www.flourishmd.com 320-424-0771

Hashimoto’s

Not just about the thyroid

Thyroid Basics

● Thyroid is a regulatory organ - hormones regulate many things in the body

● Thyroid hormones affect most tissues● Too little thyroid hormone→ sluggishness of the metabolism and

processes. Hypothyroid○ Treat with thyroid medications

● Too much thyroid hormone → hypermetabolism. Hyperthyroid○ Kill the thyroid gland - Radioactive Iodine. Then treat resulting hypothyroid.

● Both often caused by an autoimmune response/destruction.● Both cause symptoms and diseases

Hashimoto’s

● Autoimmune destruction of the thyroid (>90%) ● This leads to hypothyroidism (7 years)● This is the typical “low thyroid” that almost everyone has● Generally treated with thyroid medication● Autoimmune destruction continues● Highly associated with celiac disease (same gene sequence - HLA DQ)

○ Also the same as CIRS

● Most are women aged 20-60○ Becoming younger and younger at diagnosis

Stages of Autoimmunity

● Stage 1: Silent autoimmunity○ Elevated TPO and/or thyroglobulin antibody (anti-thyroid antibodies) with no symptoms

or loss of tissue

● Stage 2: Autoimmune Reactivity○ Elevated TPO and/or thyroglobulin antibodies with symptoms and normal TSH

● Stage 3: Autoimmune disease○ Elevated antibodies with symptoms, measurable tissue destruction, and elevated TSH

Important to pick it up and address in early stages.

Check your kids yearly if you have Autoimmune thyroid disease

Important notes

● There is no perfect replacement○ It has to be individualized

● Replacement isn’t the final treatment○ Very necessary part of the process - but the autoimmune has to be addressed

● It is actually treating the autoimmune process that is key● Need to check antibodies - not just TSH

Antibodies

● Antibodies are created to kill pathogens and foreign bodies● Antibodies tell us what the body has recognized as foreign● Autoimmune means immune killing of self● Autoimmune thyroiditis - Hashimoto’s - immune destruction of thyroid

○ Often has other processes at the same time - brain is the primary

● Anti-thyroperoxidase (anti-TPO, TPO Ab) - 95% Hashi - rare in controls○ Best marker!

● Thyroglobulin Ab (TgAb)○ Positive in 60-80% Hashimoto patients

● Thyrotropin receptor Ab - activating, blocking or neutral

Antibodies

● Anti-TPO - ○ 90% Hashimoto’s will have this - primary marker○ 75% Grave’s Disease○ 10-20% nodular goiter and cancer○ 10-15% of normal can have this

● Activating thyrotropin Ab - Grave’s/hyperthyroid● Antithyroid AB’s - increase subfertility, miscarriage, pre-term births● See Ab’s prior to clinical disease - best time to take action

○ Antibody levels are not associated with the severity of disease○ But they will go up and down from baseline

● Ab’s themselves don’t destroy tissue - They bind to bad T-cells - NK cells → destroy the thyroid (so destruction is about T cell - not Ab level)

Hashimoto’s

● Not just a thyroid disease!● It is a multi-system disease with numerous vicious cycles and must be

managed as a multi-system disorder● You cannot expect resolution of all symptoms with thyroid medication

Fluctuations TSH● Consider checking every 3 months if there are symptoms of instability● Check every 6 months overall● Check TSH but also antibodies● Get baseline level of Ab’s.

○ Then watch for changes (more stable than TSH)

● TSH can fluctuate with relapsing and remitting AI reactions against the thyroid gland, leading to alternating states of tissue breakdown and changing in circulating thyroid levels

● TSH can be low (<1) - episodes of hyper○ In active phases of destruction of the thyroid gland○ Releases excess T3/T4 when destroyed ○ Flare of tissue destruction causes hyperthyroid s/s - anxiety, insomnia, etc..

Hashimoto’s

● There is no cure● You can go into remissions - but realize it can flare at times● Remission/reactivations● All AI diseases are incurable - but goal long term remission● We need to control it once genes turned on ● Monitor symptoms - understand labs - what to do● Big picture

○ Triggers, treatments

● Important for you to know when it seems to be triggering as soon as possible

Clinical Considerations with Hashimoto’s

● Is the autoimmune reactivity stable?○ Fluctuating between hyperactivity and hypoactivity

Clinical symptoms thyroid overreactivity

● Tremor - hold hands straight out - put paper on them○ Slight shake

● Brisk reflexes● High heart rate - > 100

Due to:

● Acute thyroiditis flare (destruction leads to thyroid hormone escape)● Uncontrolled hashimoto’s● Excess thyroid replacement

2 Key Pathophysiological and Alternating Responses

● Fluctuating release of thyroid hormones from tissue breakdown● Fluctuating conversion rates (T4→ T3)● Thyroid hormone replacement fluctuations

