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Reduce Hashimoto's Antibodies with This Supplement

New Tobacco Derived Supplement That Reduces Hashimoto’s Antibodies

Medically reviewed and written by Izabella Wentz, PharmD, FASCP

Dr. Izabella Wentz / February 4, 2015

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Please note that Anatabine is not available at this time.

In doing research for my thyroid condition, I found that smoking tobacco reduced the risk of Hashimoto’s, but that it often made the outcomes of Graves’ disease much worse.  I have heard from many former smokers who reported that indeed their Hashimoto’s symptoms started around the time they stopped smoking.

When I started researching lifestyle interventions for Hashimoto’s, this one irked me. I mean here I was, a non-smoker and being a health conscious person put me at greater risk of developing Hashimoto’s. When I decided to write my book, Hashimoto’s The Root Cause, I almost didn’t want to reveal that there was indeed a connection, I mean, smoking is terrible for us, and the last thing I wanted to do was to encourage anyone to start smoking or prevent them from quitting. While I tried many interventions in an effort to heal myself, I never did take up smoking! Of course, the risks would outweigh the benefits, but I kept this nugget of information in the back of my mind and wondered what about smoking reduced the incidence of Hashimoto’s… until I came across a new supplement last year.

Anatabine

I came across some research from John Hopkins that showed  (Caturegli, et.al, July 2012). Mice models for Hashimoto’s are often used to learn more about how the condition affects humans, and benefits in mice often translate to benefits in humans.

I came to learn that Anatabine is a naturally occurring alkaloid found in the Nightshade plant family (tomato, tobacco, peppers) that is available as a dietary supplement. Anatabine has anti-inflammatory effects and reduces the expression of cytokines (IL-18, IL-1R2) associated with the development of Th-1 mediated autoimmunity.  This makes sense, as Hashi’s is often a Th-1 condition, and Graves’ is a Th-2 condition.

Hot off the presses, released on October 31st, 2013!

A brand new randomized, double-blind and placebo-controlled study (this time in humans) followed a total of 146 patients with Hashimoto’s for 3 months. Seventy of those patients were treated with Anatabine at a dose of 9-24mg per day, while the rest were treated with placebo.

The results showed a statistically significant reduction in Thyroglobulin antibodies (TgAb’s) at weeks 4, 8, and 12. TgAb’s reduced by an average of 46 points in the treatment group compared to a reduction by 4 points in the placebo group. 50% of patients reduced their antibodies by at least 25 points, while 25% reduced their TG antibodies by at least 100 points.

All of the patients in the study were euthyroid, meaning their TSH, T4, T3 were within range, either because they were taking levothyroxine or because they were in the early stages of Hashimoto’s. Anatabine did not affect the levels of TSH, T4 or T3, but the patients who were taking levothyroxine seemed to have a greater reduction in antibodies that patients that were not.

Dizziness, nausea, tingling, and headaches were some of the more common side effects.

Discussion

The authors suggested that Anatabine may affect Thyroglobulin secretion, resulting in a drop of Thyroglobulin specific antibodies.

Surprisingly, the study did not find a statistically significant reduction in TPO antibodies. The authors of the study noted that TG antibodies are often the first antibodies to come down, followed by TPO antibodies and thought that perhaps more time was needed to see a statistically significant drop in TPO antibodies.

I found the same to be true in my case as well. My TG antibodies completely went away after my first lifestyle changes, but the TPO antibodies were slower to budge and took a longer time to reduce.

Additionally, while this was not shared in the study results, the manufacturer did share some preliminary results on TPO levels last January on their healthcare professional portal. One patient who was studied had an enormous drop in antibody levels after she took a dose of 0.12 mg/kg per day of anatabine for sixteen days. Her TPO antibodies reduced from 3655 IU to 300 IU.

I tried Anatabine for three months last year when I was in the middle of my root cause search, and it actually lowered my TPO antibodies by about 50% (I didn’t have anymore TG antibodies at the time).

What I found particularly interesting is that not everyone responds the same to Anatabine, the study noted that not everyone had a drop in TG antibodies, and some had a greater drop than others did. Of course, this makes sense as not everyone has the same root cause.

