Fibrent iodine reviews

Description

Fibrent + iodine is a unique complex to cleanse the body and lose weight. Fibrent + iodine significantly increases the ability of self-regulation in the health and cleansing process of the body. Fibrent + iodine is able to absorb and rid the body of excess cholesterol, bilirubin, bile acids, urea, salts of heavy metals and toxins. Fibrent + iodine is useful for healthy and sick people.

Indications Fibrent + iodine –
– Improves bile secretion and intestinal peristalsis
– Reduces appetite
– Binds and removes excess body’s vital processes
– Support normal microflora
– Facilitates the bowel movements
Fibrent + iodine improves the condition of the liver, gallbladder, pancreas, Fibrent + iodine is an additional source of iodine, antioxidants, macro and micronutrients, vitamins, powerful enterosorbent, reduces the burden on the kidneys.

The structure Fibrent + iodine include wheat bran, beet juice, flax seeds, thistle, kelp, white clay.

– Wheat bran – is rich in fiber. They improve and regulate the functioning of the gastrointestinal tract. When ingested bran, they swell in the stomach, creating the effect of satiety. This means that you eat less (the first condition in order to lose weight).
– Beet juice – rich in betaine – a substance contributing to the removal of salts from joints and improve the work of the kidneys and the biliary tract, inhibits cancer cells and helps to prevent tumors. A rich source of iron!
– Flax seeds – are known for their effective action against tumors (cancer, tumors), an excellent remedy for the stomach, because it has a shielding effect, maintains the elasticity of blood vessels and prevents blood clots, reduces blood cholesterol levels.
– Milk thistle – Fibrent + iodine is an effective assistance to the liver – the queen of all organs. Silymarin contains, which updates the liver cell consists of more vitamins and minerals 100! Milk thistle is well proven in the treatment of liver, is used for inflammation of the bile ducts, spleen, and thyroid, obesity and deposition of salts. It helps to reduce weight. It has no side effects.
– Kelp – contains iodine in rare form. Compensates for lack of iodine in the body (which is needed to maintain a healthy thyroid gland), removes toxins, is an excellent prevention of atherosclerosis, normalizes blood pressure.
– Kaolin (white clay) – a powerful adsorbent, which takes care of all the toxins, poisons and chemicals, removes them from the body, perfectly cleanses all the organs.
Fibrent + iodine is recommended to receive an additional source of dietary fiber, enterosorbent, disorders of the liver, gallbladder, pancreas, chronic diseases of the digestive tract, goiter, obesity, diabetes, kidney disease, atherosclerosis.

Fibrent + iodine is recommended if – Do you want to lose weight (you will eat less, but at the same time, getting nutrients more!)

– Care for their health (health of the liver, kidney, thyroid and pancreas, gastrointestinal tract)
– I wish to look young (antioxidants, vitamins and sorbents renew skin cells, cleanse the body)
– Dream of having smooth, clean and beautiful skin (the skin will be smooth and shiny)

Fibrent + iodine will not cause you discomfort, side effects (diarrhea, twisting abdominal pain, flatulence), will operate smoothly and easily, naturally and completely painless, will not bring harm to the body.

Manufacturer: PE “Your health-K”, Ukraine, Zbarazh
Ingredients: Wheat bran food, thalli kelp (seaweed), the fruits of thistle ground flax seeds, juice, beet, white clay
How to use: Take 30 minutes before a meal 1 tablespoon, abundant drinking water, 3 times a day. It is important to know! Begin supplementation should gradually: 1 tablespoon of the first day, 2 tablespoons on the second day, and then 3 tablespoons according to the scheme. Wash down means you need 1 cup of water. In the day to 2 liters of drinking water !!!
Contraindications: acute period of the disease (acute phase), acute ulcerative erosive processes of the gastrointestinal tract, diarrhea syndrome, adhesive disease of the abdominal cavity. As subsided sharpness can be gradually and gently restore reception, starting with low doses
Packaging: 200 grams, in a cardboard box
Shelf life: 12 months
Certificate: TU U 15.8-34463935-001: 2007

fitomir.net

1Bayer Healthcare Pharmaceuticals Inc., Whippany, NJ 07981, USA
2RTI Health Solutions, Research Triangle Park, NC 27709, USA