○ How it’s metabolized○ How it’s converted○ Microbiome○ Binding

● Fluctuating thyroid receptor responses○ Inflammation at the receptor site

All lead to fluctuating hyper and hypo activity

Fluctuating inflammatory and Autoimmune responses

● Inflammation● Immune dysregulation● Immune suppression● Autoimmunity

These feed each other, create vicious cycles

Unstable Hashimoto’s

● Hard to find the perfect replacement● Increased metabolic activity● Hard to control● This is not a good sign● There are active environmental and AI triggers that need to be

addressed

Clinical Considerations with Hashimoto’s

● How aggressive is the autoimmune thyroid response?○ How often are we increasing dosage

Etiology of Hashimoto’s

● Combination of factors● Environment:

○ Smoking, alcohol, drugs○ Selenium, Vit D○ Iodine○ Stress, infections

● Genes:○ TSHR, TG ,HLA, CTLA4, and many more

● Essential factors:○ Female sex○ Parity

● This has escalated due to food chain, microbiome changes, toxins and more

Potential dietary triggers after the gene is turned on

● Gluten● Sodium intake● Iodine● Lectins● Lack of dietary diversity● Glyphosate-rich foods● Pro-inflammatory diet● Grains● Casein● Albumin● Dietary protein cross reactivity

Potential lifestyle triggers after the gene is turned on

● Insomnia● Sedentary lifestyle● Overtraining● Smoking● Alcohol● Drug use● Lack of rest● Unhealthy relationships● Stress

Potential chemical triggers after the gene is turned on

● Bisphenol-A (plastics!!!) - huge trigger!!● Pesticides● Air pollution● Fire retardants● Benzene● PCBS● PBDE● Perchlorate● Mercury

Potential pathogen triggers after the gene is turned on

● H Pylori● Toxoplasma Gondii● Yersinia enterocolitica● Candida● Hepatitis C● Epstein-Barr Virus● Cytomegalovirus● Herpesvirus-6● Parvovirus B-19● Borrelia Burgdoreferi

Complex web/knot

● There is no 1 protocol● Everyone is different with various triggers, starting places● The web is dynamic and changes

○ The starting point may be different with different flares

● We need to untangle the web looking at all the factors/triggers● We need to address the damage done along the way● Not caused by a single nutrient deficiency

○ Cannot supplement out of this!!

● Need to check lifestyle, environment and pathogens● Pick top targets - and then peel away layers

Clinical Priorities

● Is the thyroid disease stable or fluctuating between hyper and hypo?● Do you have appropriate thyroid replacement?

○ Do not want high TSH

● What obvious triggers can you identify?○ Lifestyle○ Food proteins○ Dysglycemia○ Antigens○ Chemicals/pollutants

● What nutritional strategies can you use to reduce thyroiditis?● What mechanisms are impacting immune tolerance?

Webs

Multiple “webs” for each system affected

Each system that is affected by thyroid can be impacted in multiple ways and interconnect

We will look at each to determine what co-existing issues that may need to be addressed

Take notes on those systems/webs/issues within that seem to affect you

Immune-thyroid web

● All Hashimoto patients have this issue● Thyroid is key for immune function● Can’t untangle the web if in a hypothyroid state (high TSH)● Need replacement first!● Thyroid hormones calm the immune system, the autoimmune response,

and inflammation● Thyroid hormones modulate every cell in the immune system● Expect a honeymoon phase● Hypothyroid → worsens oxidative stress, worsens leaky gut● Check regularly! Take hormones

Web of Hashi and Immune System

● Need to remove triggers then focus on the web● Can’t just focus on the gut - need to look at the whole web● Suppressed SigA - more vulnerable to food allergies, pathogens, toxins● Autoimmune - significant decrease in antioxidant production

○ Superfoods○ Exercise○ Sleep○ Give Antioxidants

● Blood brain barrier is important!

Clinical considerations For Hashi-immune web

● Are there any patterns of aggressive thyroiditis (thyroid swelling)?○ Hard to swallow, hoarseness, swelling over gland→ if positive - active!