How to use it

Doses of 0.12 mg/kg per day to 0.267mg/kg per day have been studied and found to be safe and effective in reducing TPO antibodies. This dose would equal to about 5 mg–12 mg per day for a 100-pound woman. Anatabine has a half-life of about eight hours and should be dosed six to eight hours apart to ensure a constant level in the body.

Anatabine should be started at a low dose of 1–2 mg per day and gradually increased to the target dose over a week. The onset of action should be seen within a couple of days to a few weeks. Early research suggests that anatabine must be taken continuously to exert its effect on the immune system.

Side effects such as headache, nausea, vomiting, and changes in liver function have been observed when doses were started too high. Some individuals with Hashimoto’s may have a nightshade sensitivity, and as anatabine is a tobacco alkoloid, there is a potential of cross-reactivity.

Anatabine lozenges are available from Rock Creek Pharmaceuticals, as Anatabloc®. This supplement can be bought over the counter. However, the manufacturing process and clinical research is pharmaceutical grade. I recommend the non-flavored lozenges for those who may be sensitive to the original minty formulation. The company is currently working on additional hypoallergenic products. Healthcare professionals can request free samples through www.anatabloc.com

When to use it

Anatabine has anti-inflammatory properties and has been shown to detoxify endotoxin, a toxin produced by our opportunistic gut bacteria (the bad guys that can outnumber the good guys). In my opinion, anatabine may likely be helpful for those with a dysbiosis or low alkaline phosphatase; alkaline phosphatase is an enzyme we all have that helps us detoxify our opportunistic bacteria and is deficient in many with Hashimoto’s and some other autoimmune conditions. Smoking, for example, has been found to increase alkaline phosphatase, so while I have not been able to find research on the effects on Anatabine on alkaline phosphatase, perhaps Anatabine works in a similar way?

This supplement may be a helpful tool in reducing inflammation and antibodies while searching for why the immune system is imbalanced. I would recommend it for someone who has already gone through an elimination diet and has already identified their food sensitivities, as the Anatabine may falsely block inflammatory reactions we experience with foods.

It may be of particular benefit for those former smokers who felt their condition got worse after they quit smoking, or for those with, particularly high Thyroglobulin antibodies. It may also be something to consider for those who want to quit smoking but are concerned about the impact of smoking cessation on Hashimoto’s.

Remember, just as with any supplement, Anatabine is not a cure, but rather a tool to help in your healing journey as you work to discover your root cause(s).

To learn more about utilizing supplements in your health journey, download my free Supplements to Subdue Symptoms eBook below!

Wishing you all the best on your journey and continue to DIG-AT-IT!

PS. You can also download a free Thyroid Diet Guide, 10 Thyroid friendly recipes, and the Nutrient Depletions and Digestion chapter for free by going to www.thyroidpharmacist.com/gift. You will also receive occasional updates about new research, resources, giveaways and helpful information.

For future updates, make sure to follow us on Facebook!

References

1.  Wiersinga WM. Smoking and Thyroid. Clin Endocrinol (Oxf). 2013;2013 79:145–151.

2. Schmeltz, Lowell R (10/31/2013). “Anatabine supplementation decreases thyroglobulin antibodies in patients with chronic lymphocytic autoimmune (Hashimoto’s) thyroiditis: A randomized controlled clinical trial.” The Journal of clinical endocrinology and metabolism (0021-972X)

3. CaturegliP,DeRemigisA,FerlitoM,Landek-SalgadoMA,Iwama S, Tzou SC, Ladenson PW. Anatabine ameliorates experimental autoimmune thyroiditis. Endocrinology. 2012;153:4580–4587

4. www.anatabloc.com healthcare professional portal. Accessed 1/10/13

5. http://jcem.endojournals.org/content/suppl/2013/10/31/jc.2013-2951.DC1/JC-13-2951_4tabs_2Figs.pdf Shows the data that was collected during the trial

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Filed Under: Autoimmune, Supplements Tagged With: Antabine, Antabloc, Root Cause, Tg Antibodies, Th1, Th2, TPO Antibodies

Dr. Izabella Wentz

Dr. Izabella Wentz, PharmD, FASCP, is a clinical pharmacist, New York Times Bestselling Author, and a pioneering expert in lifestyle interventions for treating Hashimoto’s Thyroiditis.

