[adenure]

in reply to: Recently Hyper #1171711

Yes, the liver issues are rare (5% I believe), but if you’re the 5%, you definitely want to know 😮 I’ve heard that some doctors don’t order the liver tests as they tend to rely on the patient showing symptoms of liver issues instead. So, if your doctor doesn’t order those tests, do request them.

Alexis

[adenure]

in reply to: Remission and possibly no more children…. #1171702

Hi,

I too am in a similar situation. I had my 4th baby boy in November of 2011, and I’m fairly certain it triggered Graves. I didn’t have a problem with my other 3 boys, but this time I did. I took methimazole for the last 7 weeks, but because it started damaging my liver (very abnormal liver function tests came back that were totally normal pre-medicine), I had to stop on Friday. It did make my thyroid normal though. So, I will have to have surgery or RAI probably- I call my doctor today.

I don’t plan on having any more children; I, like you, don’t want to trigger the Graves coming back/ being hyper again. I’m hoping I don’t go hyper again while I’m trying to figure out the next step right now.

That being said, I do have a friend who has Graves and took ATD’s through out her 4 pregnancies for the last 10 years and breastfed as well. So, it can be done- she has had issues with Graves on and off these last 10 years and has been on both ATD’s. I don’t know her history in detail, but it can be done- but, I suppose it’s possible that childbirth could trigger the hyper symptoms again- it is stressful (as we know!) and having a baby (although wonderful), is tough on the body. I hope you find peace in your decision and take it 1 day at a time.

Alexis

[adenure]

in reply to: Recently Hyper #1171709

Hi!

I hope all goes well for you. Like Bobbi said, there are rare side effects, but they are dangerous. I am NOT trying to steer you away from Tapazole (methimazole), but please ask your doctor to do liver function testing along with the thyroid testing for your labs. I was on methimazole (5 mg. daily- a very low dose) for 7 weeks and it did wonders for my thyroid- I was in normal range! However, it started damaging my liver and sent my liver enzymes into the 200 & 300 ranges (normal is around 25 and 46- which I was before starting the drug). I didn’t have any side effects from the abnormal liver enzymes- my pee was normal, I didn’t get a fever or sore throat and I felt fine. So, if I hadn’t had the enzyme testing, I wouldn’t have known and would have kept on taking the medicine. I stopped Friday, so today I go in to check to see if my liver is returning to normal- I’m hoping so. Next step for me is RAI or surgery- we’ll see- I call my doctor today.

Alexis

[adenure]

in reply to: RAI Questions #1170426

Hi!

I would really appreciate you keeping us up to date on your progress. I was on methimazole (5 mg. daily) for the last 7 weeks. It did a great job on my thyroid However, it beat up my liver which I just found out after getting my labs done on Friday. So, tomorrow I go for more lab work to make sure my liver is “righting” itself after stopping the meds on Friday. I don’t know if I’ll be a candidate for surgery as I was only on meds. for 7 weeks, and even though my thyroid was fine Friday, not sure if it will stay that way or not. RAI might have to be my “choice”. I have 4 young boys, so staying away from them would be hard, but I will do what I have to do. I call my doctor tomorrow to figure out what the next plan is.

Alexis

[adenure]

in reply to: Thyroid levels are normal :), liver is not. :( #1171671

Thanks Kimberly,

My baseline was pretty normal. ALT was 42 & AST was 26. Now they’re 323 & 233.

Alexis

[adenure]

in reply to: Worried & Upset About Liver Test Results #1171659

catstuart,
What do you mean that you react “to much to it”? Your pulse gets too low? The dose I think I was prescribed was 1 pill- a minimum dose. 25mg. and the 25 mg. be cut in 1/2?

Alexis

[adenure]

in reply to: What now? #1171668

The bitter sweet part of all this is that (in the 7 days), both my TSH & Free T4 have returned to normal- TSH is 1.46 (it was .01 with the normal range being .35- 4.00). My Free T4 is .9 (is was 1.92- normal range .81- 1.54). So, my next question is, how long will these numbers last off the methimazole? What’s my window for surgery? Does anyone know? Yes, I have been emailing my doctor over the weekend to get my thoughts out to him- so I plan on talking with him come Monday, but waiting is hard.