Copyright © 2015 Ateesha F. Mohamed et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. The aims of this study were to assess patients’ preferences to wait or start systemic treatment and understand how patients would make tradeoffs between certain severe adverse events (AEs) and additional months of progression-free survival (PFS). Materials and Methods. Adults in France, Germany, and Spain with a diagnosis of DTC and who have had at least one RAI treatment completed a direct-elicitation question and a discrete-choice experiment (DCE) online. The direct-elicitation question asked respondents whether they would opt out of treatment when their tumor is RAI-R. In the DCE, respondents chose between 12 pairs of hypothetical RAI-R DTC treatment profiles. Profiles were defined by magnitudes of efficacy (PFS) and safety (severe hand-foot skin reaction , severe proteinuria, and severe hypertension). A main-effects random-parameters logit model was estimated. Results. 134 patients completed the survey. Most patients (86.6%) opted for treatment rather than “wait and see” decision. Patients placed a greater weight on the risk of severe hypertension than the risk of proteinuria and HFSR. Conclusions. DTC patients showed preference toward treatment for RAI-R DTC over watchful waiting. Patients’ concerns about the risk of severe hypertension appeared to have had a greater effect on patients’ choice than severe proteinuria or HFSR.

1. Introduction

Worldwide, thyroid cancer accounts for 2.1% of all new cancers . Differentiated thyroid cancer (DTC), which includes papillary, follicular, and Hürthle cell types, accounts for nearly 94% of thyroid cancers . The main therapeutic approaches for DTC are surgical resection, radioactive iodine (RAI ) ablation, and thyroid-stimulating hormone suppression . The overall prognosis for DTC is excellent with a 10-year disease-specific survival rate of 85% . Approximately 10%–15% of patients develop distant metastases with a 10-year disease-specific survival rate of 40% . However, for some DTC patients who develop metastases, the ability to uptake RAI is lost (i.e., the patients become RAI-refractory ) with a 10-year disease-specific survival rate of 10% .

Consensus is emerging on how to best define RAI-R DTC. It is defined in patients with advanced disease either by the presence of at least one tumor focus without any uptake of RAI, or by progression of the disease during the year after a course of treatment with RAI, or by persistent disease after the administration of a cumulative activity of 22 GBq (600 mCi) radioiodine (based on individual assessment) . At progression, not all patients who develop RAI-R DTC experience disease-related symptoms, and physicians are faced with a decision on when to start treatment . Conventional chemotherapeutic agents like doxorubicin have been used to treat RAI-R DTC with poor results and weak evidence support .

There has been research conducted on the identification of intracellular pathways involved in pathogenesis of DTC . The focus is now on molecular targets like tyrosine kinase inhibitors (TKIs) and angiogenesis pathways . Recently, sorafenib and lenvatinib were both approved for the treatment of RAI-R DTC based on positive randomized clinical trials . Currently, there is no head-to-head comparison study of these two approved treatments, which makes it difficult for physicians to decide between these two systemic treatments. There are currently no published studies evaluating patient preferences regarding treatment decisions for RAI-R DTC patients.

The aims of this study were to assess patients’ preferences to wait or start systemic treatment and to understand how patients would make tradeoffs between additional months of progression-free survival (PFS) and certain severe adverse events (AEs) that differ between the two approved systemic treatments. The hypothesis is that when choosing treatments, patients consider long-term AEs with uncertain sequelae to be more important than short-term AEs that could lead to a worsening quality of life.

2. Materials and Methods2.1. Preference-Elicitation Questions

We followed good practice in designing and administering a discrete-choice experiment (DCE) to elicit patient preferences for RAI-R DTC treatments. This method is grounded in both psychology and economics and has been commonly applied in health . Several DCE studies in oncology have evaluated patient treatment preferences using online surveys . DCE studies require respondents to answer a series of choice questions where they indicate which of several hypothetical treatment alternatives they prefer. Treatment alternatives are defined by the levels to which they satisfy various treatment attributes. The attribute levels are systematically varied across choice questions, generating treatment profiles that are not representative of any existing treatment . Multinomial regression analysis of the respondents’ choices results in the relative importance of a particular treatment as a function of the attribute levels included .

A direct-elicitation question was included in the series of choice questions asking respondents to state whether they would opt out of treatment if their tumor was RAI-R. Respondents’ preferences for treatment are represented by the proportion of respondents who would accept starting any of the treatments offered in the direct-elicitation question .

