Two Cases of Armour Thyroid Interference in Thyroglobulin Monitoring for Thyroid Cancer

Thyroglobulin (Tg) monitoring is the biochemical standard for surveillance of recurrent differentiated thyroid cancer (DTC). Several assays are available to quantify Tg levels: immunometric assay (IMA), radioimmunoassay (RIA), and the newer liquid chromatography tandem mass spectrometry (LC-MS). It is well known that a number of entities can interfere with the accuracy of testing, and at this point in time, no one assay perfectly balances high sensitivity with low risk of interference. In this case study, we present two cases in which treatment with desiccated thyroid extract (Armour thyroid) led to a sudden elevation in Tg, which resolved when Armour thyroid was discontinued. This elevation occurred when Tg was measured with both IMA and LC-MS, which suggests direct interference from porcine Tg rather than heterophilic or thyroglobulin antibody (TgAb) interference. We suggest that patients with a history of DTC not be treated with desiccated thyroid extracts consistent with guidelines. Furthermore, more advances need to be made in the area of Tg testing to improve specificity and avoid detection of nonhuman Tg and other similar proteins.

Comparative effectiveness of levothyroxine, desiccated thyroid extract, and levothyroxine+Liothyronine in hypothyroidism

Introduction Studies comparing LT4 therapy with LT4+LT3 or desiccated thyroid extract (DTE) did not detect consistent superiority of either treatment. Here we investigated these therapies, focusing on the whole group of LT4-treated hypothyroid patients, while also exploring the most symptomatic patients. Methodology Prospective, randomized, double-blind, crossover study of 75 hypothyroid patients randomly allocated to one of three treatment arms, LT4, LT4+LT3 and DTE, for 22 weeks. The primary outcomes were post-treatment scores on the 36-point thyroid symptom questionnaire (TSQ-36), 12-point quality of life general health questionnaire (GHQ-12), the Wechsler memory scale-Version IV (VMS-IV), and the Beck Depression Inventory (BDI). Secondary endpoints included treatment preference, biochemical and metabolic parameters, etiology of hypothyroidism, and Thr92Ala-DIO2 gene polymorphism. Analyses were performed with a linear mixed model using subject as a random factor and group as a fixed effect. Results Serum TSH remained within reference range across all treatment arms. There were no differences for primary and secondary outcomes, except for a minor increase in heart rate caused by DTE. Treatment preference was not different and there were no interferences of the etiology of hypothyroidism or Thr92Ala-DIO2 gene polymorphism in the outcomes. Subgroup analyses of the 1/3 most symptomatic patients on LT4 revealed strong preference for treatment containing T3, which improved performance on TSQ-36, GHQ-12, BDI and visual memory index (VMS-IV component). Conclusions As a group, outcomes were similar among hypothyroid patients taking DTE vs. LT4+T3 vs. LT4. However, those patients that were most symptomatic on LT4 preferred and responded positively to therapy with LT4+LT3 or DTE.

Desiccated Thyroid Extract Versus Synthetic LT4/T3 Combination Versus LT4 Monotherapy in the Treatment of Primary Hypothyroidism With Special Attention to the Thr92AlaD2 Polymorphism. With Special Attention to the Gene Polymorphism