Alexis

Yes, I will do whatever I have to do to stay normal, even if I have to wean my baby. My 1st son was bottle fed after a month of nursing. So, I will survive and so will he, this I know. It’s just hard. But, one day at a time and trying to stay positive.

[adenure]

in reply to: Worried & Upset About Liver Test Results #1171655

I have Atenolol too- I’ve never tried either beta blocker? What are all of your experiences there?

Alexis

[adenure]

in reply to: Worried & Upset About Liver Test Results #1171654

Hi Shirley,

I did get to talk with a doctor who advised me to stop taking the methimazole. He ordered another round of liver enzyme tests for Monday to see if they start coming down (to rule out any other causes if they were to continue to rise). I have a beta blocker (Inderal/ propranolol) prescribed in case my symptoms start to come back (heart rate/ tremors)- 10 mg. 2x’s a day. I’ve never taken it, so I’m not sure how that would go. Anyone with experience there? I’m not sure what my thyroid numbers are.

If I have to choose RAI or surgery (which it would appear I’ll have to do as I don’t think they’ll prescribe PTU based on my liver numbers on methimazole, but who’s to say I guess- I haven’t asked yet), I would prefer surgery. Is that out of the question if my numbers aren’t normal? Do I HAVE to do the RAI? Thanks for the support; this is hard.

Alexis

[adenure]

in reply to: 1st Labs post ATD tomorrow! #1171645

Thanks! Any improvement works for me along with a healthy liver and white blood cell count! Of course I want to be 100% better, presto change-o, but I’m trying to remember and learn that patience is important.

Alexis

[adenure]

in reply to: Methimazole & Symptoms #1171559

Hi Shirley!

Thank you for your response and thoughts; I appreciate them all! The symptoms aren’t too bad. I think it was more like I had 4 solidly good days and then some of the symptoms came back a little and it was discouraging. I can function and am able to teach my boys and play some, but it does require more of an effort and an “act of the will” than it used to. I did have fun building some goofy looking Legos guys with the boys today and having a good laugh.

Patience. Yes, patience. I think of when we’d go EVERYWHERE- zoo, museums, park, puppet show. I’d walk the zoo for 4 hours, 7 months pregnant, pushing my other 3 boys in the stroller, up hill like it was nothing or close to nothing . Long gone are those days I tell you. Although, I sure hope I’ll be able to walk the zoo again and be that active again. It could be so much worse, and I am very blessed and grateful that I was diagnosed fairly quickly (due to my crazy persistence and constant research- hee hee! & a good primary doctor too), and I’m grateful for (what seems so far) a very good endo. who is good at getting back to me via email within a day of my communicating with him. So, things seem to be good. I suppose I’ll always feel as if I’m “not quite right” until I feel like my normal, strong 100% self. I have to learn to accept this (hopefully temporary) new “normal”. I had asked about being tested earlier (when I first got the meds.) and he said I really needed to wait 8 weeks to show what was happening with my levels. So, I figured okay.

I was just curious about thyroid storm; I do not think I am at a risk for that- I feel like, although not where I want to be, that I am getting on the right track, although slowly. Yes, I too want to be me again right now. I have moments of feeling down and without hope, but they’re usually moments after a tough day. I cry some, talk with my husband, and then watch an episode of Cake Boss- That helps- distraction with a fun show or a good book. Well, time to finish the evening with the family. Have a great night & thank you for writing!

Alexis

[adenure]

in reply to: Diagnosed today #1171440

He does sound like a good doctor- listening to you and then willing to explain his reasons behind the dosage. I hope everything works out for you & that your shoulder heals and that your thyroid gets under control. Keep us posted on how things are going.

Alexis

[adenure]

in reply to: Started PTU but levels still increasing? #1171566

Hi!