● Are there any patterns of active infections?○ Check CBC, panels, infections. Can affect intestinal permeability, decrease antioxidants

● Are there any patterns of immune suppression?○ Total WBC <4 (Can get T and B cell profile). Cyrex Array 12

● Are there clinical findings of impaired antioxidant status?○ Workout - don’t recover well○ Chemical sensitivity (no reserve)○ Chronic pain and swelling

● Are there any patterns of immune barrier breakdown? (Array 2, 20)○ BBB - brain fog, Gut - reacting to food, Lung - respiratory issues, cough with a deep

breath

Clinical considerations For Hashi-immune web

● Are there any patterns of autoimmunity in any other tissue?○ Lab screen - cyrex 5

● Are there any clinical findings of immune compromise by chemicals?○ Measure if needed○ Timelines○ Non-metals affect thyroid (BPA/plastics, pesticides, flame retardants)○ Array 11

● Are there any findings of impaired immune tolerance? ○ How a person responds to a stressor○ Intolerance to smells, jewelry, products, MCS, skin outbreaks

Hashimoto’s and the Brain

● Many develop early neurodegeneration and brain inflammation○ Source chronic fatigue and depression

● This needs to be addressed even when in remission○ Significant brain inflammation○ Autoimmune to the brain

● There is now separate AI reactions in the brain to be addressed○ TPO Ab can bind in the brain - cerebellum. Increased inflammation and then

degeneration.○ Myelin protein Abs common in Hashi○ High cytokine in the brain

● Hashi is not just thyroid - also the brain!

Cerebellar degeneration

● Depression, brain fog● Check rhomberg, ataxia (truncal)

○ If ataxia or other signs - brain is in trouble

● Cerebellum - muscles, vestibular proprioception, initiating cognitive tasks

● Check antibodies to the brain

Cerebellar Degeneration

● TPO binds to the cerebellar tissue - can destroy the tissue● Gluten also does● Car sickness - is it getting worse?● Hashimoto’s almost always affects the thyroid and cerebellum

Hashimoto’s Encephalopathy

● Significant issues with brain damage due to AI reaction● Not common but important to recognize● Responds to corticosteroids!

○ May add IvIG

● Relapsing-Remitting or Chronic Progressive● Higher anti-TPO● Exclusion of other diseases (lab, MRI)

Clinical Considerations for the Hashi-Brain Web

● Are there any clinical findings of cerebellar degeneration?● Are there any clinical findings of autoimmune demyelination of the

central nervous system?● Are there any clinical findings of autoimmune demyelination of the

peripheral nervous system?● Are there any clinical findings of peripheral nerve entrapments from

tissue swelling? (Carpal tunnel)● Are there any clinical findings of neurovascular entrapments from tissue

swelling? (Thoracic outlet syndrome)● Are there any clinical findings of neuroinflammation or microglial

priming?

Clinical Considerations

● Are there any clinical findings of blood-brain barrier permeability?○ Leaky brain

● Are there any clinical findings of impaired plasticity?○ Can’t learn new or coordinated motor skills, struggle with cognitive skills, memory

● Are there any clinical findings of disrupted synaptic activity?○ Mood disorders, depression, anxiety (Neurotransmitter pathways)

● Are there any clinical findings of Hashimoto’s encephalopathy?

Hashimoto’s and the Microbiome/GI System

● Microbiome and thyroid interact bidirectionally○ Both affect the other

● Gut microbiome is different in Hashimoto patients○ Less diversity○ Often have bacterial overgrowth

● Oral tolerance is directly related to diversity of the microbiome● High rates gallbladder issues (sludge/stones) → malnutrition → can’t

absorb fat soluble vitamins● Bile acids help modulate microbiome.

Clinical Considerations for Hashi-GI Web

● Are there any clinical findings of impaired intestinal motility (constipation)○ Chronic constipation, Hx SIBO○ Need to use magnesium or laxatives for having BM’s○ Fiber supplements make GI symptoms worse

● Are there any clinical findings of intestinal permeability?○ Category 2 on metabolic form○ GI: Increased reactions to food, Chronic GI symptoms (diarrhea, pain, bloating), IBD○ Non GI: Autoimmunity, Chronic pain, chronic depression, CFS, Multiple food

sensitivities

● Are there any clinical findings of malabsorption syndromes?○ Discuss later

● Are there any clinical findings of gallbladder dysfunction?○ Category 8. How would a very greasy or fatty meal make you feel?

Clinical Considerations for Hashi-GI Web

● Are there any clinical findings of digestive enzyme impairment?○ Unable to digest high protein meals → HCL need○ Unable to digest high fiber or starchy meals → pancreatic enzyme need○ Unable to digest fatty meals or tolerate fried foods → Pancreatic lipase and GB

dysfunction

● Are there any clinical findings of dysbiosis or microbiota imbalances?● Are there any clinical findings of reduced microbiome diversity?● Are there any clinical findings of intestinal infection?

○ Red flags: Acute change in symptoms, Eosinophil - >3%, Gi panel

● Are there any signs of intestinal autoimmunity? Cyrex 5○ Nothing seems to fix it - has tried many things

● Are there any clinical findings of SIBO? Category 7

Hashi and Blood Sugar Issues

● Most overlooked issue with Hashimoto’s● It is a main trigger!● Hypoglycemia and/or insulin resistance

Dysglycemia

● If you can manage this - will calm the AI response○ Can improve up to 50% with this

● Hyperglycemia and hypoglycemia → oxidative stress, inflammatory markers○ Cerebral cell death○ BBB permeability

Clinical considerations for Hashi-Glycemic Web

● Are there any clinical findings of hypoglycemia? Category 10● Are there any clinical findings of insulin resistance? Category 11● Are there any clinical findings of mixed patterns of both?

