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59 | Thoughts on an ashwagandha thyrotoxicosis case report
As I was preparing for a lecture on ashwagandha (Withania somnifera), I came across a case report sharing information about a women who went to the ER with tachycardia, palpitations and other symptoms of hyperthyroidism.
Her TSH was almost absent, while T4 and T3 were within normal limits. The doctors there ruled out other causes and eventually determined that she had been taking ashwagandha root extract daily instead of her regular thyroid medication for approximately 2 years after a diagnosis of hypothyroidism. They suspected this might be causing her hyperthyroid symptoms.
She was asked to discontinue the ashwagandha root, and at two follow-ups her TSH began to rise, while her T3 and T4 started dropping, suggesting a return to her hypothyroid state. The physicians suspected that she was in the early stages of hyperthyroidism when she presented in the ER, due to her T3 and T4 being WNL.
Here is a copy of the case (open access!) if you'd like to check it out: Kamal HI, Patel K, Brdak A, Heffernan J, Ahmad N. Ashwagandha as a Unique Cause of Thyrotoxicosis Presenting With Supraventricular Tachycardia. Cureus. 2022 Mar 25;14(3):e23494. doi: 10.7759/cureus.23494. PMID: 35475098; PMCID: PMC9035336.
In this episode, I discuss what we can learn from this case report, and what I wish the authors had included in their case presentation.
I hope you find this discussion helpful. If you have thoughts or clinical observations regarding ashwagandha and thyroid disease, I'd love to hear them!
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Transcript
Camille (00:00)
Well, hi there.
Camille (00:01)
Welcome to In the Clinic with Camille. My name is Camille Freeman. I am a licensed nutritionist and registered herbalist. And in this podcast, I share little tips and tidbits that might be interesting or helpful for other practitioners.
Camille (00:21)
Hi there. I have been working on preparing a lecture about Ashwagandha today. And as part of my lecture, I was poking around in the literature to get up to date with some of the studies that have been published in the last couple of years. I came across a case study that I thought was really interesting and that also irked me. I thought I would get on here and do a little bit of an overview of the case and also share some of the things to look out for in case you ever come across something like this in the literature. Now, I am not on social media, so it's possible that this has been fully hashed out on the socials and everybody's already familiar with all these little bits and pieces. And if so, awesome. You can skip ahead to the next episode. But in case you aren't familiar with this or you want to dig in a little bit, come along for the ride. The title of this case study is Ashwagandha as a unique cause of thyrotoxicosis presenting with supraventricular tachycardia. This was published in March 2022 in the journal Cureus, which is spelled C U R E U S.
Camille (01:22)
It is an open access article. Yay for the authors, gold star for that. I will share a link to it in the show notes in case you would like to check it out yourself. Here's the deal. I'm not going to read every single piece of the case, but I'm going to give you an overview of it. What happened is a 73 year old female presented to the emergency department. She had heart palpitations, chest pain, shortness of breath. She reported that over the past few weeks, she had been experiencing tachycardia, rapid heart rate, palpitations, dizziness, fatigue, irritability, loose stools, and hair thinning. They ruled out all kinds of things. They checked her heart for everything. They looked at the medications she was taking. She wasn't on anything like that. She didn't have any history of cigarettes, no excessive caffeine, alcohol. They even did a urine screen for illicit drug use. She hadn't had any renal infections, anything like that. Her blood pressure was slightly elevated, diastolic, but otherwise pretty normal. But her heart was beating at 173 beats per minute, which was very fast. They did all these studies and they found that her TSH was incredibly low, almost not even there.
Camille (02:34)
Whereas her free T3 and her free T4 were normal within normal limits. They tested her thyroid antibodies. They did find that thyroid microsomal antibody was elevated. Some of the other ones were normal. And she reported that several years ago she had been diagnosed with Hashimotos. She was taking the levothyroxine but stopped taking it about two years before showing up at the emergency room. And at that time, she had started taking ashwagandha root as an alternative. It was specifically presented as an alternative. So what they did is they gave her some medications for the heart stuff. They told her to stop taking the ashwagandha and they did a follow up two weeks later. And at that time, her TSH was back within normal limits. It was all the way up to 3.49. Her free T 4 and free T 3 had dropped substantially. And then several weeks after that, her TSH kept going up. Her T 3 and T 4 kept going down. So she was becoming a hypothroid again. So they concluded that the ashwagandha had pushed her into the thyrotoxicosis. It's an interesting case. Then they go on to talk about ashwagandha might be dangerous, etc.