2.2. Study Sample

Respondents who were at least 18 years old with a diagnosis of DTC and who had previously had at least one RAI treatment were recruited through medical clinics in France, Germany, and Spain (current use of systemic treatment was not an inclusion criterion). Respondents were invited to participate in the 25-minute online survey in February 2015. Each respondent was paid €30 in France and €25 in Germany and Spain as compensation for his or her time and inconvenience. The Office of Research Protection and Ethics at RTI International (Research Triangle Park, North Carolina, USA) approved this study, and respondents were required to provide online informed consent before participating in the survey.

2.3. Survey Instrument

To determine the four attributes and accompanying levels for the choice questions, we reviewed package inserts and phase 3 clinical trial data of recently approved systemic treatments . We included a main efficacy measure (months of PFS) and three main safety measures (grade 3/4 AEs): risk of severe hand-foot skin reaction (HFSR), risk of severe proteinuria, and risk of severe hypertension. The three severe AEs were chosen based on the severe AEs with the largest difference (at least 10%) in incidence rates reported in the phase 3 clinical trial data for the two approved TKIs . The levels for each attribute were designed to encompass the range observed in clinical trials and the range over which respondents were willing to make tradeoffs among the four attributes (Table 1). The definition for each attribute was presented using nontechnical language .

Table 1: Attributes and levels included in the final survey instrument.

To assess the validity of the survey instrument, a draft version was tested in 15 face-to-face semistructured interviews in November, 2014, after which minor changes were made to the wording to improve respondent comprehension. During these interviews, patients were asked to “think aloud” as they completed the draft survey instrument and a series of debriefing questions to ascertain that they understood the attribute definitions, accepted the hypothetical context of the survey, and were able to complete the choice questions as instructed .

In each choice question, patients were asked to choose between two hypothetical treatment profiles (Table 2). Each profile was defined by the levels of the four attributes that varied in a systematic way (i.e., the experimental design). The experimental design was a main-effects D-efficient experimental design consisting of 36 choice questions and generated using SAS version 9.3 (SAS, Cary, North Carolina, USA) . The 36 choice questions were blocked into three sets of 12 choice questions, and respondents were randomly assigned to each block. Within each block, the order of the 12 choice questions was varied to control for potential order effects . In addition to the choice questions, the survey included demographic and disease-experience questions, a risk tutorial to assist patients in understanding the AE risk levels included, and a direct-elicitation question (within the series of choice questions) to determine if patients would opt to start systemic treatment and avoid the severe treatment-related AEs rather than to “wait and see” if their tumor progressed in the way expected from RAI-R DTC.

Table 2: Example choice question.

2.4. Statistical Analysis

Responses to the choice questions were analyzed using a random-parameters logit model . The dependent variable was the treatment choice, and the explanatory variables were the attribute levels. All of the attributes listed in Table 1 were included in the model as continuous variables, where nonlinear effects were approximated with higher-order polynomial terms. Specification tests determined that preferences for improvements in PFS and severe hypertension changed nonlinearly and were modeled with quadratic and linear terms. Therefore, a one-unit change in each of these two attributes could have a different impact on preferences depending on the initial point of that improvement. The resulting parameter estimates quantified the relative strength of preference or preference weight of each attribute level . All analyses were conducted using NLOGIT 4.0 (Econometric Software, Inc., Plainview, New York, USA).

Results from the analysis of the choice questions were used to estimate patients’ stated risk tolerance, or maximum acceptable risk (MAR), that would be tolerated for improvements in PFS. MAR is the mean maximum level of treatment-related risk patients are willing to accept for a given improvement in treatment benefit as inferred from responses to the choice questions. It is calculated as the change in the risk of a given severe AE (HFSR, proteinuria, or hypertension) that would exactly offset the perceived benefit of a given improvement in PFS .

3. Results3.1. Patients Sample Characteristics

Of the 162 patients invited to participate, 144 responded to the invite and 141 were eligible. Of the eligible respondents, 134 (response rate = 82.7%) provided informed consent and were included in the final analysis, which is a sample size consistent with current DCE practices in health . Table 3 summarizes the demographic characteristics of the final sample: 84% were female, 78% were married, 58% were employed, 87% had papillary thyroid cancer, and 68% were diagnosed at least 2 years ago; the mean (standard deviation ) age was 47.2 (12.5) years. Nearly 20% of the sample (19.4%) reported having high blood pressure, though no information was available on the severity of this health problem or whether it was attributable to DTC medications. Of the patients who completed the survey, 8.2% stated they were on systemic therapy.

Table 3: Summary of patient characteristics.

