Natural Thyroid Replacement Therapy - CHI - Preventive Medicine

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Natural Thyroid Replacement Therapy - CHI - Preventive Medicine

    Natural Thyroid

    Replacement Therapy

    In an Anti-Aging Practice

    New Thyroid Concepts

    New Thyroid Concepts Patients with HGH replacement therapy may require Thyroid RT

     Replacing T3 + T4 is better treatment than just T4 (synthroid)

     T3 is active hormone and T4 is pro-hormone

     Many factors decrease T4 to T3 conversion including

     Low fat low protein diets

     Zinc, selenium deficiency

     Beta blockers, dilantin and other drugs

    Problems with TSH

Subclinical hypothyroidism (SCHT) so common that normal

    reference ranges include hypothyroid patients

     TSH > 2 are often clinically hypothyroid

     Monitored thyroid treatment keeping TSH “normal” has no adverse

     effects. “The risksof properly monitored thyroxine treatment are

    almost non-existent. Symptomatic benefits plus lipid improvement in treating subclinical


     Suspect SCHT in women over 40 with non-specific symptoms

     Follow the patient, not the TSH

     A P Weetman Hypothyroidism: screening and subclinical disease BMJ 1997;314:1175 (19 April)


    Symptoms of Hypothyroidism

     % of % of

    Symptom Cases Symptom Cases

    Weakness 99 Constipation 61

    Dry skin 97 Gain in weight 59

    Coarse skin 97 Loss of hair 57

    Lethargy 91 Pallor of lips 57

    Slow speech 91 Dyspnea 55

    Edema of eyelids 90 Peripheral edema 55

Sensation of cold 89 Hoarseness or aphonia 55

    Decreased sweating 89 Anorexia 45

    Cold skin 83 Nervousness 35

    Thick tongue 82 Menorrhagia 32

    Edema of face 79 Palpitation 31

    Coarseness of hair 76 Deafness 30

    Pallor of skin 67 Precordial pain 25 Thyroid Hormones Memory impairment 66

    Schematic Diagram of the Role of T and T in the Regulation 43

    TRH and TSH Secretion

    Thyroid hormones

     Daily production

     Thyroxine=T4 100 micrograms per day


     30 micrograms per day

     20% produced by thyroid gland

     80% by deiodination

     4 x as potent as T4

     T1 and T2 trace amounts


    Diagnosis of Hypothyroidism

    Thyroid tests

     Free T3

     Normal 2.3-4.3

     Optimal 3.6-4.3

     Basal temperature

     AM 97.6

     PM 98.6

     Examine the thyroid

    Educate patients - thyroid excess Sometimes only temporary



Feeling hot and sweaty

     Rapid weight-loss

     Fine tremor

     Clammy skin

     Sometimes after d/c 3-4 days treatment can be


    Thyroid Activation and Inactivation Catalyzed by Human

    iodothyronin deiodinases (D)

    Serum thyroid effect of decreased D1,

    D2 activity:

    T3 rT3 T4 TSH temporarily T3/T4

    Factors That Impair Peripheral Conversion of T to 4



     Fetal and early neonatal life

     Old age?


     Fasting, malnutrition

     Hepatic or renal dysfunction

     Systemic illness

     Trauma, postoperative state Pharmacologic

     Drugs (propylthiouracil, glucocorticoids, propanolol, amiodarone, beta


     Oral cholecystographic agents

     Vitamin and mineral deficiencies

     Zinc, selenium

    Patients will benefit from T3

    Is T3 + T4 better than just T4?

     50 micrograms of T4 replaced by 12.5 micrograms T3

     Cognitive performance mood and depression improved

No adverse effects on combination

Bunevicius R et al. Effects of thyroxine as compared with thyroxine

    plus triiodothyronine in patients with hypothyroidism. N Engl J Med

    1999 Feb 11;340(6):424-9

    T4 vs T3 + T4

Editorial in NEJM

     “The ideal medication would contain approximately 100 µg of

    thyroxine and 10 µg of triiodothyronine”

     Conclusion: But don’t really treat patients that way???