She received a Doctor of Pharmacy degree from the Midwestern University Chicago College of Pharmacy at the age of 23, and has worked as a community pharmacist, a clinical consulting pharmacist, as well as a medication safety pharmacist. She is a Fellow of the American Society of Consultant Pharmacists and holds certifications in Medication Therapy Management and Advanced Diabetes Care.

Dr. Wentz has dedicated her career to addressing the root causes of autoimmune thyroid disease, after being diagnosed with Hashimoto’s Thyroiditis in 2009. As a patient advocate, researcher, clinician and educator, she is committed to raising awareness on how to overcome autoimmune thyroid disease.

Disclaimer: The information contained herein is for informational purposes only and should not be construed as medical advice. Please consult your physician for any health problems and before making any medical or lifestyle changes.

Lifestyle changes can result in improved thyroid function and/or an increased absorption of thyroid hormone medications, leading to a lower required dose and possible symptoms of hyperthyroidism at a dose that was previously stable. Please discuss lifestyle changes with your physician and ensure that your thyroid function is monitored every 6-8 weeks while making lifestyle changes. Symptoms of overmedication include, but are not limited to: rapid or irregular heartbeat, nervousness, irritability or mood swings, muscle weakness or tremors, diarrhea, menstrual irregularities, hair loss, weight loss, insomnia, chest pain, and excessive sweating. Do not start, change, increase, decrease or discontinue your medications without consulting with your physician.

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Reader Interactions

Comments

  1. Silvermaven says

    December 4, 2013 at 11:55 PM

    It stops the antibodies but NOT what is infecting the glands. Multiple Chronic infections in immune suppression the infections cause. And like Autism kids many make no antibodies to say pos. for ANY of the infections because THE INFECTIONS turn off the TLR’s to not even know you have infections.
    http://www.youtube.com/watch?v=yOno_2m_8LY
    ALL Chronic disease the masses suffer today we all got in infective vaccines used for decades KNOWING spirochetal prion proteins could not be killed by any means known to man. You treat the multiple infections to cure. NOT antibodies.
    http://www.lymeneteurope.org/forum/viewtopic.php?f=6&t=4840&sid=15cf99c738bdb12bce3c358ac6412d3c
    Reply
  2. Izabella Wentz, PharmD says

    January 30, 2014 at 2:31 PM

    Thank you Silvermaven. I agree with you that infections are a very important cause of autoimmunity and are often at the root cause. My approach is to get to the root cause of the condition, but often times finding the root cause may be difficult and elusive. I have a book that focuses on different root causes, lab tests, treatments, etc. While someone searches for his/her root cause, it’s often helpful and necessary to manage the symptoms through medications and supplements so I try to give people any information that can be helpful 🙂
    .
    Reply
  3. Paula says

    March 7, 2014 at 9:30 PM

    Thank you Izabella, yes, you make it clear in your book to find the root cause, but I greatly appreciate that you continue to inform us of other avenues that may help our immune system while we’re waiting for our big find/s: individual root causes/s of Hashis”. I only have TG antibodies, which have recently lowered from 7.7 IU/ml (11/13/13 1st test) to 4.3 IU/ml (considered “low positive” by LabCorp) and the test method is “Beckman Coulter”. Unfortunately, my dose of NDT (natural desiccated thyroid) isn’t high enough bc my TSH is elevated again 3.7, Free T4/Free T3 are both on the very low side of “normal”, I’ve already started a higher dose, and this time Westhroid instead of Nature-Throid. Anyway, I WOULD TRY ANTABLOC, but I’m concerned about the nightshade issue. If my antibodies aren’t completely down after ensuring that I’ve conquered this candida issue (discovered through home blood test via Candia5) and awaiting confirmation from GI Effects stool results (via mymedlabs), I’ll try the anatabloc, because who knows how long it will take to my next root cause discovery. But, right now, it makes sense to solve the problems in front of me: candida (if it showed up in my blood that means it’s systemic, I reckon), high arsenic levels (awaiting confirmation that the DMSA pills eliminated the arsenic), continuing treatment for my low estrogen, as well as continued diet/supplement/environmental approaches (low endocrine disruptors). Has anyone figured out a way around the nightshade problem?
    Reply
    • Dr. Izabella Wentz says

      December 26, 2016 at 2:31 PM

      Paula- Most people will see a dramatic reduction in gut symptoms, brain symptoms, skin breakouts and pain by eliminating the foods they are sensitive to. Some will also see a significant reduction in thyroid antibodies! An additional subset of people, will actually be able to get their Hashimoto’s into complete remission just by getting off the foods they react to, normalizing their thyroid antibodies, and some even normalizing their thyroid function! Here are a couple of articles you may find helpful.