3.2. Patient Preferences

Most patients (86.6%) opted for treatment rather than “waiting and seeing” if their tumor progressed in the way expected from RAI-R DTC. Figure 1 presents the estimated preference weights and 95% confidence intervals (CIs) for the four attributes. The mean estimates were ordered as expected (i.e., better clinical outcomes had higher estimates) and were statistically significantly different () between all adjacent levels for all four attributes.

Figure 1: Preference weights (). Only relative differences matter when interpreting preference weights. The differences between adjacent preference weights indicate the relative impact of moving from one level of an attribute to an adjacent level of that attribute. Note: the vertical lines around each mean preference weight denote the 95% confidence interval about the point estimate.

Only relative differences matter when interpreting preference weights. The differences between adjacent preference weights indicate the relative impact of moving from one level of an attribute to an adjacent level of that attribute; the greater the difference, the more significant the change from one level to the next. For example, the relative impact of moving from 6 months of PFS to 10 months of PFS was approximately 1.97 (−2.11 − ).

Similarly, the relative impact of a specific change in one attribute can be compared with the relative impact of a specific change in another attribute to understand whether the magnitude of the impact of a given change was comparable across attributes. For example, the relative impact of moving from 0% to 10% on severe proteinuria (1.68) was approximately 2 times the relative impact of moving from 0% to 10% on severe HFSR (0.83). As both of these variables were linear, the implication is that a 1%-point increase in the risk of severe proteinuria was twice as impactful to patients as a 1%-point increase in the risk of severe HFSR.

The vertical distance between the preference weights for the best and worst levels of any attribute indicates the overall relative importance of that attribute. Over the range of attributes and levels included in the survey, respondents considered improving PFS from 6 months to 24 months (i.e., improving PFS by 18 months) to be the most important attribute. Reducing the treatment-related risk of severe hypertension from 50% to none was approximately 0.86 times as important as improving PFS by 18 months. Improving the treatment-related risk of severe HFSR from 20% to none was approximately equally as important as improving the treatment-related risk of severe proteinuria from 10% to none; these changes were approximately 0.24 times and 0.25 times as important as improving PFS by 18 months, respectively. Among the three severe AEs shown, and given the ranges of risk presented to patients, greater weight was assigned to hypertension than the risk of proteinuria and HFSR.

3.3. Stated Risk Tolerance

Table 4 lists the MARs associated with improving PFS from 10 months to 16 months and improving PFS from 10 months to 18 months, respectively. For example, for an 8-month improvement in PFS, the maximum tolerated risk (i.e., prevalence) for severe hypertension was 21.8% (95% CI: 16.0%–27.7%), for severe proteinuria was 18.8% (95% CI: 12.9%–24.8%), and for severe HFSR was 38.5% (95% CI: 27.6%–49.3%). The 8-month improvement was clinically relevant, as the difference in the median PFS reported in the phase 3 clinical trial data for the two approved TKIs was approximately 7.5 months .

Table 4: Maximum acceptable risks.

4. Discussion

Our study had three main findings and potential clinical implications. First, DTC patients showed preference toward treatment for RAI-R DTC over watchful waiting given the tradeoffs offered in the direct-elicitation question. Under this scenario, 86.6% of patients opted to start treatment rather than to “wait and see,” as patients understood that once DTC progresses to RAI-R, it is no longer a slow-moving disease . On the other hand, being RAI-R DTC usually means that the patients have undergone a number of previous and ultimately unsuccessful treatments, which may impact the decision to start a new treatment when they can observe the outcome of their disease in response to treatment.

Second, our study indicated that patients had clear preferences among the four selected treatment-related benefits and risks of RAI-R DTC treatments and traded off among them when choosing a treatment. This adds to the existing literature in RAI-R DTC, as there are currently no available data on patients’ treatment preferences. Patients’ perspectives can be considered in shared decision making between patients and physicians. Studies like this one also can offer some patient insights into aspects of treatment versus “wait and see” decision.

Third, patients valued improvement in PFS as the most important attribute. However, patients’ concerns about the risk changes included in this study for severe hypertension appeared to have had a greater impact on patients’ choice of treatment than the changes included for the risks of severe proteinuria or severe HFSR. Potential explanations for this finding came from the face-to-face interviews where patients mentioned that they were more concerned about AEs that had no short-term symptoms but that could result in potentially serious sequelae like life-threatening cardiac events due to chronic hypertension or renal impairment due to proteinuria. It is possible that patients were concerned that these AEs may require regular monitoring and may cause permanent health problems. Although bothersome and painful, onset of HFSR is evident to patients and the symptoms may be transient, which may give patients more control of the event. This information from the patients could help us understand patients’ perspectives on these three common AEs and suggest areas for discussion between patients and physicians to make a treatment decision for RAI-R DTC.