Toft A. Thyroid Hormone Replacement -- One Hormone or Two?

    The New England Journal of Medicine -- February 11, 1999 -- Vol. 340,

    No. 6

    Armour thyroid Pig thyroid glands

     Grain fed contented pigs

     38 mcg T4 + 9 mcg T3 per grain (60 mg)

     Supplied in ?, ?, 1, 1 ?, 2 , 3, 4, 5 grain

     To convert from synthroid (T4)

     T4 + 3-4 x T3

     But probably higher dose would be optimal

     Best clinical response and least side effects

    Thyrolar (Liotrix)- synthetic T3 + T4

    Strength T3 T4

     ? 3.1 12.5

     ? 6.25 25

     1 12.5 50

     2 25 100

     2 37.5 150

    Other T3 options Cytomel

     5, 25, 50 mcg

     Compounded extended release T3


     Short half life

     Ideally give BID

    Sub Clinical Hypothyroidism (SCHT)

    and CV Disease Hypothyroidism associated with CV disease

     Mean age 69

     Subclinical HT defined as Free T4 “normal” and TSH > 4.0

     11% had SCHT

     Associated with aortic atherosclerois and MI

     Hak AE et al. Subclinical hypothyroidism is an independent risk factor for atherosclerosis and myocardial infarction in elderly women: the

    Rotterdam Study Ann Intern Med 2000 Feb 15;132(4):270-8

    T3 treatment of Advanced CHF

     Low T3 predictor of mortality in CHF

     Low ratio of T3/RT3 strongest predictor of mortality

     IV T3 in advanced heart failure

     No change in heart rate or metabolic rate

     Well tolerated

     Increased cardiac output and decreased SVR

     Hamilton MA Safety and hemodynamic effects of intravenous triiodothyronine in advanced congestive heart failure. Am J Cardiol 1998 Feb 15;81(4):443-7

     Hamilton MA Thyroid hormone abnormalities in heart failure: possibilities for therapy Thyroid 1996 Oct;6(5):527-9

    Thyroid hormones and coronary artery

    vasodilation T3 and T4 produces coronary artery vasodilation

     No effect from RT3

     “Our results also suggest that thyroid hormones may play a

    role in preventing myocardial ischemia by inducing

    coronary artery vasodilation.” Yoneda K et al. Direct effects of thyroid hormones on rat coronary artery:

     nongenomic effects of triiodothyronine and thyroxine. Thyroid 1998 Jul;8(7):609-13

    T3 and Tachyarrythmias

Chronic CHF

     V Tach associated with low T3 low ratio of T3/T4 and high reverse


Shimoyama N et al. Serum thyroid hormone levels correlate with

    cardiac function and ventricular tachyarrhythmia in patients with

    chronic heart failure. J Cardiol 1993;23(2):205-13

    Low T3 and Death Low T3 < 3.1 Free T3

     Low-T3 syndrome is a strong predictor of death in

    cardiac patients and might be directly implicated in

    the poor prognosis of cardiac patients.

     Strongest independent predictor of death > lipids or


     Iervasi, G et al. Low-T3 Syndrome, A Strong Prognostic Predictor of Death in Patients With Heart Disease Circulation. 2003;107:708

    Does Thyroid Replacement cause


     Suppressive therapy

     No decrease in BMD in pre or post menopausal

    women or men

     Gorres G et al. Bone mineral density in patients

    receiving suppressive doses of thyroxine for

    differentiated thyroid carcinoma Eur J Nucl Med 1996


    Does Thyroid Replacement cause


Nuzzo V et al. Bone mineral density in premenopausal women

    receiving levothyroxine suppressive therapy.

    Gynecol Endocrinol 1998 Oct;12(5):333-7

     No loss of BMD

Faber J et al. Changes in bone mass during prolonged subclinical

    hyperthyroidism due to L-thyroxine treatment: a meta-analysis.