○ Energy after meals, fatigue after meals, both

● Are there patterns of dysglycemia induced by lifestyle, diet or other factors?○ Meal and snack type - skipping meals

● Are there any patterns of pancreatic autoimmunity (Type 1, LADA)? Array 5○ Fatigue after meals, weight change, increased thirst, urination, appetite. Labs +

● Are there any patterns of adrenal autoimmunity (21-hydroxylase Ab)● Are there any patterns of advanced glycation end products (A1C)?● Are there any clinical patterns of post-prandial dysglycemia?

Hashimoto’s and Hepatic Function

● Thyroid hormone metabolism entirely depends on a healthy liver ● A biologically healthy liver is crucial for the well being of thyroid

hormone● If we hurt the thyroid → hurt the liver

○ Antithyroid drug therapy -> hepatitis, cholestasis, damage of liver

Clinical considerations for Hashi-Hepatic Web

● Are there any clinical findings of chemical burden?○ Toxin testing (metals and non-metals, Toxic Core, Cyrex 11 (Ab)

● Are there any clinical findings of impaired biotransformation?○ Category 9

● Are there lab elevations of ALT, AST?● Are there lab elevations of cholesterol and lipoproteins (LDL, HDL,

VLDL)?● Are there elevations of bilirubin or creatinine on blood tests?● Are there any clinical findings of chemical-induced inflammation?

○ Symptoms inflammation/pain/swelling, elevated CRP and ferritin

● Are there any clinical findings of liver disease?

Hashi and the female hormone system

● Autoimmune thyroid disease occurs in 18-40% of PCOS women● Infertility in Hashi - 47%

Clinical considerations for Hashi-Female Endo Web

● Are there any clinical patterns of flare-ups associated with the menstrual cycle?○ PMS, pelvic pain (hormone spikes can trigger an AI response)

● Are there any patterns of thyroid symptoms after taking oral contraceptives?○ BCP increase TBG - decreases free thyroid available

● Are there any patterns of thyroid/autoimmune flare-ups with hormones?● Are there any patterns of dysmenorrhea or amenorrhea?

○ Fixing glucose can help this alot

● Are there any patterns of hormonal fluctuations with perimenopause?

What to do?

So what do we do?

● Level 1 interventions○ Diet○ Nutraceuticals○ Lifestyle○ Hormone replacement

● Level 2○ Personalized autoimmune plan based on your web and triggers○ This will be dynamic, changing, and fluid○ It will build upon itself○ Re-evaluate often

Level 1 recommendations

Iodine

● Hashimoto’s is not caused by an Iodine deficiency!● Normal consumption of food is enough iodine● Iodine can actually cause flares of Hashi/AI reactivity● There is absolutely no research to support giving Iodine● 2011 - “Excessive iodine intake is a well-established environmental factor

for triggering thyroid autoimmunity” - Current Genomics● “Iodinated thyroglobulin is responsible for triggering the autoimmune

process….exposed to prolonged iodine supplementation” - 2007● Excess iodine promotes thyroid cell death● Increase in all thyroid issues with increasing iodine intake

Iodine

● Iodine increased in China - increased TPO Ab● “Iodine may change the natural course of autoimmune thyroiditis,

resulting in a more rapid progression towards hypothyroidism” - Journal Endocrinology

● Slovenia - increased I in kitchen salt from 10mcg->25mcg○ Hashi more than doubled○ Turned on the genes of susceptible people

● Study - 78.3% hypothyroid patients with HT - returned to normal thyroid function with only iodine restriction within 3 months○ Less than 100/ug/day○ Table salt has more than this in a tsp.

●

Low-Iodine Diet - try 3-4 weeks (esp if stuck)● No iodine in salt (use Sea salt)● Seasoning mixed with with iodized salt● Onion salt, garlic salt, or seasoned salt made with iodized salt● Seaweed, most seafood (except fresh water fish)● Any food with iodates, iodides, algin, alginates, carrageen, agar● Commercial bread and bakery products with calcium iodate, potassium iodate● Milk and milk products● Egg yolks● Check your minerals or multivitamins for Iodine - stop● Food, pills, capsules with Red Dye #3● Restaurant and processed foods● Soy products - edamame, tofu and soy burgers (Boca)

Goitrogens

● Foods - cassava, lima beans, linseed, sweet potato● Cruciferous vegetables such as cabbage, kale, cauliflower, broccoli,

turnips, rapeseed● Tremendous benefits for Hashi patients!!!● Testing in vitro (test tube) - goitrogen● Testing in human - shows benefit● No disruption T3 or T4 output● Benefits due to combating oxidative stress