Although DCE studies are increasingly used in health applications, they have limitations. First, respondents evaluate hypothetical treatments; although the tradeoffs are intended to simulate possible clinical decisions, they do not have the same clinical, financial, or emotional consequences of actual decisions. Thus, differences can arise between stated and actual treatment choices. Second, this study included only the selective AEs that differed between the two approved systemic therapies. There may be other factors that can influence actual treatment decisions that are not accounted for in this study.

Third, our sampling strategy within the study design limits the confidence with which these results can be generalized to the RAI-R DTC patient population. For example, we surveyed a convenience sample of DTC patients in France, Germany, and Spain with access to the Internet. Our sample was younger and had more females compared with the actual patient populations in the clinical trials . Our sample included a small proportion (8.2%) of RAI-R DTC patients on systemic therapy; therefore, a portion of patients who participated in this study did not have experience with RAI-R disease and would not have been exposed to treatment-related risks of the three AEs included in the study. Although our study was not powered to test for variations in preferences between subgroups of respondents, it is unclear whether these differences mattered as previous preference studies have found that patient characteristics or experiences do not always have an effect on treatment preferences . Nevertheless, caution should be exercised when trying to generalize our findings to patients with different demographic or treatment histories or to patients in other countries in Europe, or elsewhere. For example, the finding that PFS was the most important attribute and severe hypertension was more important than severe proteinuria or severe HFSR may have a different impact on an older sample of actual RAI-R DTC patients who may have other comorbidities and can better understand the impact of comorbidities such as severe hypertension in their lives. Future research using a randomized patient sample being treated with TKIs for RAI-R DTC to verify our findings would be particularly valuable.

In conclusion, DTC patients showed preference toward treatment for RAI-R DTC over watchful waiting. Patients’ concerns about the risk of severe hypertension appeared to have had a greater impact on patients’ choice of systemic treatment than concerns about severe proteinuria or severe HFSR. The results of this study may offer some insights into patients’ perspectives on treatments and offer some guidance in shared decision making between patients and physicians for RAI-R DTC treatments.

Conflict of Interests

Juan Marcos González and Angelyn Fairchild have no conflict of interests to declare. Ateesha F. Mohamed is employed by Bayer Healthcare and owns stock in Bayer AG.

Acknowledgments

The authors would also like to thank Christina Darden, Marc Fellous, A. Brett Hauber, Maria Lucas, Keiko Nakajima, Christopher Ngai, Joshua Posner, Niclas Ringberg, Mark Rutstein, and Darrell Wakefield for their assistance at various stages of this study. The authors would like to thank the respondents who chose to participate in the face-to-face interviews and the main survey. This study was funded by Bayer Healthcare Pharmaceuticals, Inc., Whippany, NJ 07981, USA, by a fixed-price contract with full publication rights granted.

www.hindawi.com

The haloform reaction is a chemical reaction where a haloform (CHX3, where X is a halogen) is produced by the exhaustive halogenation of a methyl ketone (a molecule containing the R–CO–CH3 group) in the presence of a base. R may be alkyl or aryl. The reaction can be used to transform acetyl groups into carboxyl groups or to produce chloroform (CHCl3), bromoform (CHBr3), or iodoform (CHI3).

Mechanism

In the first step, the halogen disproportionates in the presence of hydroxide to give the halide and hypohalite (example with bromine, but reaction is the same in case of chlorine and iodine; one should only substitute Br for Cl or I):

Br2+2OH− → Br−+BrO−+H2O{displaystyle {mbox{Br}}_{2}+2{mbox{OH}}^{{}-{}}~rightarrow ~{mbox{Br}}^{{}-{}}+{mbox{BrO}}^{{}-{}}+{mbox{H}}_{2}{mbox{O}}}

If a secondary alcohol is present, it is oxidized to a ketone by the hypohalite:

If a methyl ketone is present, it reacts with the hypohalite in a three-step process:

1. Under basic conditions, the ketone undergoes keto-enol tautomerization. The enolate undergoes electrophilic attack by the hypohalite (containing a halogen with a formal +1 charge).