Yes, I had his blood drawn when I started the meds. (6 weeks ago) to establish a baseline (which was normal). The recommended testing is every 3 mo. I think. Although on 5 mg., he should be fine. Yeah, poor guy was napping in my arms when they stuck the needle in his arm to draw blood 😮 Ouch! He cried, but was fine after it was done. For me, breastfeeding is very important. I wasn’t able to nurse my 1st son and he has asthma and anaphylaxis to peanuts (anaphylactic allergies to food and medicine runs in my family). I nursed my 2nd son for 2 years & my 3rd son for 3 years and neither of them have any allergies or asthma. So, I’m committed to nursing my youngest as long as I possibly can. I’ve nursed him through 2 emergency room visits (my own) and through the worst part of my Graves when I was dealing with my worst hyper symptoms a few months ago. It hasn’t been easy, but I’m going to do my best to stick with it.

Alexis

[adenure]

in reply to: Pregnancy and PTU / 17 weeks #1171579

Here’s ATD info. & breastfeeding per Dr. Thomas Hale:

-Alexis

METHIMAZOLE

Trade Names: Tapazole

Uses: Antithyroid agent

LRC: L3

AAP: Maternal Medication Usually Compatible with Breastfeeding

Methimazole, carbimazole, and propylthiouracil are used to inhibit the secretion of thyroxine. Carbimazole is a prodrug of methimazole and is rapidly converted to methimazole. Milk levels of methimazole depend on maternal dose but appear too low to produce clinical effect. In one study of a patient receiving 2.5 mg methimazole every 12 hours, the milk/serum ratio was 1.16, and the dose per day was calculated at 16-39 µg methimazole.[1] This was equivalent to 7-16% of the maternal dose. In a study of 35 lactating women receiving 5 to 20 mg/day of methimazole, no changes in the infant thyroid function were noted in any infant, even those at higher doses.[2] Further, studies by Lamberg in 11 women, who were treated with the methimazole derivative carbimazole (5-15 mg daily, equal to 3.3 -10 mg methimazole), found all 11 infants had normal thyroid function following maternal treatments.[3] Thus, in small maternal doses, methimazole may also be safe for the nursing mother. In a study of a woman with twins who was receiving up to 30 mg carbimazole daily, the average methimazole concentration in milk was 43 µg/L.[4] The average plasma concentrations in the twin infants were 45 and 52 ng/mL, which is below therapeutic range. Methimazole milk concentrations peaked at 2-4 hours after a carbimazole dose. No changes in thyroid function in these infants were noted. In a large study of over 134 thyrotoxic lactating mothers and their infants. Methimazole therapy was initiated at 10-30 mg/day for one month, and reduced to 5-10 mg/day subsequently. Even at methimazole doses of 20 mg/day, no changes in infant TSH, T4 or T3 were noted in over 12 months of study.[5] The authors conclude that both PTU and methimazole can safely be administered during lactation. However, during the first few months of therapy, monitoring of infant thyroid functioning is recommended.

Pregnancy Risk Category: D, D

Lactation Risk Category: L3, L3

Adult Concerns: Hypothyroidism, hepatic dysfunction, bleeding, drowsiness, skin rash, nausea, vomiting, fever.

Pediatric Concerns: None reported in several studies, but propylthiouracil may be a preferred choice in breastfeeding women.

Drug Interactions: Use with iodinated glycerol, lithium, and potassium iodide may increase toxicity.

Relative Infant Dose Range: 2.3%

Adult Dose: 5-30 mg daily.