    Eur J Endocrinol 1994 Apr;130(4):350-6

     No Loss of BMD

    T3 and Depression T3 improved depression when added to SSRI’s in PTSD

Agid O. Triiodothyronine augmentation of selective

    serotonin reuptake inhibitors in posttraumatic stress

    disorder. J Clin Psychiatry 2001 Mar;62(3):169-73

    Fibromyalgia and CFS Increased CRH activity in Fibromyalgia

     Somatostatin stimulated which decreases HGH and TSH

     Decreased T3 in FM and CFS

     Neeck G Neuroendocrine perturbations in fibromyalgia and chronic fatigue syndrome. Rheum Dis Clin North Am 2000 Nov;26(4):989-1002

     Riedel W Secretory pattern of GH, TSH, thyroid hormones, ACTH, cortisol, FSH, and LH in patients with fibromyalgia syndrome

    following systemic injection of the relevant hypothalamic-releasing

    hormones Z Rheumatol 1998;57 Suppl 2:81-7

    RT3 and cellular metabolism

RT3 decreases cellular energy production

     T3 reverses this decline

Okamoto R et al. Adverse effects of reverse triiodothyronine on

    cellular metabolism as assessed by 1H and 31P NMR spectroscopy.

    Res Exp Med (Berl) 1997;197(4):211-7

    Low T3 , high RT3 predicts mortality

     Surviving patients improved the T3/RT3 ratio

     Sick euthyroid syndrome

Schulte C et al. Low T3-syndrome and nutritional status as prognostic

    factors in patients undergoing bone marrow transplantation.

    Bone Marrow Transplant 1998 Dec;22(12):1171-8

    Thyroid and Ankylosing Spondylitis

     FT4, FT3 and TT3 were significantly lower

     TSH and TT4 were found to be in the normal range

     rT3 was significantly increased.

     The prevalence of anti-thyroid antibodies was significantly higher in the AS-


Lange U et al. Thyroid disorders in female patients with ankylosing


    Eur J Med Res 1999 Nov 22;4(11):468-74

    Selenium supplementation and thyroid

     Critically ill patients

     500 mcg Seleneium, 150 mg alpha tocopherol, 13 mg zinc

     Normalization of TT3. TT4 and RT3 with improvement in T3/RT3

    ratio with selenium

     No chance with alpha tocopherol or zinc

Berger MM et al. Influence of selenium supplements on the post-

    traumatic alterations of the thyroid axis: a placebo-controlled trial.

    Intensive Care Med 2001 Jan;27(1):91-100

Thyroid and regaining lost weight after

    dieting T3/RT3 falls during acute and chronic calorie restriction

     Is this a factor why lost weight is usually regained?

     Weinsier RL et al. Do adaptive changes in metabolic rate favor weight regain in weight-reduced individuals? An examination

    of the set-point theory. Am J Clin Nutr 2000 Nov;72(5):1088-94

    Anti-Aging Medicine

    Thyroid replacement therapy

    Wilson’s reverse T3 dominance

    syndrome Stress….Increased Cortisol….Impaired T4 to T3 conversion….increased

    RT3 conversion

     RT3 occupies binding sites of T3, impairs T4 to T3 conversion and may feed

    back to decrease TSH

     “Hypometabolism” produced which decreases enzyme activity in all


     Fatigue, headache, migraine, PMS, irritability, fluid retention, anxiety and

    panic attacks, hair loss, depression, decreased memory and concentration,

    low sex drive, unhealthy nails, low motivation and ambition

     No references to Wilson’s syndrome on medline

    Wilson’s syndrome

     Ratio of T3/RT3 < 10:1

     Low body temp


    Treatment Wilson’s syndrome

     Compounded extended release T3 7.5 mcg q12 hours x 2 days

     If oral temp not 98.2 increase to 15 mcg q 12 hours x 2 days

     Increase till 98.2 or symptoms of thyroid excess

     Then taper back at same rate

     Then temp should stay normal or another cycle required

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