2. When the α position has been exhaustively halogenated, the molecule undergoes a nucleophilic acyl substitution by hydroxide, with −CX3 being the leaving group stabilized by three electron-withdrawing groups. In the third step the −CX3 anion abstracts a proton from either the solvent or the carboxylic acid formed in the previous step, and forms the haloform. At least in some cases (chloral hydrate) the reaction may stop and the intermediate product isolated if conditions are acidic and hypohalite is used.

Scope

Substrates are broadly limited to methyl ketones and secondary alcohols oxidizable to methyl ketones, such as isopropanol. The only primary alcohol and aldehyde to undergo this reaction are ethanol and acetaldehyde, respectively. 1,3-Diketones such as acetylacetone also give the haloform reaction. β-ketoacids such as acetoacetic acid will also give the test upon heating. Acetyl chloride and acetamide don’t give this test. The halogen used may be chlorine, bromine, iodine or sodium hypochlorite.Fluoroform (CHF3) cannot be prepared by this method as it would require the presence of the highly unstable hypofluorite ion. However ketones with the structure RCOCF3 do cleave upon treatment with base to produce fluoroform; this is equivalent to the second and third steps in the process shown above.

Applications

Laboratory scale

Negative and positive iodoform test

This reaction forms the basis of the iodoform test which was commonly used in history as a chemical test to determine the presence of a methyl ketone, or a secondary alcohol oxidizable to a methyl ketone. When iodine and sodium hydroxide are used as the reagents a positive reaction gives iodoform, which is a solid at room temperature and tends to precipitate out of solution causing a distinctive cloudiness.

In organic chemistry, this reaction may be used to convert a terminal methyl ketone into the analogous carboxylic acid.

Industrially

It was formerly used to produce iodoform, bromoform, and even chloroform industrially.

As a by-product of water chlorination

Water chlorination can result in the formation of haloforms if the water contains suitable reactive impurities (e.g. humic acid). There is a concern that such reactions may lead to the presence of carcinogenic compounds in drinking water.

History

The haloform reaction is one of the oldest organic reactions known. In 1822, Georges-Simon Serullas added potassium metal to a solution of iodine in ethanol and water to form potassium formate and iodoform, called in the language of that time hydroiodide of carbon. In 1831, Justus von Liebig reported the reaction of chloral with calcium hydroxide to form chloroform and calcium formate. The reaction was rediscovered by Adolf Lieben in 1870. The iodoform test is also called the Lieben haloform reaction. A review of the Haloform reaction with a history section was published in 1934.

References

  1. ^ March, Jerry; Smith, Michael B. (2007). Knipe, A.C., ed. March’s Advanced Organic Chemistry Reactions, Mechanisms, and Structure (6th ed.). Hoboken: John Wiley & Sons. p. 484. ISBN 9780470084946. 
  2. ^ a b Reynold C. Fuson and Benton A. Bull (1934). “The Haloform Reaction”. Chemical Reviews. (3): 275–309. doi:10.1021/cr60052a001. 
  3. ^ Chakrabartty, in Trahanovsky, Oxidation in Organic Chemistry, pp 343–370, Academic Press, New York,
  4. ^ Bain, Ryan M.; Pulliam, Christopher J.; Raab, Shannon A.; Cooks, R. Graham (2016). “Chemical Synthesis Accelerated by Paper Spray: The Haloform Reaction”. Journal of Chemical Education. (2): 340–344. Bibcode:2016JChEd..93..340B. doi:10.1021/acs.jchemed.5b00263. ISSN 0021-9584. 
  5. ^ Rook, Johannes J. (1977). “Chlorination reactions of fulvic acids in natural waters”. Environmental Science & Technology. (5): 478–482. Bibcode:1977EnST…11..478R. doi:10.1021/es60128a014. ISSN 0013-936X. 
  6. ^ Reckhow, David A.; Singer, Philip C.; Malcolm, Ronald L. (1990). “Chlorination of humic materials: byproduct formation and chemical interpretations”. Environmental Science & Technology. (11): 1655–1664. Bibcode:1990EnST…24.1655R. doi:10.1021/es00081a005. ISSN 0013-936X. 
  7. ^ Boorman, GA (February 1999). “Drinking water disinfection byproducts: review and approach to toxicity evaluation”. Environmental Health Perspectives. 107 Suppl 1: 207–17. doi:10.1289/ehp.99107s1207. PMC 1566350 . PMID 10229719. 
  8. ^ László Kürti and Barbara Czakó (2005). Strategic Applications of Named Reactions in Organic Synthesis. Amsterdam: Elsevier. ISBN 0-12-429785-4. 
  9. ^ Georges-Simon Surellas, Notes sur l’Hydriodate de potasse et l’Acide hydriodique. – Hydriodure de carbone; moyen d’obtenir, à l’instant, ce composé triple (Metz, France: Antoine, 1822). On pages 17–20, Surellas produced iodoform by passing a mixture of iodine vapor and steam over red-hot coals. However, later, on pages 28–29, he produced iodoform by adding potassium metal to a solution of iodine in ethanol (which also contained some water).