○ Helps glutathione production (master detoxer) - protects thyroid

● Chemical goitrogens (pollutants) are harmful

Gluten

● GF diets shown to decrease titers, AI response, T3/T4 doses, and increases Vit D

● Celiac - High T cell response and devastation to gut wall and inflammation

● Gluten sensitivity - also problematic● If you have celiac - GF diet can be profound● Gluten sensitivity - GF diet is very helpful● Wheat germ agglutinin directly cross reacts with TPO - so may be

another reason to be GF (Array 3X)

Lectins

● Can have cross reactivity with TPO● This causes a TPO Autoimmune reaction● This can lead to thyrocyte destruction● We can check this with Cyrex Array 10● Cyrex Array 3X - Wheat Germ Agglutin - tells us also● Not all react to lectins

○ Can do a trial off○ Check labs

Autoimmune Protocol

● Improved vitality, physical and general health at 10 weeks● CRP decreased● WBC went to normal● Can be helpful if you are stuck● Most will do GF/DF → AIP (with nightshades) → AIP without nightshades

Specific Dietary Protein Cross-Reactivity

● Cross reactivity can occur between dietary proteins and human tissue due to molecular mimicry○ Have similar amino acid sequences

● If you have Ab’s to tissues - food can mimic this○ Only happens if you have auto-antibodies

● AIP diet first● Cyrex 10 if not better and remove possible cross reactive foods

Microbiome Diversity

● Studies show less diversity in HT patients● Bacterial overgrowth also common● Dietary fiber diversity = microbiome diversity● Don’t eat the same foods over and over!!● With some of the food restrictions - it is common to eat the same foods

○ Don’t do this!!

● Veggie mash-up○ But many vegetables, herbs - Wash - Food process - final product of each○ Combine into different mixes - freeze in glass jars○ 2 Tbsp daily○ Kale (3 types), broccoli, parsley, cilantro, dandelion greens, cabbage, beet tops, celery,

mint, ginger, carrots, yellow beets, radishes…..

Immune Tolerance - microbiome diversity

● If you are limited - need to focus on immune tolerance (program to come)○ Dr. Kharrazian’s 3D immune tolerance program

● SCFA (short chain fatty acids)○ Butyrate, proprionate, and acetate - fuel to the microbiome and T reg cells

● Fibers - help diversify bacteria○ Guar gum, pectins, flaxseed bran, cellulose gum, psyllium

● Critical for AI issues - microbiome diversity

Sodium Intake

● An immune response occurs from excess sodium○ Increased inflammation○ Decreased T regulatory cells needed to dampen inflammation○ Increases cytotoxic T cells

● Try not to eat too much salt (and definitely not table salt)● Use potassium with a salty meal (blocks the bad effects)

○ 1000mg with the meal

●

Blood glucose

● Need to manage this● Hypoglycemia - feels better after eating● Insulin Resistance - feels tired after eating● Mixed - can be either/varies● Hypoglycemia: No missed meals, avoid sugar and limit carbs, small

portions○ Don’t do fruit smoothies, no hangry episodes

● Consider ketogenic and IF if Insulin R issues

Lifestyle

● Stress○ Affects turning genes on and also reactivation

● Sleep○ T4, T3 decreased and rT3 increased significantly with sleep deprivation○ OSA - increases risk AI disease

● Exercise○ Keeps metabolic balance, influences AI status○

Hormone Therapy● Consider many options - don’t get stuck in one● Focus patient symptom relief and labs - not just labs● Consider T4 vs combination based on patients

○ Synthetic vs. non-synthetic - either may work just fine○ If tissue breakdown is too high - T3 can be very stimulating and not tolerated

● Brand name synthetics:○ T4: Synthroid, levothroid, levoxyl, unithroid, Tirosint○ T3: Cytomel○ T3 and T4: Thyrolar

● Brand name Bioidenticals (fixed doses)○ Armour, Westhroid, Nature-throid, NP thyroid

● Generic T4: Levothyroxine, L-thyroxine● Generic T3: Liothyronine Generic T3/T4: Liotrix Bioidentical:

Dessicated

Treatment of hypothyroid with hormones

● Decreases oxidants and increases antioxidants● CRP and inflammation improved● Decreased antibody levels● Need to check often in unstable Hashimoto’s (every 3 months)● Others need to check every 6 months

○ Don’t want to be hypothyroid!○

How to pick treatment?