Alternatives: Propylthiouracil

T½ = 6-13 hours M/P = 1.0
PHL = PB = 0%
Tmax = 1 hour Oral = 80-95%
MW = 114 pKa = 11.64
Vd =
References
1. Tegler L, Lindstrom B. Antithyroid drugs in milk. Lancet 1980; 2(8194):591.
2. Azizi F. Effect of methimazole treatment of maternal thyrotoxicosis on thyroid function in breast-feeding infants. J Pediatr 1996; 128(6):855-858.
3. Lamberg BA, Ikonen E, Osterlund K, Teramo K, Pekonen F, Peltola J, Valimaki M. Antithyroid treatment of maternal hyperthyroidism during lactation. Clin Endocrinol (Oxf) 1984; 21(1):81-87.
4. Rylance GW, Woods CG, Donnelly MC, Oliver JS, Alexander WD. Carbimazole and breastfeeding. Lancet 1987; 1(8538):928.
5. Azizi F, Khoshniat M, Bahrainian M, Hedayati M. Thyroid function and intellectual development of infants nursed by mothers taking methimazole. J Clin Endocrinol Metab 2000; 85(9):3233-3238.

PROPYLTHIOURACIL

Trade Names: PTU, Propyl-Thyracil

Uses: Antithyroid

LRC: L2

AAP: Maternal Medication Usually Compatible with Breastfeeding

Propylthiouracil reduces the production and secretion of thyroxine by the thyroid gland. Only small amounts are secreted into breastmilk. Reports thus far suggest that levels absorbed by infant are too low to produce side effects.[1] In one study of nine patients given 400 mg doses, mean serum and milk levels were 7.7 mg/L and 0.7 mg/L respectively.[2] No changes in infant thyroid have been reported. PTU is the best of antithyroid medications for use in lactating mothers. Monitor infant thyroid function (T4, TSH) carefully during therapy.

Pregnancy Risk Category: D, D

Lactation Risk Category: L2, L2

Adult Concerns: Hypothyroidism, liver toxicity, aplastic anemia, anemia.

Pediatric Concerns: None reported, but observed closely for thyroid function.

Drug Interactions: Activity of oral anticoagulants may be potentiated by PTU associated anti-vitamin K activity.

Relative Infant Dose Range: 1.8%

Adult Dose: 100 mg TID

Alternatives:

T½ = 1.5-5 hours M/P = 0.1
PHL = PB = 80-95%
Tmax = 1 hours Oral = 50-95%
MW = 170 pKa = 12.89
Vd = 0.87
References
1. Cooper DS. Antithyroid drugs: to breast-feed or not to breast-feed. Am J Obstet Gynecol 1987; 157(2):234-235.
2. Kampmann JP, Johansen K, Hansen JM, Helweg J. Propylthiouracil in human milk. Revision of a dogma. Lancet 1980; 1(8171):736-737.

[adenure]

in reply to: Started PTU but levels still increasing? #1171564

Hi again!

I’m breastfeeding as well (on 5 mg. of methimazolel daily). Here is Dr. Hale’s info. on ATD’s (both Methimazole & PTU) and breastfeeding.

-Alexis

METHIMAZOLE

Trade Names: Tapazole

Uses: Antithyroid agent

LRC: L3

AAP: Maternal Medication Usually Compatible with Breastfeeding

Methimazole, carbimazole, and propylthiouracil are used to inhibit the secretion of thyroxine. Carbimazole is a prodrug of methimazole and is rapidly converted to methimazole. Milk levels of methimazole depend on maternal dose but appear too low to produce clinical effect. In one study of a patient receiving 2.5 mg methimazole every 12 hours, the milk/serum ratio was 1.16, and the dose per day was calculated at 16-39 µg methimazole.[1] This was equivalent to 7-16% of the maternal dose. In a study of 35 lactating women receiving 5 to 20 mg/day of methimazole, no changes in the infant thyroid function were noted in any infant, even those at higher doses.[2] Further, studies by Lamberg in 11 women, who were treated with the methimazole derivative carbimazole (5-15 mg daily, equal to 3.3 -10 mg methimazole), found all 11 infants had normal thyroid function following maternal treatments.[3] Thus, in small maternal doses, methimazole may also be safe for the nursing mother. In a study of a woman with twins who was receiving up to 30 mg carbimazole daily, the average methimazole concentration in milk was 43 µg/L.[4] The average plasma concentrations in the twin infants were 45 and 52 ng/mL, which is below therapeutic range. Methimazole milk concentrations peaked at 2-4 hours after a carbimazole dose. No changes in thyroid function in these infants were noted. In a large study of over 134 thyrotoxic lactating mothers and their infants. Methimazole therapy was initiated at 10-30 mg/day for one month, and reduced to 5-10 mg/day subsequently. Even at methimazole doses of 20 mg/day, no changes in infant TSH, T4 or T3 were noted in over 12 months of study.[5] The authors conclude that both PTU and methimazole can safely be administered during lactation. However, during the first few months of therapy, monitoring of infant thyroid functioning is recommended.