en.wikipedia.org

By Kelly Bonyata, IBCLC

Following are various diagnostic tests and treatments that moms with thyroid problems might encounter. The information summarized below is only a general overview. For detailed information, please review the references listed below with your health care provider.

Thyroid screen

This is a blood test that checks thyroid function. Blood tests are compatible with breastfeeding. Tests may include:

  • TSH (thyroid stimulating hormone, produced by the pituitary gland)
  • total T4 (thyroxine, a thyroid hormone) and/or free T4
  • total T3 (triiodothyronine, a thyroid hormone) and/or free T3
  • Thyroid Binding Globulin (TBG)
  • Thyroid Stimulating Antibodies (TSAb)
  • Thyroid Stimulating Immunoglobulin (TSI)

Thyroid medications

  • levothyroxine (Synthroid, Levoxyl) synthetic T4 hormone (1)
  • liothyronine (Cytomel) synthetic T3 hormone
  • combination of T3 & T4 (Thyrolar/Liotrix, Armour Thyroid)

Info on selected thyroid meds

Name of medication

Notes
Levothyroxine (T4)

L1 (safest)

(1)
Liothyronine (T3)

L2 (safer)

(2)
** Per Medications’ and Mothers’ Milk by Thomas Hale, PhD (2014 edition).

(1) “Most studies indicate that minimal levels of maternal thyroid are transferred into human milk, and further, that the amount secreted in extremely low and insufficient to protect a hypothyroid infant even when nursing… it is generally recognized that some thyroxine will transfer but the amount will be extremely low… (Hale 2014, p. 649-50)

Now infants can get
all their vitamin D
from their mothers’ milk;
no drops needed with
our sponsor’s

TheraNatal Lactation Completeby THERALOGIX.

(2) “From these studies it is apparent that only exceedingly low levels of T3 are secreted into human milk and are insufficient to protect an infant from hypothyroidism. (Hale 2014, p. 657-58)

Anti-thyroid medications

  • carbimazole (Neo-Mercazole)
  • methimazole (Tapazole)
  • propylthiouracil (PTU)

Info on selected anti-thyroid meds

Name of medication

Notes
carbimazole (Neo-Mercazole) L2 (safer) (1)
methimazole (Tapazole) L2 (safer) (2)
propylthiouracil (PTU) L2 (safer) (3)
** Per Medications’ and Mothers’ Milk by Thomas Hale, PhD (2014 edition).

(1) “Carbimazole is a prodrug and is rapidly converted to methimazole.” (Hale 2014, p. 723-24)

(2) Levels of methimazole in milk depend on the maternal dose but appear too low to produce clinical effects.” (Hale 2014, p. 723-24)

(3) “Only small amounts are secreted into breastmilk. Reports thus far suggest that levels absorbed by infant are too low to produce side effects… 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.” (Hale 2014, p. 920)

I’m not hyperthyroid myself, but my sister was diagnosed with Grave’s disease after her first child was born. She breastfed her children while taking anti-thyroid meds for her hyperthyroidism.

Other medications

Some moms with hyperthyroidism are also prescribed beta-blockers (such as Propranolol/Inderal) or calcium channel blockers to relieve the neurological and cardiovascular symptoms of hyperthyroidism. Many of these drugs (including Propranolol/Inderal) are considered to be acceptable for use in breastfeeding mothers.

Ultrasound

Ultrasound is compatible with breastfeeding.

Fine needle aspiration (FNA) biopsy

This procedure is compatible with breastfeeding.

You don’t need to stop nursing for a fine needle biopsy. It’s a bit scary to think of (at least it was for me!), but it doesn’t really hurt at all (about like having blood drawn from your arm) and it just takes a few minutes. I’ve had 2 fine needle biopsies and the second was so much easier since I know what to expect.

Thyroidectomy

In this surgery, all or part of the thyroid is removed. Mom can resume breastfeeding as soon after the surgery as she feels up to holding baby.