      FOOD SENSITIVITIES AND HASHIMOTO’S
      https://thyroidpharmacist.com/articles/food-sensitivities-and-hashimotos

      AUTOIMMUNE PALEO DIET
      https://thyroidpharmacist.com/articles/autoimmune-paleo-diet

      Reply
  4. Carol says

    January 8, 2014 at 3:48 PM

    I believe my Hashi’s started when I quit smoking in March 2013. In October I was diagnosed, after I convinced my PCM NP to check me for ABs. TPO- 246, TG-413. I have also completely changed my way of eating since FEB 2013, by following Dr. Hyman’s teachings. I have been feeling much better, while also adding in increased Vit D, selenium (2x Brazil nuts/day), magnesium, and probiotics. My antibody levels were discovered in October 2013. I still have yet to see an endo (pending in April). My NP won’t treat me with compounded T3/T4 like I have researched may be best for my and my ABs count. As yet, I am still not on medication, and suffer primarily from cold intolerance, occasional bradycardia, hyper symptoms, and HA. Do you think I should try Anatabine? Compared to others, my ABs are not so very high. You recommend in this blog for high ABs. Thank you for your time.
    Reply
  5. Izabella Wentz, PharmD says

    January 30, 2014 at 2:33 PM

    Hi Carol- Anatabine can be helpful as your search for your root cause. I apologize I can’t give specific advice for your condition- you may find additional helpful strategies in my book 🙂
    Reply
  6. Carol Newton says

    May 25, 2014 at 12:57 AM

    Thank you for summarizing the research into Anatabine. I have just come across the research papers and am excited that this might work for me. I developed Hashimotos after giving up smoking over ten years ago. I remember feeling so bad about six months after giving up smoking that I nearly started again. Years of battling weight, fibromyalgia and all symptoms that go with Hashimotos, I’m hopefull that this may work.
    I do hope that more research is done, but in the meantime I’m going to give it a go, thanks again for the summary.
    Reply
  7. Izabella Wentz, PharmD says

    June 15, 2014 at 2:21 AM

    Carol- keep up the great work and keep us posted!
    Reply
  8. Carol rivers says

    June 15, 2014 at 3:49 PM

    I’d like to give Anabloc a try. I am wondering if the offer is still available?
    Reply
  9. Jack says

    June 15, 2014 at 5:36 PM

    Great article. I’m a little confused about something. You stated you tried Anatabine for three months, and that it lowered your TPO-AB by 50%.. So if that’s true, then why did you stop using it?
    Reply
  10. Izabella Wentz, PharmD says

    June 19, 2014 at 8:54 AM

    Jack, I stopped using it because I felt that I was reacting to it. Some have been able to stay on it long term
    Reply
  11. Izabella Wentz, PharmD says

    June 19, 2014 at 8:56 AM

    Carol, Not anymore, but I think you may still be able to get it from the company’s website
    Reply
  12. Aleesa says

    July 9, 2014 at 9:32 AM

    Anatabloc is the supplement that Dr Izabella was talking about, and it’s available at GNC only. If you’re concerned about artificial sweeteners, it’s also available unflavored. I haven’t tried it due to it being too costly to add to my already rising supplement costs, lol.
    Reply
    • Dr. Izabella Wentz says

      December 26, 2016 at 2:34 PM

      Aleesa- Not everyone will need every single supplement! In fact, I believe that most nutrients should come from the diet, this is why I always list food sources for most of the nutrients, vitamins, minerals and probiotics that are depleted in Hashimoto’s in the book and on the blog. However, some may require/prefer supplements and the supplements on the website are a resource for those that do. I recommend getting tested for deficiencies to determine your need for a supplement as instructed in the book and blog. I also don’t recommend starting multiple supplements all at once. I recommend starting one at a time and then adding another a week or so later once it has been confirmed that the first supplement is not causing any harm.