● T4 monotherapy or T4/T3?○ Patient dependent○ T4: Covered by insurance, not bioidentical, Tirosint gel (no fillers), more tolerable in

aggressive disease○ T3/T4: Typically not covered, can support impaired conversion, can support those with

greater need T3

● Go on signs and symptoms● rT3 high - may be better with combination if tolerated● Don’t expect hormones to correct weight, or make you go into remission● The goal is to normalize TSH (not be hypothyroid)

Synthetic Vs. Bioidentical

● Synthetic: ○ Covered by insurance○ Used for those who cannot tolerate T3○ less reactivity to those that have autoimmunity against T3,T4, ○ Cytomel available for T3 (easier to dose seperately)○ Liotrix/thyrolar - combination

● Bio-identical:○ Not covered usually○ Cannot be used by those sensitive to T3○ More reactivity to those with AI for T3, T4

Thyroid absorption concerns

● Celiac not treated - malabsorption and many GI issues that impact● General appearance of malabsorption:

○ Dry unhealthy hair and scalp○ Pale skin, dry or flaky skin○ Loss muscle mass

● Clinical red flags on labs for malabsorption○ Low cholesterol (<150) → significant malnutrition○ Anemia → Iron, B12, or internal bleeding○ Low albumin → Protein malnutrition○ Vit D deficiency → Fat soluble-vitamin and or/D malabsorption○ Low platelets → Fat soluble vitamin and/or K malabsorption

● Vitamin C with thyroid - can improve absorption!! (helps with GI issues)

Reactions to fillers?

● Many fillers in tablets/capsules to hold it together● Modified wheat starch (glutenfreemeds)● Lactose monohydrate, dyes, confectioner’s sugar, microcrystalline

cellulose● BHA, Talc, Croscarmellose sodium, calcium phosphate, silicon dioxide● Mannitol, Mg stearate, acacia, sucrose, povidone, Sodium lauryl sulfate● Some will react to these or the gelatin of the capsule (Cyrex)

○ Those with significant food and chemical sensitivities○ Forget meds awhile and feel better??

● Gel has no fillers - Tirosint (T4, gelatin, water, glycerin)● Tirosint also has liquid - if sensitive to gelatin

○ Better absorption overall

Autoimmune reactivity to thyroid hormones?

● If the AI reactions are severe - may create reactivity to T3, T4● This can make it hard to tolerate at all● If this occurs - synthetics are often easier to tolerate

Correct Dosing

● Important in management of thyroid● Both excess and insufficient thyroid hormone may produce adverse

effects in various target tissues● Very important to manage high TSH (hypothyroid)● Also important to manage a hyperactive response (too much overall or

too much T3)

How often to evaluate labs?

Patient dependent

● 1. Is the thyroid autoimmune reactivity stable?○ Or fluctuating between hyper and hypoactivity

● 2. How aggressive is the autoimmune response○ Is there a constant need to increase dosage

Triggers and Nutriceuticals

Pathogens

● We don’t generally start with pathogen finding and treatment unless there are clinical indications such as abnormal lab work or a clear history that pathogens are an issue

● Could spend $1,000s ● Could chase your tail and not focus on main immune issue● H.Pylori - may want to screen- esp. With symptoms - stool● Hep C - fatigue, fever, muscle aches, L sided abdominal pain● Candida - serum Ab’s are best testing/OAT● Parasites - can be helpful/dormant/or active

○ If inflammatory markers on stool - may be active and treat!

Supplements

● Vitamin D - check levels (ideal 50-100)○ Vitamin D helps decrease inflammation, helps immune tolerance, metabolic balance,

repair..○ Many have low D and hard to raise (genes, inflammation, malabsorption gut)○ Dose 10,000 - 50,000IU per day

● Selenium - essential○ Helps the immune system, increases glutathione, improved inflammation, improved

markers● Magnesium

○ Needed for function, mitochondrial function and more! ○ Often low if taking diuretics

● Myo-inositol○ Regulates oxidation for thyroid hormone generation○ 600 mg twice daily (with selenium 83 mcg twice daily)

Supplements

● Glutathione ○ Master detoxer, decreases inflammation, decreases autoimmunity

● These can be individualized for symptoms and the web

Level 2 - Webs and triggers

Environmental Pathogens

● Viruses can directly infect the thyroid → painful thyroiditis○ Pain and swelling○ Can get alot of thyroid release and hyperthyroid symptoms

● Viruses can turn on the immune system → Ab’s and inflammation → flares auto-Ab’s → painless thyroiditis

● Pathogen reactions:○ Thyroid gland swelling

■ Difficulty swallowing■ Neck mass sensation■ Hoarseness■ Painful or painless

Pathogens associated with Hashimoto’s● Cosmetic/Therapeutic: Botox (high link to AI thyroid - mimics TPO AB)● GI Pathogens:

○ H. Pylori - most common infection. GERD/ulcers/asymptomatic. Can spread families.○ Toxoplasma gondii - can be benign - but if s/s - address. Neg Ab/PCR - in the gut only○ Yersinia enterocolitica○ Candida

