[NP-Clinical] Re: endo questions, was (no subject)

[Julie Orfirer]

Re: #1 - there are other endo people here more versed with thyroid but I'll throw in my two cents.  If she's symptomatic and has had elevated levels it's probably worth giving her a trial of treatment.  You might also want to get TPO antibodies and see if she does have Hashimoto's but it may not change what you do.  I'd probably start her on 30 of Armour ("usual" dose is 60) and retest TSH in 2 months (just like you'd do on levothyroxine) mainly to make sure that the TSH isn't too supressed and see how she's feeling.  The general consensus is to give it a 6 month trial and if she's not feeling any better to trash the Armour.  It's hard, as you know, because that list of symptoms that goes with hypothyroid is a list of lots of things from depression to menopause to plain old age.
   
  Re #2 - I'd ammend your recommendations to "everyone".  If someone's 25 (OH) D is over 32 I suggest 1000 units of vitamin D3 (cholecalciferol) daily.  If under 32 I suggest 2000 units of D3 daily or 50,000 of ergocalciferol weekly.  The 1000 of D3 is thought to be the amount we need to maintain a good level.  (Of course, I found for myself that even on 1000 daily this winter my count dropped a little so now I'm on 2000 until the sun comes back.)  The 400 that's recommended isn't enough for most people especially in the winter north of Atlanta.  I'll recheck the D after 3 months on either the high dose D3 or the rx'ed D2.  If it's normal I ask them to then continue on 1000 D3.  1000 D3 is available at Whole Foods (their store brand is 90 pills for $6.  Otherwise it can be hard to find.  Ask a good natural foods store or locally owned small pharmacy in your area if they can carry it.  We have a natural foods store that carries the 2000's for us too.
   
  Also, I do a comprehensive metabolic profile on everyone so don't do the ionized calcium -  just the regular calcium and do the corrected calculation based on albumin.  (My cheat: http://www.globalrph.com/calcium.htm )

  Hope that helps,
   
  Julie O
  
Message: 1
Date: Wed, 14 Mar 2007 18:01:24 -0400
From: arezendes at aol.com
Subject: [NP-Clinical] (no subject)
To: np-clinical at nurse.net
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I am looking for some expert opinions on a couple of issues,

1. I had a 70 year old female, new to the practice come in last week. She was having some typical symptoms of hypothyroidism (hair loss, dry skin, fatigue). She brought in copies of labs done within the last year, and I noticed 2 TSH done that were above the target (1 value of just over 5 and the other over 6) and nothing was done about it. I repeated the TSH and free T4, now both are normal (repeat TSH was 3.57, within the norm). Did not do antibodies. We talked about thyroid meds, she wants a "natural med" and mentioned Armour thyroid, which I have never prescribed. The question is now that the TSH is normal, should she be treated or watch and wait? Also, does anyone have experience in starting, adjusting Armour thyroid?

2. We are doing labs on patients with osteopenia and osteoporosis - 25 vitamin D, ionized calcium, intact PTH. The normal levels for vit D from our lab are 
vitamin D insuffiency less than 20
vitamin D suffiency 40-100
toxicity over 100
we are recommending vit d if anything under 40. What is the general consensus re dose and rechecking of the levels? When would a dose of 50,000 units per week vs OTC daily be in order?

3. Woman who is 44 having usual periods but had endometrial cells on her pap. LMP was 2/22 and pap done 3/1. Any guidelines? 

Thanks to all ahead of time.
Ann, NP
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