hormone and anti-thyroid peroxidase antibody levels in subclinical hypothyroidism. Adv Biomed Res. 2021;10(1):33. doi:10.4103/abr.abr_252_20. View Article; Raknes G, Småbrekke L. No change in the consumption of thyroid hormones after starting low dose naltrexone (LDN): a quasi-experimental before-after study. BMC Endocr Disord. 2020;20(1):151. Published 2020 Oct 1. doi:10.1186/s12902-020-00630-4; Soens M, Sesso H, Manson J, et al. The effect of vitamin D and omega-3 fatty acid supplementation on pain prevalence and severity in older adults: a large-scale ancillary study of the VITamin D and OmegA-3 triaL (VITAL). PAIN. 2024;165(3):635-643. doi:10.1097/j.pain.0000000000003044. View Article; Thatipamala P, Noel JE, Orloff L. Quality of life after thyroidectomy for Hashimoto disease in patients with persistent symptoms. Ear Nose Throat J. 2022;101(7):299-304. doi:10.1177/0145561320967332. View Article; Wang X, Li Y, Xie H, et al. Effect of acupuncture on Hashimoto thyroiditis: A systematic review and meta-analysis. Medicine. 2024;103(9):e37326. doi:10.1097/MD.0000000000037326. View Article.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Angell has received grant/research support from Immunovant Inc. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Angell was recorded at USC Peter A. Singer Thyroid Symposium, held on May 18, 2024, in Los Angeles, CA, and presented by the Keck School of Medicine of the University of Southern California. For more information about the upcoming CME activities from this presenter, please visit keck.usc.edu/cme. Audio Digest thanks the speakers and the presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

FP730301

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.