● Viral pathogens:○ Hepatitis C - very common○ EBV - Can be cause or flare○ CMV - can get a thyroid flare with active EBV/CMV○ HHV6 - Everyone has had. Re-activation with PCR, fever, roseola, seizures → HT○ Parvovirus B19

● Spirochete: Borrelia Burgdorferi

Environmental pollutants

● Rising in number● Autoimmune thyroid and thyroid cancer continue to rise● Pathway 1: Chemicals that act as Goitrogens

○ Goiter caused by increased TSH or GH (hcg)○ Interrupt thyroid hormone production → increased TSH → goiter○ Many chemicals - PCBs, phthalates, DDT and more. ○ Iodine, lithium, antifungals, bromine and flourine

● Pathway 2: Chemicals that disrupt thyroid signaling pathways○ BPA!!!!!!!! BPA free is BPS - even worse. Avoid all plastic!! Even a lid on coffee

■ Cutting BPA almost as serious as cutting gluten!○ Also phthalates, perchlorate, pesiticides

Toxins

● Pathway 3: Chemicals that promote AI thyroiditis○ 28% increase HT with glyphosates○ Glyphosate binds and changes the wheat - HLA-DQ with HT and celiac○ Many grains have increased pesticides and glyphosate

● AIP diet - may help because of pulling grains and thus decreasing glyphosate

● BPA - TPO positivity, destroys thyroid cells, increased thyroid cancer● Toxic metals - lead, cadmium

Toxins

● We all have chemicals in our body and exposures● Pull the web slowly

○ Chelation too early can be harmful○ Often we address this later - unless the s/s started after acute exposure

● Work on toxins that you can● Toxin course● Pull all plastics!!● Look at clinical considerations

Clinical considerations - toxins

● Ongoing exposure that can be avoided○ BPA, fire retardants, carpets, etc..

● Biotransform and metabolize chemicals?○ Thyroid needed for phase II - support phase I and II○ Check Phase II: High homocysteine/MTHFR, sulfation, etc..

● Do you have proper AO reserves to protect against free radicals?○ Exercise response? Chemical exposure response?

● Permeability issues?● Increased load - can test this● Chemical-immune reactivity? Can test for AB to chemicals

Clinical considerations - pathogens

● Active infection? Lab work. May be a priority if active● Are there patterns of silent infection?● Can it be eradicated by medicine?● Are there strategies to improve immune function to eradicate the

pathogen?● If not sure - decide together if these are initial targets or later.

Overview

● Look at the big picture first● Draw out your web - specific to your symptoms and findings● Decide where to start and order to address issues

5 initial considerations

● Is the thyroid autoimmune reactivity stable?○ Varying from hypo to hyper?

● How aggressive is the AI thyroid response?○ Increasing dose steadily - yearly or more

● Does the patient have cerebellum cross-reactivity?● Does the patient have AI reactivity in any other tissue?● Are there any medication interactions with the thyroid gland?

Physical Exam

● Hair thinning○ Insulin and inflammation

● Thinning of lateral third eyebrow● Facial swelling● Hand swelling/carpal tunnel● Signs of poor circulation

○ Pale nail beds, weak nails, fungal toenails

● Cold hands and feet (can check temps)● Capillary refill● Thyroid swelling/goiter/nodules●

Next - Assess the web - Metabolic Assessment Form

● Category 1 - Dysbiosis● Category 2 - Intestinal permeability● Category 3 - Loss of immune tolerance● Category 4 - HCL need● Category 5 - Gastric ulcer symptoms● Category 6 - Pancreatic Enzyme Need● Category 7 - SIBO● Category 8 - Gallbladder sludge/stone● Category 9 - Impaired hepatic biotransformation● Category 10 - Hypoglycemia● Category 11 - Insulin Resistance

Metabolic Assessment

● Category 12 - Underactive Adrenal Function● Category 13 - Overactive Adrenal Function● Category 14 - Electrolyte Imbalance● Category 15 - Low Thyroid Function● Category 16 - Hyperactive Thyroid Function● Category 17 - Prostate (males)● Category 18 - Andropause symptoms (male)● Category 19 - Perimenopause (female)● Category 20 - Menopause (female)

Overall Care

● Dynamic and changing ● We will try things which may or may not work● Take a new approach● Dig into triggers and pathways as we go● Must understand the big picture and what to tackle first● Must continue to be vigilant and monitor● Understand this is not just about thyroid medication● There will be relapses and remissions

○ Goal is you recognize them early

● Goal - longest remission possible with minimal symptoms● Must be out of hypothyroid state first - then triggers and web

Summary

● Thyroid gland recommendations● Lab and special testing ● Lifestyle recommendations● Dietary recommendations● Supplement recommendations

