According to the research, someone with one autoimmune condition is more likely to develop other autoimmune conditions in the future. As a result, if someone has Graves’ disease or Hashimoto’s thyroiditis, they are more likely to develop other autoimmune conditions. This of course is why it’s important to find and remove the triggers and improve the health of your immune system.
Since someone with one autoimmune condition has a greater chance of developing other autoimmune conditions in the future, it’s not surprising that some people have elevated autoantibodies for both Graves’ disease and Hashimoto’s. Before I discuss this further, let’s quickly take a look at the three most common types of thyroid autoantibodies:
Thyroid peroxidase (TPO) antibodies. These are commonly found in both people with Hashimoto’s thyroiditis and Graves’ disease, although they are more specific to Hashimoto’s. And the reason for this is because when someone has elevated TPO antibodies, this means that the immune system is attacking the enzyme thyroid peroxidase, which is important for the production of thyroid hormone. As a result, having these antibodies is likely to result in hypothyroidism, although it can take many years for this to occur.
Thyroglobulin antibodies. These are associated with Hashimoto’s thyroiditis. Thyroglobulin is a protein of the thyroid gland, and it also is important for the production of thyroid hormone. As a result, if someone has these antibodies then they are also likely to become hypothyroid over time.
TSH receptor antibodies. These are associated with Graves’ disease. Thyroid stimulating immunoglobulins (TSI) are the most common type of TSH receptor antibody. If someone has these antibodies then this means that the immune system is attacking the TSH receptors, which usually results in hyperthyroidism. Thyrotropin-blocking antibodies (TBAb) are another type of TSH receptor antibody. Unlike thyroid stimulating immunoglobulins, the thyrotopin-blocking antibody blocks the TSH receptor to prevent TSH from binding. This results in hypothyroidism.
What’s The Significance Of Having Both Types of Thyroid Antibodies?
If you happen to test positive for both the autoantibodies to Graves’ disease and Hashimoto’s, you might wonder what’s the significance of this. First of all, while it is possible to fluctuate back and forth between hyperthyroidism and hypothyroidism, in many cases the person with both types of thyroid antibodies will initially present with either hyperthyroidism or hypothyroidism. So for example, if a person has elevated thyroid stimulating immunoglobulins (TSI), thyroglobulin antibodies, and TPO antibodies, then they very well might present with hyperthyroidism initially. But over time, if the autoimmune component isn’t addressed and reversed, the person will most likely become hypothyroid.
The reason for this is because even if the person initially presents with hyperthyroidism, the damage to the thyroid gland will usually lead to hypothyroidism, although it can take many years to reach this point. And until the thyroid gland sustains significant damage that results in low or depressed thyroid hormone levels, the person with the autoantibodies to both Graves’ disease and Hashimoto’s may be predominantly hyperthyroid. On the other hand, there is also the possibility that they won’t initially become predominantly hyperthyroid, as they very well might be predominantly hypothyroid. Another scenario is that they may fluctuate between a hyperthyroid and hypothyroid state over the years.
So just to clarify, those who have both Graves’ disease and Hashimoto’s autoantibodies might never become predominantly hyperthyroid. It’s also worth mentioning that a person with Hashimoto’s might experience symptoms of hyperthyroidism that’s unrelated to having elevated thyroid stimulating immunoglobulins. The reason for this is because with Hashimoto’s, as the immune system damages the thyroid gland, thyroid hormone gets released into the bloodstream, and can make someone temporarily hyperthyroid.
This condition is sometimes referred to as hashitoxicosis. So hashitoxicosis is a transient form of hyperthyroidism that is caused by the release of thyroid hormone due to destruction of the thyroid cells (1). In this condition, TSH receptor antibodies are typically negative, although some people will have thyroid stimulating immunoglobulins and/or thyroid-blocking antibodies (2).
Why Do Some People Develop Both Types of Thyroid Antibodies?
As for why some people develop the autoantibodies for both Graves’ disease and Hashimoto’s, genetics is one reason. According to the triad of autoimmunity, in order for any autoimmune condition to develop you need a genetic predisposition, an environmental trigger, and a leaky gut. If someone has the genetic markers for both Graves disease and Hashimoto’s then they can develop the antibodies for both of these conditions.
However, just because someone has a genetic marker for a specific autoimmune condition doesn’t mean that the person will develop that autoimmune condition. Once again, the person needs to be exposed to an environmental trigger and have a leaky gut. It’s also worth mentioning that while a single environmental trigger can lead to multiple autoimmune conditions, there are times when exposure to multiple triggers is required. As an example, if someone with the genetic markers for both Graves’ disease and Hashimoto’s gets an H. pylori infection, this might trigger both of these autoimmune thyroid conditions simultaneously. However, it’s also possible for the person to only develop the autoantibodies for one of these conditions, and then in the future be exposed to a different trigger which causes them their body to produce a different type of thyroid autoantibody.
Is The Treatment Approach Different When Someone Has Multiple Thyroid Antibodies?
Remember that both Graves’ disease and Hashimoto’s are autoimmune conditions, and so with either condition, the goal is to find and remove the triggers. While I mentioned earlier that there can be a single autoimmune trigger that leads to the development of multiple autoantibodies, many times there are multiple autoimmune triggers. And so it usually takes some detective work to find the triggers.