      I do have a full supplements chapter in my book. Have you checked it out? Not everyone should be taking every supplement and the book will help uncover your root cause. This will help you figure out your supplementation.
      Hashimoto’s Root Cause
      http://www.amazon.com/gp/product/0615825796?ie=UTF8&camp=1789&creativeASIN=0615825796&linkCode=xm2&tag=thyroipharma-20
      Hashimoto’s Protocol
      https://smile.amazon.com/Hashimotos-Protocol-Reversing-Thyroid-Symptoms/dp/006257129X/ref=sr_1_1?ie=UTF8&qid=1482698453&sr=8-1&keywords=Hashimoto%27s+Protocol

      Reply
  13. Don says

    August 28, 2014 at 11:19 PM

    Another FDA bias This product actually works and reduces internal inflammation. The AMA must be running this federal unregulated agency.
    Reply
  14. Cindy Jones says

    May 1, 2015 at 9:20 PM

    I am a 51 year old who is almost post-menopausal, last period 9 months ago.) I have been an on-off smoker since I was a teenager. Quit for 6 years starting in my 20’s and quit again for 6 years upon my first pregnancy at 35. During my pregnancy and nursing years I suffered depression and extreme fatigue, not uncommon for a new mother but I kept feeling that something was off and repeatedly asked for my thyroid to be checked. It was 4 years before I was diagnosed with hypothyroid and after 4 months of synthroid I began to feel like my pre-pregnancy self and finally lost the baby weight. However, I still had my life long issues with constipation and my skin was dry and scaly with my hair falling out. Things were good for a couple years and then my energy and mood began to fall again and I was repeated told that my TSH was still in range. Somewhere in there I started smoking again. For the last 10 years I have tried quitting smoking multiple times managing for several months before starting again. I kept feeling that something more was in play than physical and emotional addiction. In 2011, an Integrative MD switched me to Nature Throid and after getting the dose right I began to feel better again. My TPO antibody was 100 at the time and I was disturbed about the idea of Hashimotos. My doctor however said that she had patients whose numbers were in the thousands and that mine was just residual toxicity and I needed to keep up with juicing, infrared sauna, dry skin brushing, protelytic enzymes & coffee enemas.I have kept up this protocol for 4.5 years. I began to follow Julia Ross, The Mood Cure and Dr Mark Hyman and study about how smoking affects our neurotransmitters and that I had probably been deficient all in my life in dopamine and the cigarettes were a way to self medicate and maintain energy and mood levels. Last October, after much research about how to support myself, I made an effort to quit smoking again. I began an amino acid protocol along with Tabex, a plant based stop smoking aid that I ordered from Eastern Europe. Over 2 months I got myself down to less than 4 cigarettes a day, (Organic American Spirit) and by Christmas I had stopped completely. In January my energy crashed and I began to have severe mood swings, anxiety, irritability, emotional outbursts, tremors, etc. In late February, still not smoking I experienced a mind crushing headache and was later told was an orgasmic headache. it subsided after 10 minutes until my workout that night when it peaked again. The next morning I had a series of symptoms that prompted me to call 911 for an ambulance. It started with what felt like a rise in my body temp, sweating, headache returned, sudden need to evacuate by bowels, heart palpatations, feeling faint, left arm and left side of face numb. My blood pressure was 240/105 when paramedics arrived. A 2 day stay in the ER ruled out stroke, heart attack, brain tumor. I had 2 CT’s and an MRI of my brain, chest Xray, & lumbar puncture. I was released to follow up with my primary doctor, (not the Intergrative MD) My primary doctor ran labs and I had the big 3–high cholesterol, (despite being vegan for 2 years for the purposes of detoxing my body.), borderline high glucose, and high blood pressure. My TSH was 6.6 and he increased my Narure Throid by 1/2 a grain. He suspected an adrenal gland tumor but to be safe referred me to an endocrinologist, cardiologist and neurologist. It is now May 1 and my headache has not gone away. Sometimes is subsides to a dull ache but can be intensified by loud repetitive noises-dishes banging, alarm clocks, sirens, etc or when I work out, take a hot bath or use my infrared sauna. I have become extremely heat and stress intolerant. In March I started smoking again and soon after started having palpitations again. My new TSH came back at .20 and I was told that the 1/2 grain increase was too much. My TPO is 140. I could not convince the Endo to run Free T3/T4, RT3 or the second antibody. I have a nodule on my thryroid and am scheduled for an ultrasound. I can’t stop feeling that even though my antibody numbers are low that somehow my quitting smoking brought on a full blown Hashi’s attack. I just received your book yesterday and have also ordered The Autoimmune Protocol book. I also feel that my thyroid issues are directly connected to my inability to quit smoking despite the drastic changes I have made to my lifestyle in the last 4 years and don’t know how to support myself through the process. Doctor’s are condescending and even friends think that I just don’t want to quit bad enough. I have worked with practitioners to release my shame about smoking acknowledging that shame could be a roadblock. I have tried acupuncture, hypnotherapy, wellbutrin, cold turkey, tapering, amino acids, Tabex, Ondimed EM, etc. I still have constipation, dry/scaly skin, hair loss, THAT headache, uncontrolled high blood pressure despite mediation & supplements, heat/stress intolerance, fatig
    Reply
    • Dr. Izabella Wentz says