Apex Energetics

● Dr. Kharrazian● Made in the US, with US products● Verified dairy and gluten free● Temperature controlled●

Thyroid Wellness

● Thyroxal○ MVT for Hashimoto’s - without Iodine!○ A,D,B5,Mg, Selenium and more○ 45 days (90 tabs) - $20

● Thyro-CNV○ Helps with the conversion T4-->T3 (5 deiodinase enzyme)○ Good for those on T4 only or T3 is in the lower range○ 45 days (90 tabs) - $20

Glutathione (master antioxidant)

● OxiCell - Cream over the thyroid (pain or swelling) - $24○ Massage in for a minute or two○ With or without essential oils

● Trizomal Glutathione - $37○ NAC and Glutathione○ Acetyl form glutathione is better absorption○ Liquid - able to titrate easily○ 10 ml three times daily to start → down to 1-2 times daily

● AC-Glutathione - $31 (month)○ Capsule for travel, work, when can’t have liquid

● Glutathione recycler - $20 (month)○ Helps to increase glutathione in the cell

● Use oxicell, trizomal and recycler if significant AI flares

Gluten

● GlutenFlam○ Many have issues - so important to decrease reaction○ Digestive enzymes to break down the gluten peptide (specific)

■ Peptides are damaging - once broken down - it is not○ Botanicals to decrease intestinal inflammation○ 1-2 every few hours after exposure until feeling better○ $22

Intestinal Permeability

● RepairVite (continue once healthy) $26○ L-glutamine, DGL, Aloe, and others to soothe and heal the GI tract

● RepairVite● RepairVite GT - adds ginger● RepairVite SE - for those with many intolerances - $23

○ SIBO, extreme sensitivity

● RepairVite Program available - food program with the product

Blood Sugar Issues - hypoglycemia

● Eat more frequently● Eat more protein and fiber vs. carb meals and snacks● Proglyco SP - $22 month

○ MVT/mineral 1-2 with each meal - amino acids - glandulars and other to help BS

● Adaptocrine - $20 (45-90 days)○ Synergistic herbs for adaption, cortisol and other BS support

● AdrenaStim - for low BP/dizziness - $24○ Licorice cream. Helps retain sodium - helps BP

Blood Sugar Issues - Insulin resistance

● Fibromin - $15○ 1-2 with meals - slows the glucose uptake to decrease sugar spike

● Glysen - $26○ 1-2 with meals up to 3-4 with a meal○ How many does it take to not get tired after a meal?○ If not helpful - add glycoberine

● Glycoberine● Glycoberine MX

Biotransformation

● Support the pathways - 2-3 weeks initially● Everyone should do this 1-2 x a year for 3 weeks● ClearVite

○ Phase I,II, minerals

● -CLA - collagen for the protein● -PSF - vegetarian version - no collagen. Pea protein

○ So not good with lectin issues

● -GL - no protein at all

Immune Support

● X-Viromin○ TH1 Support - T cells, NK cells○ Astralagus, echinacea, mushrooms, pomegranate

● X-FLM○ TH2 Support - B cells○ Green tea extract, Grapeseed extract, Resveratrol

● Autoimmune patient - with a virus - do both● Some have trouble with 1 or the other - check history

○ Try one and then the other○ There are small bottles to try 1st

Other:

● GI Synergy○ Pathogens GI

● Turmero Active ○ Turmeric

● Resvero Active○ Resveratrol

● Both - 10 ml 1-3 times a day initially ● Someone with a lot of inflammation and oxidants

○ Use both plus X-FLM

Immune Modulation

● Enterovite - SCFA○ Helps microbiome, energy, T reg cells○ 4-5 capsules 1-2x/day

● Enzymix Pro○ Digestive Enzyme

● Liquid A and D if higher doses needed● Strengtia

○ Probiotic with most common needed for the gut

Cyrex Panels

● 2 - Intestinal Permeability $195● 3x - Wheat and gluten $269● 4 - Gluten Cross Reactive $225● 5 - Multiple autoimmunity $575● 6 - Diabete AI $175● 7 - Neuro AI $275● 7x - Neuro expanded $430● 8 - Joint AI $195● 10 - Food $469● 10: 10-90 Food $299

Cyrex Panels

● 11 - Chemical $295● 12 - Pathogen $379● 14 - Mucosal $339● 20 - BBB $225● 22 - IBS/SIBO $259

With an order: Get the following at this price

10 - $399, 10-90 - $269, 20 - $175

2,3,and 4 - $595

Keto and Fasting

● Needs to be entered into cautiously for those with hypoglycemia● Ketones dampen anti-gliadin cells and autoimmune reactions● Autophagy - clears out the bad

○ IF helps this

● 3 day fasts - rid of brain debris and are the best once worked up to