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Thyroid (Expert Forum)
Adrenal problems after synthroid treatment
Answered by
Mark Lupo, M.D. - Thyroid Nodules, Thyroid Cancer, hyperthyroidism, hypothyroidism, Thyroid Ultrasound
Thyroid & Endocrine Center of Florida
Sarasota - FL
Questions in the Thyroid forum are answered by Dr. Mark Lupo. Topics covered include goiter, graves disease, Hashimoto's thyroiditis, hyperthyroid, hypothyroid, thyroid cancers, thyroiditis, and thyroid stimulating hormone (TSH).
Adrenal problems after synthroid treatment
by florinef, Sep 26, 2006 12:00AM
Hi Dr. Mark,
I have a theory question.
I stopped by here last year, very ill after starting thyroxine-TSH 200. Symptoms were salt wasting and excessive urination leading to joint/muscle pain, headaches, nausea, blue numb hands and feet and eventually bouts of delirium when I drank water or electrolytes. 3 endos all agree that it looked adrenal but adrenal tests were all normal. No one has any answers. I got better after taking florinef when starting the synthroid and rapidly improved. Another lady also posted on the board with the exact same set of symptoms.
Importantly-no pretreatment edema at all- likely due to the protective effects of a collagen disorder (EDS III). Reduced interstitial space I believe thus much less water and poly saccaride buildup. see through skin, reduced skin thickness and so on.
I think my brain thought it needed to dump water and salt due to the sudden drop in TSH but my body didn’t have any water to drop. Thus diabetes insipidus like symptoms, extreme dehydration and salt loss.
A paper-by george choreoas at the NIH-discusses the role ADH plays in modulating ACTH production in the pit along with CRH. Could it be that some of the mild AI symptoms people show up here with are due to drops in ADH upon TSH normalizing which then trigger drops in ACTH? There is no adrenal problem but there are mild adrenal like symptoms.
What do you think?
I have a theory question.
I stopped by here last year, very ill after starting thyroxine-TSH 200. Symptoms were salt wasting and excessive urination leading to joint/muscle pain, headaches, nausea, blue numb hands and feet and eventually bouts of delirium when I drank water or electrolytes. 3 endos all agree that it looked adrenal but adrenal tests were all normal. No one has any answers. I got better after taking florinef when starting the synthroid and rapidly improved. Another lady also posted on the board with the exact same set of symptoms.
Importantly-no pretreatment edema at all- likely due to the protective effects of a collagen disorder (EDS III). Reduced interstitial space I believe thus much less water and poly saccaride buildup. see through skin, reduced skin thickness and so on.
I think my brain thought it needed to dump water and salt due to the sudden drop in TSH but my body didn’t have any water to drop. Thus diabetes insipidus like symptoms, extreme dehydration and salt loss.
A paper-by george choreoas at the NIH-discusses the role ADH plays in modulating ACTH production in the pit along with CRH. Could it be that some of the mild AI symptoms people show up here with are due to drops in ADH upon TSH normalizing which then trigger drops in ACTH? There is no adrenal problem but there are mild adrenal like symptoms.
What do you think?
Doctor's Answer
by Mark Lupo, M.D., Sep 26, 2006 12:00AM
, Sep 26, 2006 12:00AM
Adrenal insufficiency sx are different from DI sx that would be the result of a transient drop in ADH -- ADH comes from posterior pituitary, whereas TSH from the anterior. I do not know of any definite link b/w TSH and ADH. THe CRH/ACTH link may make more sense b/c of the ADH effect on salt/fluid that is governed in part by the adrenal -- however this effect (mineralocorticoid) is not governed by ACTH in the way that glucorticoid production is. So, interesting question.
The fluid retention seen in severe hypo is linked to decreased renal function due to low thyroid. Correcting this mobilizes fluid due to improved kidney filtration. I don't think it is ADH mediated.
The fluid retention seen in severe hypo is linked to decreased renal function due to low thyroid. Correcting this mobilizes fluid due to improved kidney filtration. I don't think it is ADH mediated.
Endocrinology. 1998 Feb;139(2):437-40. Review. No abstract available.
PMID: 9449607 [PubMed - indexed for MEDLINE]
Sorry, here's that ref. It's pretty old but when I stumbled across it it made me rethink my med combination substantially as well as all the problems I had been having.
Also, remember Ar who got orthostatic hypotension after large doses of cortisol and florinef wasn't helping much? Something like that happened to me as well later on due to a very small 5 mg dose of cortisol. Perhaps the same type of problem?