Camille (03:55)
Here's the things that I'm thinking about. First of all, this drives me up the wall that they don't say what extract, what was the dose, not mentioned anywhere in the study. We don't know, was she taking 1 gram of powdered root? Was she taking 10 grams of a 50 to 1 extract? Was she taking tincture? Was she taking capsules, powder? What was it? How often was she taking it? That was not mentioned. The other thing that didn't happen, which we really need to do with herbs, and I think most of the time people coming from the medical world may not realize this, but with herbs, if there is a suspected adverse reaction, we always want to test the product. We want to get our hands on the actual product so we can test it and see if what it says on the label is actually what it is. Because if she was taking some product from a gas station somewhere, it's possible that it says ashwagandha on the label, but in fact, it actually has ashwagandha plus a whole bunch of other stuff. Or that it says it's ashwagandha, but actually this one batch had seven times the dose that it normally does, etc.
Camille (05:01)
So we don't have any indication of anything about the product other than that it was ashwagandha root extract. So it's no verification that it actually is ashwagandha root extract. There's no indication of what the dose was supposed to be or what it actually was. So those to me are all absolutely critical if we're going to get any useful information about this from the perspective of a practicing herbalist or nutritionist. Now, from the medical perspective, the takeaway point, I think, is just, Oh, be wary of that scary ashwagandha and don't recommend it for your patients. However, I think it's very interesting that she stopped taking her thyroid medicines two years prior and had, based on her symptoms, maintained healthy thyroid function for almost two years in the interim. Now, is it possible that the ashwagandha was slowly and gradually pushing her towards this point, and then after two years, it was the tipping point and she developed thyrotoxicosis, yes, but it's also possible that something else changed, either with the dosing, the product itself, a stressful event in her life, whatever else that may have contributed. One of the things that wasn't pointed out in this whole situation is, Wow, it's really interesting that this ashwagandha may have actually been supportive for maintaining thyroid health for this long.
Camille (06:28)
So I think that's something to consider as well. Now, in terms of the big picture takeaways for me as an herbalist, like I said, there are two case studies of thyrotoxicosis in people taking ashwagandha root extract. Although, again, we don't know the dose, we don't know what kind, we don't know if it was verified to be what it says it is or not. What do I make of that? Well, there's certainly a number of animal studies and a small handful of human studies suggesting that ashwagandha root may be helpful for folks who are experiencing hypothyroid conditions. But does that mean it's unsafe for people who are hyperthyroid? Does that mean we shouldn't be giving this to folks who are hypothyroid because it might push them into becoming hyperthyroid? My takeaways are, first of all, that it's always useful to be cautious. It's always useful to keep an eye on things. Personally, if I have a client who does have a hypothyroid condition and we do want to work with ashwagandha, we want to take into consideration, are they on any thyroid medicines or not? And how frequently are they being followed up by their prescribing practitioner?
Camille (07:41)
Because if somebody is taking a thyroid med and they're only going in once every year or two, I'm going to be a lot more cautious with using ashwagandha because I do think it's useful to be aware. Okay? If somebody's going in regularly every three to six months, having their TSH levels checked and maybe some of the other thyroid hormones as well, I feel more comfortable playing around with ashwagandha to see, make sure that it's going to be a good fit for that person and so forth. It's not the only herb that I might consider using. Obviously, we want to do a constitutional analysis and so forth. What about the hyperthyroid client? For me, based on what's available right now, I would not consider ashwagandha overtly contraindicated in all hyperthyroid clients. However, again, I would want to be keeping a close eye on things and I would want to make sure that it's an energetic match. I have to say that most people who are hyperthyroid are not really going to fit the ashwagandha profile. Ashwagandha is probably not going to be my first choice for many of those claims anyway. However, it's been my experience that it does have some amphoteric effects, and I wouldn't be surprised to find that it might be nourishing to both ends of the thyroid spectrum.
Camille (08:59)
It's not one of my first choices for folks who are in a hyperthyroid condition. But personally, I wouldn't 100 % rule it out. If you are a more cautious practitioner, if you like to take an extremely safety first, absolutely no risks taken approach, then I think you might want to avoid ashwagandha entirely in your folks who do have hyperthyroid or you suspect might be leaning in that direction. Okay, so anyway, the takeaways from this are, A, if you are reading a case study, please take a look at the dose, the fact about whether they did or did not verify that whatever the person was taking is what it says it is, and the type of extract used. There's a difference between a 1 to 2 extract and a 50 to 1 extract in terms of the dose and the suitability and the way that we interpret what we've learned. All right. Lest this all seem super negative to the people who wrote this up, sure, they won't listen to this, but anyway, just to put it out there, I do love that people are writing this up because this is the only way that we learn and grow.