Pregnancy Risk Category: D, D

Lactation Risk Category: L3, L3

Adult Concerns: Hypothyroidism, hepatic dysfunction, bleeding, drowsiness, skin rash, nausea, vomiting, fever.

Pediatric Concerns: None reported in several studies, but propylthiouracil may be a preferred choice in breastfeeding women.

Drug Interactions: Use with iodinated glycerol, lithium, and potassium iodide may increase toxicity.

Relative Infant Dose Range: 2.3%

Adult Dose: 5-30 mg daily.

Alternatives: Propylthiouracil

T½ = 6-13 hours M/P = 1.0
PHL = PB = 0%
Tmax = 1 hour Oral = 80-95%
MW = 114 pKa = 11.64
Vd =
References
1. Tegler L, Lindstrom B. Antithyroid drugs in milk. Lancet 1980; 2(8194):591.
2. Azizi F. Effect of methimazole treatment of maternal thyrotoxicosis on thyroid function in breast-feeding infants. J Pediatr 1996; 128(6):855-858.
3. Lamberg BA, Ikonen E, Osterlund K, Teramo K, Pekonen F, Peltola J, Valimaki M. Antithyroid treatment of maternal hyperthyroidism during lactation. Clin Endocrinol (Oxf) 1984; 21(1):81-87.
4. Rylance GW, Woods CG, Donnelly MC, Oliver JS, Alexander WD. Carbimazole and breastfeeding. Lancet 1987; 1(8538):928.
5. Azizi F, Khoshniat M, Bahrainian M, Hedayati M. Thyroid function and intellectual development of infants nursed by mothers taking methimazole. J Clin Endocrinol Metab 2000; 85(9):3233-3238.

PROPYLTHIOURACIL

Trade Names: PTU, Propyl-Thyracil

Uses: Antithyroid

LRC: L2

AAP: Maternal Medication Usually Compatible with Breastfeeding

Propylthiouracil reduces the production and secretion of thyroxine by the thyroid gland. Only small amounts are secreted into breastmilk. Reports thus far suggest that levels absorbed by infant are too low to produce side effects.[1] In one study of nine patients given 400 mg doses, mean serum and milk levels were 7.7 mg/L and 0.7 mg/L respectively.[2] No changes in infant thyroid have been reported. PTU is the best of antithyroid medications for use in lactating mothers. Monitor infant thyroid function (T4, TSH) carefully during therapy.

Pregnancy Risk Category: D, D

Lactation Risk Category: L2, L2

Adult Concerns: Hypothyroidism, liver toxicity, aplastic anemia, anemia.

Pediatric Concerns: None reported, but observed closely for thyroid function.

Drug Interactions: Activity of oral anticoagulants may be potentiated by PTU associated anti-vitamin K activity.

Relative Infant Dose Range: 1.8%

Adult Dose: 100 mg TID

Alternatives:

T½ = 1.5-5 hours M/P = 0.1
PHL = PB = 80-95%
Tmax = 1 hours Oral = 50-95%
MW = 170 pKa = 12.89
Vd = 0.87
References
1. Cooper DS. Antithyroid drugs: to breast-feed or not to breast-feed. Am J Obstet Gynecol 1987; 157(2):234-235.
2. Kampmann JP, Johansen K, Hansen JM, Helweg J. Propylthiouracil in human milk. Revision of a dogma. Lancet 1980; 1(8171):736-737.

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