See also Breastfeeding when mom has surgery.

I had thyroid surgery (a partial thyroidectomy for what turned out to be a benign cold nodule) about a year before my daughter was born, so I was not breastfeeding at the time. As I recall, I was really uncomfortable the day of the surgery, but it got better pretty quickly after that. My neck muscles were sore for weeks – it might take a little creative positioning to help you to breastfeed comfortably. You might want to take a nursing pillow to the hospital to raise baby up so you can see her without moving your head as much, etc. Nursing while lying down might help, too.

I also urge you to nurse right before the surgery and as soon afterwards as you feel you can. Ask your doctor how you can expect to be feeling after surgery. I recall feeling really rotten the first day, but I think I could have nursed just fine as long as someone brought the baby to me. Your milk supply could go down a bit if you miss any nursings, so try to pump if you miss any feedings.

One thing I was worried about with thyroid surgery was the scar… in my case, it was pretty difficult to see after about 6 months (my surgeon said to give it a year), and now (4 years later) I cannot find the scar at all.

Thyroid Scan

This scan can be done using radioactive iodine (I-131 or I-123) or technetium-99m pertechnetate. This test requires temporary weaning for a minimum of 12 hours, depending upon the isotope used (see below). Many times, this test can be skipped and a fine needle aspiration biopsy done instead (which does not require an interruption of breastfeeding).

Technetium-99m has a very short half-life (6.02 hours, compared to 8.1 days for I-131). The amount of time suggested for suspending breastfeeding varies depending on the dosage and form of the isotope (there are many forms of Tc-99m). For some tests, breastfeeding can be resumed immediately; for others it is recommended to suspend breastfeeding for amounts of time varying from 6 hours to 48 hours. See the NRC Table for additional guidance.

I-123 has a half-life of 13.2 hours, and is available in several forms. For one of the forms of the isotope, Hale suggests suspending breastfeeding for 12-24 hours, depending upon the dose, but a couple of other forms/dosages do not require suspension of breastfeeding.

I-131 concentrates in breastmilk and high levels in breastmilk can suppress baby’s thyroid function (or even destroy the thyroid) and increase risk of thyroid cancer. Therefore it is important that breastfeeding be discontinued until breastmilk levels are safe (this depends upon the dose and ranges from 8 days to 106+ days). The half-life for I-131 is 8.1 days. Hale recommends that when I-131 is used, breastmilk samples should be tested with a gamma (radiation) counter before breastfeeding is resumed to ensure that radiation in the milk has returned to safe levels. Lactation Risk Category is L4 (possibly hazardous).

Important note: If you do suspend breastfeeding due to use of radioactive isotopes, it is important to pump regularly during this time. See also Maintaining milk supply when baby is not nursing. You do not need to dump this milk. It can be dated, frozen and used after 5+ half-lives of the radioisotope have passed (after 5 half-lives, 96.9% of the radiation is gone; after 10 half-lives, 99.9% of the radiation is gone). You may also get the milk checked for radiation by your nuclear medicine department.

Reference: Hale, 2002, p. 365-367, 675-676, 689-690. See also Use of Radioisotopes during Lactation.

Radioactive iodine (RAI) Uptake Scan

This scan is done using radioactive iodine (I-131), and is usually done at the same time as a thyroid scan. See the info above on thyroid scans using I-131.

See also Use of Radioisotopes during Lactation.

The type of thyroid scan I had was a radioactive iodine uptake & thyroid scan. I had to drink some radioactive iodine, then come back later in the day to have the scan (like a x-ray). I was not nursing at the time.

For nursing moms, there are usually other diagnostic procedures that can be done instead of a scan, for example, blood tests, ultrasound, and/or fine needle biopsy. The second time I needed diagnostic procedures, my doctor skipped the scan and just did a fine needle biopsy.

Radioactive iodine treatment (RAI)

This treatment is done using radioactive iodine (I-131), but in much larger doses than used for a diagnostic scan. Its purpose is to partially or completely destroy the thyroid. It is recommended that the mother discontinue breastfeeding several days to weeks before this therapy, and pump and dump milk for several weeks after therapy to reduce exposure of the breast tissue to radiation. The US Nuclear Regulatory Commission recommends complete weaning after I-131 is used therapeutically.

See also Use of Radioisotopes during Lactation.

Breastfeeding and Thyroid Problems: Links

Breastfeeding and Thyroid Problems: Studies and References


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