Introduction: Before the availability of levothyroxine (LT4), patients were treated with desiccated thyroid extract (DTE). When switching from DTE to LT4, despite adequate dosing based on serum TSH levels, some patients still feel unwell with fatigue, mental fogginess, weight gain etc. A recent randomized, crossed over study between DTE vs. LT4 conducted in our department showed that once-daily DTE caused modest weight loss and possible improvement in mental health scores without appreciable adverse effects; also, nearly half of the study patients preferred DTE over LT4. A few studies have shown that LT4/T3 combination had beneficial effects in improving quality of life relative to LT4 alone. Furthermore, it has been reported that patients with CC genotype in the deiodinase type 2 polymorphism responded more favorably with LT4/T3 combination than T4 monotherapy. Hypothesis: This study investigated the efficacy and effectiveness of DTE vs. LT4/T3 combination vs. LT4 monotherapy in hypothyroid patients based on genotypic differences of deiodinase type 2. Methodology: This was a prospective, randomized, double-blind, crossover study. 75 subjects completed the study. There were 3 arms: DTE, LT4+T3 combination, and LT4 alone. Each subject was randomly allocated to one of these 3 arms for 12 weeks randomly. The study was powered to detect the primary outcome. The primary endpoint was post-treatment score on the 36-point thyroid symptom questionnaire. Secondary endpoints were weight, general health questionnaire, the Beck depression inventory, Wechsler Memory testing, lipid panels and thyroid function tests. Analysis was performed with a linear mixed model using subject as a random factor and group as a fixed effect. Results: There was no significant difference between the 3 arms on the thyroid symptom questionnaire (p=.32), and the secondary outcomes showed no between group differences. Auditory memory index (p=.008), and visual working memory index (p=.02) were higher in the Hashimoto’s than non-Hashimoto’s group. There was no significant primary or secondary outcome difference among various genotypes of deiodinase 2. There was no relationship between Hashimoto’s vs. non-Hashimoto’s based on genotypes or likelihood of carrying Thr92AlaD2 polymorphism. Though there was no statistically significant preference for any treatment, numerically more patients with Hashimoto’s preferred DTE and LT4/T3 combination than LT4-monotherapy. Conclusions: There was no significant difference between hypothyroid patients taking DTE vs. LT4/T3 combination vs. LT4 monotherapy. Numerically, Hashimoto’s patients tended to prefer DTE and LT4/T3 combination. Also, there was no observed relationship between Hashimoto’s and polymorphism. Further studies with more patients may be needed.

A Tale of Two Therapies- A Comparison of Armour Thyroid and Levothyroxine

Treatment of hypothyroidism is predominantly with levothyroxine due to its ability to generate stable T3 levels and its long half-life. Many patients report continued hypothyroid symptoms despite normal TSH values on levothyroxine and request to switch to desiccated animal thyroid extract. Desiccated thyroid extract is less used for fear of side effects and risks. There are only a handful of studies available comparing desiccated animal thyroid extract to levothyroxine. We conducted a retrospective study on 250 hypothyroid patients over the age of 18 who presented to our clinic from 2008-2018. We excluded patients who had a history of thyroid cancer and documented non-adherence. We analyzed 125 patients on levothyroxine (males=43, females=82) and 125 patients who were on levothyroxine but chose to switch to Armour Thyroid (males=7, females=118). We examined the following variables; when comparisons of proportions were made between the two groups, N-1 chi square test was used to determine significance. 1. Reason for change to Armour Thyroid from levothyroxine: Top reasons were fatigue (n=51/125, 40.8%), inability to lose weight (n=32/125, 25.6%), mental fog (n=8/125, 6.4%), hair loss (n=8/125, 6.4%) and desire for a natural product (n=7/125, 5.6%) 2. Percentage of patients complaining of fatigue/weight gain in euthyroid state: 16/125 (12.8%) of patients on Armour Thyroid and 29/125 (23.2%) of patients on levothyroxine had complaints of fatigue and weight gain with a normal TSH. This 10.4% difference was significant (p value=0.033, 95% CI 0.84% to 19.8%). 3. Presence of side effects: 24/125 (19.2%) patients on Armour Thyroid discontinued it before 6 months. The top reasons were no improvement of symptoms (n=9/24, 37.5%), palpitations (n=5/24, 20.8%), worsening anxiety (n=3/24, 12.5%), cost (n=2/24, 8.33%), and loss of appetite (n=2/24, 8.33%). 5/125 (4.00%) patients on levothyroxine chose to discontinue it before 6 months. The reasons included presence of palpitations (n=3/5, 60.0%), hair loss (n=1/5, 20.0%), and gluten intolerance (n=1/5, 20.0%). A total of 11/125 (8.8%) had adverse effects from Armour Thyroid while 4/125 (3.2%) of patients on levothyroxine had adverse effects to the medication. The difference of 5.6% leaned toward clinical significance and trended toward being statistically significant (p value=0.06, CI -0.4842% to 12.1677%). Our research shows that patients generally feel better on Armour Thyroid compared to levothyroxine. Armour Thyroid is an effective medication to use for patients who remain symptomatic on levothyroxine and should be considered as a viable option in clinical practice. However, our study also indicated that patients may have more adverse effects on Armour Thyroid when compared to levothyroxine and further studies are needed comparing the two medications. Limitations of our study include the retrospective nature of the study and the sample size.

Breast cancer cure by castration and oral administration of a thyroid extract

Dr. Beatson performed its operation at Glasgow Cancer Hospital and the fact that breast cancer has been cured in this case has been certified by all hospital medical staff.