      December 26, 2016 at 2:37 PM

      Cindy- Thank you so much for your support. I’m looking forward to hearing your progress on this page. Make sure to take the book slow, take notes, highlight, and establish a baseline when making changes. 🙂

      Reply
    • MH says

      January 10, 2023 at 10:16 PM

      I’m really interested to hear how you are doing? How is your health? I think it’s interesting that there’s a study (I suppose there is a study for anything though) that showed smoking worsened hyperthyroid but not other thyroid conditions. It’s important to listen to our bodies, right?

      Reply
  15. Leslie Davis says

    June 12, 2015 at 1:53 PM

    Carol – I’m interested if you tried taking Anatabine? If so, how did it work? Were you able to lose weight easier / feel better?
    Reply
  16. Ionela says

    August 1, 2015 at 8:06 AM

    Hi Dr. Wentz, So, if anatabine reduces citokines in those with Th-1 condition, would you recommend it for someone with Th-2 condition or would it aggravate the disease? And if you recommend it which quantity per day? Thank you.
    Reply
    • Dr. Izabella Wentz says

      December 26, 2016 at 2:46 PM

      Ionela- I can’t make any direct medical recommendations to any single person for legal reasons. I would highly recommend that you work with a functional medicine clinician. It’s a whole medical specialty dedicated to finding and treating underlying causes and prevention of serious chronic disease rather than disease symptoms.

      FUNCTIONAL MEDICINE APPROACH TO THE THYROID
      https://thyroidpharmacist.com/articles/functional-medicine-approach-to-the-thyroid

      CLINICIAN DATABASE
      http://www.thyroidpharmacistconsulting.com/clinician-database.html

      FIND A FUNCTIONAL MEDICINE CLINICIAN
      https://www.functionalmedicine.org/practitioner_search.aspx?id=117

      Reply
  17. Ionela says

    August 3, 2015 at 6:54 PM

    Would you recommend anatabine before/after or with meals? And would anatabine cause addiction just like tobacco does?
    Reply
  18. Rebecca says

    September 19, 2017 at 9:45 AM

    I was diagnosed with Hashi’s after quitting smoking six years ago and I am 100% convinced, it was no coincidence. I expected to feel bad while I dealt with the detoxing and overcoming the addiction of smoking, but I have felt progressively worse ever since. I am at a loss now though be a I can’t find anatabine supplements anywhere to try. If it still available at all anymore? I have tried the website of the company that manufactures/manufactured it, and it no longer seems to exist…any thoughts?!

    Reply
    • Dr. Izabella says

      September 21, 2017 at 9:19 AM

      Rebecca – thank you for following this page. Please email my team at info@thyroidpharmacist.com and they will be happy to help you with this! 🙂

      Reply

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Disclaimer: The information contained herein is for informational purposes only and should not be construed as medical advice. Please consult your physician for any health problems and before making any medical or lifestyle changes.


Lifestyle changes can result in improved thyroid function and/or an increased absorption of thyroid hormone medications, leading to a lower required dose and possible symptoms of hyperthyroidism at a dose that was previously stable. Please discuss lifestyle changes with your physician and ensure that your thyroid function is monitored every 6-8 weeks while making lifestyle changes. Symptoms of overmedication include, but are not limited to: rapid or irregular heartbeat, nervousness, irritability or mood swings, muscle weakness or tremors, diarrhea, menstrual irregularities, hair loss, weight loss, insomnia, chest pain, and excessive sweating. Do not start, change, increase, decrease or discontinue your medications without consulting with your physician.


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