Camille (10:07)
I do appreciate that the authors were curious enough to ask into these questions that they did ask more about what was going on, that they followed up not just once, but twice after this person's visit to the emergency room, and that they did poke around in the literature and try to find out what's going on here. I do want to give a shout out to anybody who takes the time to publish. It's way harder than it sounds to get something pulled together, to get it through peer review, to put it out in an open access journal. I send out major props to the authors for doing those pieces of things. I always want to be grateful for folks who take the time and effort to do these kinds of things for the advancement of all of us. I hope that was helpful. There's a little off the cuff thoughts on this topic. I will be back soon with some more information. If you have any questions or things you'd like for me to cover, please reach out anytime. All right, take care.
Camille (11:07)
Thanks for listening to In the Clinic with Camille. Hey, did you know that I write a weekly practitioner note for herbalists and nutritionists? If you would like to get that in your inbox, you can sign up at CamilleFreeman.Com/newsletter.
Camille (11:20)
I'd love to have you.
Camille (11:20)
Join us there.
Well, hi there.
Camille (00:01)
Welcome to In the Clinic with Camille. My name is Camille Freeman. I am a licensed nutritionist and registered herbalist. And in this podcast, I share little tips and tidbits that might be interesting or helpful for other practitioners.
Camille (00:21)
Hi there. I have been working on preparing a lecture about Ashwagandha today. And as part of my lecture, I was poking around in the literature to get up to date with some of the studies that have been published in the last couple of years. I came across a case study that I thought was really interesting and that also irked me. I thought I would get on here and do a little bit of an overview of the case and also share some of the things to look out for in case you ever come across something like this in the literature. Now, I am not on social media, so it's possible that this has been fully hashed out on the socials and everybody's already familiar with all these little bits and pieces. And if so, awesome. You can skip ahead to the next episode. But in case you aren't familiar with this or you want to dig in a little bit, come along for the ride. The title of this case study is Ashwagandha as a unique cause of thyrotoxicosis presenting with supraventricular tachycardia. This was published in March 2022 in the journal Cureus, which is spelled C U R E U S.
Camille (01:22)
It is an open access article. Yay for the authors, gold star for that. I will share a link to it in the show notes in case you would like to check it out yourself. Here's the deal. I'm not going to read every single piece of the case, but I'm going to give you an overview of it. What happened is a 73 year old female presented to the emergency department. She had heart palpitations, chest pain, shortness of breath. She reported that over the past few weeks, she had been experiencing tachycardia, rapid heart rate, palpitations, dizziness, fatigue, irritability, loose stools, and hair thinning. They ruled out all kinds of things. They checked her heart for everything. They looked at the medications she was taking. She wasn't on anything like that. She didn't have any history of cigarettes, no excessive caffeine, alcohol. They even did a urine screen for illicit drug use. She hadn't had any renal infections, anything like that. Her blood pressure was slightly elevated, diastolic, but otherwise pretty normal. But her heart was beating at 173 beats per minute, which was very fast. They did all these studies and they found that her TSH was incredibly low, almost not even there.
Camille (02:34)
Whereas her free T3 and her free T4 were normal within normal limits. They tested her thyroid antibodies. They did find that thyroid microsomal antibody was elevated. Some of the other ones were normal. And she reported that several years ago she had been diagnosed with Hashimotos. She was taking the levothyroxine but stopped taking it about two years before showing up at the emergency room. And at that time, she had started taking ashwagandha root as an alternative. It was specifically presented as an alternative. So what they did is they gave her some medications for the heart stuff. They told her to stop taking the ashwagandha and they did a follow up two weeks later. And at that time, her TSH was back within normal limits. It was all the way up to 3.49. Her free T 4 and free T 3 had dropped substantially. And then several weeks after that, her TSH kept going up. Her T 3 and T 4 kept going down. So she was becoming a hypothroid again. So they concluded that the ashwagandha had pushed her into the thyrotoxicosis. It's an interesting case. Then they go on to talk about ashwagandha might be dangerous, etc.
Camille (03:55)
Here's the things that I'm thinking about. First of all, this drives me up the wall that they don't say what extract, what was the dose, not mentioned anywhere in the study. We don't know, was she taking 1 gram of powdered root? Was she taking 10 grams of a 50 to 1 extract? Was she taking tincture? Was she taking capsules, powder? What was it? How often was she taking it? That was not mentioned. The other thing that didn't happen, which we really need to do with herbs, and I think most of the time people coming from the medical world may not realize this, but with herbs, if there is a suspected adverse reaction, we always want to test the product. We want to get our hands on the actual product so we can test it and see if what it says on the label is actually what it is. Because if she was taking some product from a gas station somewhere, it's possible that it says ashwagandha on the label, but in fact, it actually has ashwagandha plus a whole bunch of other stuff. Or that it says it's ashwagandha, but actually this one batch had seven times the dose that it normally does, etc.