1) A very skinny person who is substantially hypo. I had a TSH of 200. My mother was at TSH of 120 when diagnosed. We seem to have a genetic protective factor of some sort that prevents the majority of edema associated with hypo. There was some-my hearing was bad and my face was puffy-but none at all in my arms, legs or torso. Likely this is a collegen disorder which causes joint hyperflexibility and reduced interstitial spaces under the skin due to disorganization of the collegen structure. (EDS type III). My body tried to retain the water/polysaccharide/salt mix that most hypos have but didn¡¦t have anyplace to put it. Taking small amounts of synthroid-25 ug-caused massive dilute urination, headaches, weakness, nausea, blue arms and legs and eventual delirium. Extreme salt cravings. I found a nephrology paper which did show drops in ADH upon treatment of profound hypo-TSH of 100 or so but noted many studies had been inconclusive.
I figure my body dumped water and salt when it didn¡¦t really need to. My brain was too dumb to listen to my body likely due to the extremity of the hypo situation. Just taking florinef-100 ug a day- helped keep in the water and the salt cause for every molecule of salt you have to keep a molecule of water. A lady named Becky a long time ago had this happen to her as well so I don¡¦t think I am alone here.
2) Apparent symptoms of Adrenal insufficiency while taking large or small doses of cortisol. A lady named Ar came here after taking five days of 70 mg cortisol a day. She developed low blood pressure, nausea, and felt really horrible for about four months until it slowly got better. Florinef helped a little but didn¡¦t raise her blood pressure they way you would expect it to normally. It isn¡¦t really AI because it should have happened after stopping the cortisol not while taking it.
I (idiotically) tried taking a boving adrenal extract last summer-likely about 5 mg of cortisol. After four days I began to get very lightheaded with rounds of ¡§wooziness¡¨. I stopped the extract and the next day began running a fever, lay on the floor with a very rapid heartrate, with waves of nausea and lightheadedness due to plummets in blood pressure. I started a weaning dose of prednisone-20 down to 0.25 mg over about ten days. The acute AI symptoms went away but the rounds of afternoon nausea and lightheadedness did not. Over six weeks it got worse and worse. I couldn¡¦t stand up after noon and I couldn¡¦t eat or sleep. Extreme stomach inflammation, gastric reflux, apparent gall bladder pain, blood pooling in my extremities, and drops of BP from 120/80 to 80/40. Insomnia at night due to cortisol spikes and gradually over the course of several weeks development of mild psychosis and seizure like twitches. Continually decline. Continual increase of florinef in an attempt to raise BP. 1 mg of Cortisol would relieve the acute symptoms but then I would be in bed all day unable to stand up as it made the chronic problem worse.
Suicidal at this point but still trying to find an answer I stumbled across the above paper. It was illogical to me at first and then I realized that potentially I had a messed up cycling of the ADH-CRH-cortisol loop with the adrenal extract due to my special-ed endocrine system. I realized the florinef might be suppressing the ADH side as florinef causes some retention of water in the molecular sense. I weaned off the florinef, became very thirsty, my urine became very concentrated, and my BP rose back up to normal. I began retaining water, mostly in the soles of my feet within hours of weaning the dose down and the above problems all ceased. I think this is indicative of an ADH increase thus perhaps for folks like myself and Ar, treating with a weaning ADH dose may be a better answer than florinf or cortisol.
DON¡¦T TAKE ADRENAL EXTRACTS PLEASE.
3) I have heard from many, many people that they had mild adrenal like problems when starting thyroid hormone replacement and eventually they founds docs who put them on cortef and they got better. Perhaps a disruption of ADH levels due to the water loss upon thyroid treatment is enough to disrupt the ADH-CRH-ACTH loop. It isn¡¦t severe enough to kill you but makes you uncomfortable. Perhaps treating with an ADH replacement is a better idea than the cortisol which could substantially disrupt the loop even more.
ADH Mediated Central Adrenal Fatigue-ADHMCAF (he¡Khe¡K.he¡K ƒº )
First, are you saying that no one should take adrenal extracts, or just those with similar conditions?
Are you also saying that physiologic doses of hydrocortisone are not appropriate, or just that within the adrenal extracts?
Is this a feedback loop you're referring to? Please expand...in layman's terms simple enough for a hypobrain! :)
Thanks!
I think the cortisol extracts may be okay for many people but when you hang around some of the adrenal groups on the web long enough you'll find people do some crazy stuff. One guy would take 60 mg of prednisone for 1 month then stop abruptly in an attempt to combat chronic fatigue. That would kill many people.
So it's the same idea with the cortisol or extracts. They likely work okay for many-most people but the worry is that the more "off" and unstable your endocrine