Case Report:

Fast reversal of Severe

Osteoporosis after correction of
excessive levothyroxine treatment
and long-term follow-up

Ruth Astry Evangelia

030.15.171
 Introduction

Hyperthyroidism is a known cause of accelerated bone

turnover and bone loss and increases the risk of
osteoporosis and fragility fractures

Hyperthyroidism is a known risk factor for

osteoporosis and fractures
 Introduction
Also, subclinical hyperthyroidism, and even
serum thyrotropin (S-TSH) levels within the low-
normal range in euthyroid elderly women, has
been shown to increase the risk of low bone
mineral density (BMD) and fractures

Patients with long-term levothyroxine

treatment have been indicated to increase
the risk of fragility fractures
Case Presentation
This case report describes a 38-year-old
woman, who presented with bilateral
femoral stress fractures and osteoporosis
after years of excessive levothyroxine
treatment.

She had undergone thyroidectomy

at the age of 12 years due to a
papillary thyroid adenoma and had
thereafter received levothyroxine
replacement therapy

She trained excessively, running 10–20 km 5–6

times a week, and had recently experienced
debilitating pain in both thighs caused by bilateral
femoral stress fractures
Follow up
Had recently experienced debilitating High serum free T4, an
Thyroidectomy at the age of pain in both thighs caused by bilateral elevated osteocalcin level. The
12 years and received femoral stress fractures, which was levothyroxine dose was lowered
levothyroxine replacement confirmed by bone scintigraphy. Her to 0.1 mg (100 μg) daily. 6
therapy. Daily dose of 0.3 mg anterior-posterior lumbar BMD Z- months later, her femoral pain
(300 μg) score (L1-L4) was −2.5 had subsided

1967 1992 1993

During follow-up for over 20 years, Her lumbar spine BMD

her BMD remained normal past normalized within 2 years
menopause, and she has not without any bone-specific
experienced fractures or bone treatments or supplements
pain

2013 1995
  1993 1994 1996 2000 2016

Height, cm 172 172 171 170 169

Body weight, kg 60 59 61 60 62
BMI, kg/m2 20.3 19.9 20.9 20.8 21.7
Levothyroxine, average daily dose (μg) 300 125 100 112.5 107
Free T4, pmol/L (10–22) 37 15 15 12 22
T3, nmol/L (1.3–3.1) 2.6 2.4     1.6
TSH, mU/L (0.2–4.2) 0.0001 0.015 0.03 0.28 0.06
Osteocalcin, μg/L (3.0–7.5)(5.4–59)* 9.6 6.8 7.0 6.0 19*
PTH, ng/L (10–64)(1.6–6.9 pmol/L)* 31.8   41.2 53 3.77*
Calcium, mmol/L (2.15–2.5) 2.39 2.37 2.36 2.34 2.5
Ionized calcium, mmol/L(1.18–1.31) 1.30   1.27 1.21 1.23
 Discussion
Neither young nor elderly women
receiving TSH-suppressive
therapy after treatment for thyroid
cancer exhibited adverse effects
on BMD or fracture rates during
at least 10 years of follow-up
TSH induces a direct effect on
bone cells through TSH receptors,
and low TSH receptor activation
may enhance osteoclast function
and downregulate osteoblast
differentiation inducing a state of
high-turnover bone metabolism,
while other studies show that T3
controls bone cells through
activating thyroid hormone receptor

This patient suffered significantly

from her hyperthyroid bone
Osteocalcin levels are known to condition, but on the other hand,
rise with increasing T3 levels, and she had used a higher
bone resorption markers to levothyroxine dose than normally
decline with treatment for prescribed in TSH suppressive
hyperthyroid therapy (5.0 vs 2–3 μg/kg/day)
 Discussion

Other factors, such as heredity and nutrient intake,

can also affect the tendency for bone loss in an
individual

The levothyroxine dosage to achieve TSH suppression

after thyroid cancer should be titrated to the smallest
possible dose as to avoid complications
Conclusion The patient suffered severe symptoms from her
osteoporosis and her condition was rapidly reversed
with a lowering of levothyroxine dosage

Serum free T4 and TSH should be kept within the

reference range for the usual regimen of
levothyroxine replacement in hypothyroidism

Osteocalcin levels are known to rise with increasing

T3 levels, and bone resorption markers to decline
with treatment for hyperthyroid

Even though levothyroxine supplementation in the

hypothyroid patient may seem like a routine matter
for many physicians, decent follow-up of patients
with levothyroxine supplementation is mandatory.
Thank You