Camille (05:01)
So we don't have any indication of anything about the product other than that it was ashwagandha root extract. So it's no verification that it actually is ashwagandha root extract. There's no indication of what the dose was supposed to be or what it actually was. So those to me are all absolutely critical if we're going to get any useful information about this from the perspective of a practicing herbalist or nutritionist. Now, from the medical perspective, the takeaway point, I think, is just, Oh, be wary of that scary ashwagandha and don't recommend it for your patients. However, I think it's very interesting that she stopped taking her thyroid medicines two years prior and had, based on her symptoms, maintained healthy thyroid function for almost two years in the interim. Now, is it possible that the ashwagandha was slowly and gradually pushing her towards this point, and then after two years, it was the tipping point and she developed thyrotoxicosis, yes, but it's also possible that something else changed, either with the dosing, the product itself, a stressful event in her life, whatever else that may have contributed. One of the things that wasn't pointed out in this whole situation is, Wow, it's really interesting that this ashwagandha may have actually been supportive for maintaining thyroid health for this long.
Camille (06:28)
So I think that's something to consider as well. Now, in terms of the big picture takeaways for me as an herbalist, like I said, there are two case studies of thyrotoxicosis in people taking ashwagandha root extract. Although, again, we don't know the dose, we don't know what kind, we don't know if it was verified to be what it says it is or not. What do I make of that? Well, there's certainly a number of animal studies and a small handful of human studies suggesting that ashwagandha root may be helpful for folks who are experiencing hypothyroid conditions. But does that mean it's unsafe for people who are hyperthyroid? Does that mean we shouldn't be giving this to folks who are hypothyroid because it might push them into becoming hyperthyroid? My takeaways are, first of all, that it's always useful to be cautious. It's always useful to keep an eye on things. Personally, if I have a client who does have a hypothyroid condition and we do want to work with ashwagandha, we want to take into consideration, are they on any thyroid medicines or not? And how frequently are they being followed up by their prescribing practitioner?
Camille (07:41)
Because if somebody is taking a thyroid med and they're only going in once every year or two, I'm going to be a lot more cautious with using ashwagandha because I do think it's useful to be aware. Okay? If somebody's going in regularly every three to six months, having their TSH levels checked and maybe some of the other thyroid hormones as well, I feel more comfortable playing around with ashwagandha to see, make sure that it's going to be a good fit for that person and so forth. It's not the only herb that I might consider using. Obviously, we want to do a constitutional analysis and so forth. What about the hyperthyroid client? For me, based on what's available right now, I would not consider ashwagandha overtly contraindicated in all hyperthyroid clients. However, again, I would want to be keeping a close eye on things and I would want to make sure that it's an energetic match. I have to say that most people who are hyperthyroid are not really going to fit the ashwagandha profile. Ashwagandha is probably not going to be my first choice for many of those claims anyway. However, it's been my experience that it does have some amphoteric effects, and I wouldn't be surprised to find that it might be nourishing to both ends of the thyroid spectrum.
Camille (08:59)
It's not one of my first choices for folks who are in a hyperthyroid condition. But personally, I wouldn't 100 % rule it out. If you are a more cautious practitioner, if you like to take an extremely safety first, absolutely no risks taken approach, then I think you might want to avoid ashwagandha entirely in your folks who do have hyperthyroid or you suspect might be leaning in that direction. Okay, so anyway, the takeaways from this are, A, if you are reading a case study, please take a look at the dose, the fact about whether they did or did not verify that whatever the person was taking is what it says it is, and the type of extract used. There's a difference between a 1 to 2 extract and a 50 to 1 extract in terms of the dose and the suitability and the way that we interpret what we've learned. All right. Lest this all seem super negative to the people who wrote this up, sure, they won't listen to this, but anyway, just to put it out there, I do love that people are writing this up because this is the only way that we learn and grow.
Camille (10:07)
I do appreciate that the authors were curious enough to ask into these questions that they did ask more about what was going on, that they followed up not just once, but twice after this person's visit to the emergency room, and that they did poke around in the literature and try to find out what's going on here. I do want to give a shout out to anybody who takes the time to publish. It's way harder than it sounds to get something pulled together, to get it through peer review, to put it out in an open access journal. I send out major props to the authors for doing those pieces of things. I always want to be grateful for folks who take the time and effort to do these kinds of things for the advancement of all of us. I hope that was helpful. There's a little off the cuff thoughts on this topic. I will be back soon with some more information. If you have any questions or things you'd like for me to cover, please reach out anytime. All right, take care.
Camille (11:07)
Thanks for listening to In the Clinic with Camille. Hey, did you know that I write a weekly practitioner note for herbalists and nutritionists? If you would like to get that in your inbox, you can sign up at CamilleFreeman.Com/newsletter.
Camille (11:20)
I'd love to have you.
Camille (11:20)
Join us there.
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