While the process of detecting triggers in both Graves’ disease and Hashimoto’s is similar, the management of symptoms will differ depending on how the person is presenting. Thankfully most people are either predominantly hyperthyroid or hypothyroid. If someone with both types of autoantibodies is predominantly hyperthyroid (i.e. depressed TSH and elevated thyroid hormone levels), then the person will usually be put on antithyroid medication (i.e. Methimazole) or herbs (i.e. bugleweed). On the other hand, if someone is predominantly hypothyroid then they will usually be told to take thyroid hormone replacement (i.e. levothyroxine, desiccated thyroid hormone).
In some cases people will fluctuate back and forth between hyperthyroidism and hypothyroidism, and this can be challenging to manage. In this scenario, focusing on modulating the immune system is something to consider. Low dose naltrexone (LDN) can sometimes help with this, although you can also try to use nutrients and herbs to modulate the immune system, including vitamin D, curcumin, and selenium. I also mentioned earlier that some people with Hashimoto’s will experience temporary hyperthyroidism due to thyroid hormone in the bloodstream caused by damage to the thyroid gland. While this person might eventually need to take thyroid hormone replacement depending on the extent of the damage, the goal should be to improve the health of the immune system.
Should You Get Tested For All Thyroid Antibodies?
Although I can’t say that everyone needs to test for all of the different thyroid antibodies, it isn’t a bad idea to do so. One can argue that the process of detecting triggers won’t differ regardless of whether someone has one autoantibody or multiple autoantibodies. However, the end goal should be to normalize ALL autoantibodies. And there are times when someone who tests positive for all three thyroid autoantibodies will achieve normalization with one or two of the autoantibodies, but not all of them. And so if you only tested for one of them and this eventually normalized, you might assume that you’re in remission, but there is always the chance that you have other thyroid autoantibodies that are elevated.
Should You Get Tested For Other Autoantibodies?
Based on what I just said you might wonder if it is a good idea to test for other types of autoantibodies. After all, someone with an autoimmune thyroid condition isn’t only more likely to have another autoimmune thyroid condition, but they are more likely to have other types of autoimmune conditions as well. And while it’s a major bummer to have either Graves’ disease or Hashimoto’s, some autoimmune conditions are even worse to have. Here are just a few of the different autoimmune conditions someone can have:
- Addison’s disease
- Alopecia areata
- Ankylosing spondylitis
- Behcet’s disease
- Celiac disease
- Guillain-Barre syndrome
- Lichen planus
- Multiple sclerosis
- Rheumatoid arthritis
- Sjögren’s syndrome
- Type 1 diabetes
That being said, I can’t say that I have all of my patients test for autoantibodies to different autoimmune conditions. I do recommend testing the antibodies associated with Celiac disease, as if someone is positive then without question they need to strictly avoid gluten on a permanent basis. And while it is a good idea for everyone to avoid gluten permanently, some people need more convincing than others. Of course the downside is that a negative Celiac panel doesn’t rule out a sensitivity to gluten, but this is a topic for another article. It’s also important to know that if you have been avoiding gluten for awhile then it’s pointless to do a Celiac panel. For more information on Celiac disease you can read an article I wrote entitled “Celiac disease and Thyroid Health”.
Getting back to whether you should test for other autoantibodies, if you have a known family history of certain autoimmune conditions then it might be a good idea to test for these. For example, if you have parents or siblings who tested positive for rheumatoid arthritis, then you might want to get these autoantibodies tested. This is especially true if you are experiencing some of the symptoms associated with this condition. And the same concept applies with other autoimmune conditions.
There are labs that offer panels that measure multiple autoantibodies. One of these is Cyrex Labs, as they have a panel called the “Multiple Autoimmune Reactivity Screen“, also known as the Array #5. These are the markers this panel tests for:
- Parietal Cell
- Intrinsic Factor
- ASCA + ANCA
- Thyroid Peroxidase
- 21 Hydroxylase (Adrenal Cortex)
- Myocardial Peptide
- Platelet Glycoprotein
- Collagen Complex
- Arthritic Peptide
- Cytochrome P450 (Hepatocyte)
- Insulin + Islet Cell Antigen
- Glutamic Acid Decarboxylase 65 (GAD 65)
- Myelin Basic Protein
- Alpha + Beta Tubulin
While this is a great panel, keep in mind that you can also test for some of these autoantibodies at most local labs. And in some cases they might even be covered by your health insurance. On the other hand, if you are paying out of pocket it might be more cost effective to go with Cyrex Labs. This of course assumes that you are interested in such a test, as I don’t commonly recommend this panel to my patients, but some people might be interested in knowing if they have other autoantibodies. And in some cases it might even change the person’s mindset, as if they see that they have autoantibodies other than Graves’ disease and Hashimoto’s thyroiditis, then they might be even more likely to do what is necessary to improve the health of their immune system.
In summary, my practice focuses on those with thyroid and autoimmune thyroid conditions. And I commonly see people with the autoantibodies for both Graves’ disease and Hashimoto’s thyroiditis. Most people will predominantly be hyperthyroid or hypothyroid, although sometimes they will fluctuate between the two states. Managing the symptoms will differ depending on how someone presents, as those who are predominantly hyperthyroid will usually take antithyroid medication or herbs, while those who are predominantly hypothyroid will usually take thyroid hormone replacement. Regardless of whether you have multiple thyroid autoantibodies, or other types of autoantibodies, the goal is to reverse the autoimmune component, and eventually to normalize all of the autoantibodies.