Innovative Strategies For Optimizing Thyroid Function - Free CE ...

Page 4Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.HYPOTHYROIDISMHYPERTHYROIDISMLiver• Increased LDLCholesterol• ElevatedTriglyceridesIntestines• ConstipationReproductive System• Decreased Fertility• Menstrual AbnormalitiesBrain• Depression• DecreasedConcentration• General Lack of InterestHeart• Decreased Heart Rate• Increased/DecreasedBlood Pressure• Decreased CardiacOutputKidneys• Decreased Function• Fluid Retention andEdemaNervousnessIrritabilityDifficulty SleepingBulging EyesSwelling (Goiter)Menstrual IrregularitiesMoist PalmsFrequent Bowel MovementsExcessive Vomiting in PregnancyRapid or Irregular HeartbeatInfertilityWeight LossHeat IntoleranceIncreased SweatingTHEHYPOTHALAMOPITUITARYADRENAL(HPA) AXISHPA AXIS DYSFUNCTION AND THYROIDDISEASEThe role of STRESS on the body:• TBG activity• conversion of T4 to T3• detoxification capacity (liver, gutrequiredactions for proper thyroidconversion)• Weakens the immune system• Causes excess estrogen in the blood,decreasing levels of active T3!

Page 5Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.HPA AXIS AND THE STRESS RESPONSE• Acute Stress• Immunological Stress• Repeated Stress• Chronic StressHPA AXIS AND THYROID DISEASE• Response to Stress…Initial increase in Cortisol…thendecreased baseline cortisol, with an increased release ofcortisol in response to new stress…SENSITIZED HPAAXIS• Sensitized HPA Axis leads to enhanced immune state(sensitized peripheral lymphocytes)…leads toautoimmune disease of the thyroid gland (Grave’s andHashimoto’s Thyroiditis)THYROID HORMONEREPLACEMENT THERAPYLevothyroxine (T4)Liothyronine (T3 or triiodo-L-thyronine)LiotrixDesiccated Thyroid Tablets, USP: Nature-Throid TM , Westhroid TM , Armour®CLINICAL PHARMACOLOGY OVERVIEWT3 & T4• Synthesis of thyroid hormones controlled by TSHsecreted by anterior pituitary• Controlled by feedback mechanisms (thyroidhormones and TRH from the hypothalamus)• Hormones enhance oxygen consumption bymajority of tissues, increase metabolic rate,increase metabolism of CHOs, lipids, proteins

Page 6Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.CLINICAL PHARMACOLOGY OVERVIEWT3 & T4• Profound influence on every organ system in thebody including development of the centralnervous system.• Normal thyroid gland: 200 mcg of T4/gm of gland,15mcg of T3/gm.• In circulation, 80% of peripheral T3 derived frommonodeiodination of T4. rT3 (calorigenicallyinactive) also formed from this process.CLINICAL PHARMACOLOGY OVERVIEWT3 & T4• T3 levels low in fetus/newborn, old age, chronicstarvation, hepatic cirrhosis, renal failure, surgicalstress, chronic illness.• Only partial absorption of T4..in GI tract can belimited and is dependent on healthy intestinal flora,proper delivery vehicle (like albumin), andavoidance of foods/drugs/supplements that blockabsorption.• T3 is almost totally absorbed (95% in four hours)CLINICAL PHARMACOLOGY OVERVIEWT3 & T4• Over 99% of circulating hormones bound to TBg,TBPA, and TBa.• T4 has higher affinity for TBg and TBPA as comparedto T3• May explain higher serum levels and longer half lifefor T4.LEVOTHYROXINE (T4)• Eutirox, Tirosint, Levoxyl andSynthroid• 1/2 life approx: 6.7 days• ~100% bioavailable• Metabolized mainly in liver,kidney, brains and muscles• Prohormone-requiresconversion in cell to active T3• Takes up to 10 days to seechange in activity

Page 7Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.LEVOTHYROXINE (T4)Average doses:• Adults: 1-1 1/2 tablet (1.7microg/kg body weight )per day• Children: may requiremore (up to 4 microg/kgbody weight) per day• Adults over 50 oryounger patients with hxof cardiac disease: .025-.05mg qd, check after 6-8weeks.• Best administered on emptystomach, in morning, at least 2hours prior to meal.• Adverse interactions: e.g. iron,soy, bran, calcium, coffee,grapefruit juice, cholestyramine,aluminum or Mg containingantacids can slow absorptionsignificantly.LEVOTHYROXINE (T4)LEVOTHYROXINE (T4)Other drugs, esp. theanticonvulsants phenytoinand carbamazepine andthe antituberculous agentrifampin, may acceleratelevothyroxine metabolism,necessitating higherlevothyroxine doses.LEVOTHYROXINE (T4)• Lithium, TCA’s can causetoxicity.• Overdose symptoms(hyperthyroid…tachycardianervousness, excessivehunger, etc.) may notappear for 6 hours to 11days.

Page 8Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.• Cytomel• 5 times more active thenT4..T3 is major mediatorof physiological effects• Fast onset of action (30min), shorter 1/2 life (1-2days), short effects (3-4hours)LIOTHYRONINE (T3)• Binds to high affinityreceptors (TR1, TR2,TR1)• Modulates genetranscription and proteinsynthesis & causes ALLactions at thetranscription level (T4does not alter geneexpression)LIOTHYRONINE (T3)• Used for quicker onset ofaction (myxedema coma,preparation of patient forI 131 therapy in thyroidcancer), when peripheralconversion of T4 to T3 issuspected, in Wilson’sTemperature Syndrome (T3combined with sustainedrelease agent).• Dose: 10-75micrograms/day in divideddose (up to 4 times per day)LIOTHYRONINE (T3)• Thyrolar®LIOTRIX• Synthetic 4:1 mixture ofT4 and T3• Dose: 1-2 tablets per day,1-2 x per day• AM activity is high, PMactivity is low

Page 9Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.DESSICATED THYROID, USP• Nature-Throid TM , Westhroid TM ,Armour®• Porcine Thyroid Powder, U.S.Pharmacopoeia (USP)- highestlevel of T3• High therapeutic valueDESSICATED THYROID, USP• Contains T4, T3, T2, T1 and possibly Calcitonin aswell as nutrients/cofactors naturally occurring in thethyroid gland.• Dose: 16-325 mg qd (1/4 to 5 grains)• Each grain contains 9 mcg of T3 and 38 mcg of T4• Positive patient response• Long actingDESSICATED THYROID, USP• Due to higher bioactivity, you may considerstarting with a lower dose to obtain similarresults for patients converting from syntheticthyroid replacement.• Start with 1/4 grain and gradually increase in10-14 days, by 1/2 grain.DESSICATED THYROID, USP• If patient is deficient in cortisol they will convertT4 to T3 too quickly. Wait 14 days betweenincreasing dose and treat the cortisol deficiency• Avoid abrupt switches from T4 to T4/T3combination. Slowly increase the T4/T3 over 6-12 weeks, while slowly decreasing the T4.

Page 10Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.DESSICATED THYROID, USP• Advise patient to divide dose between morningand evening- empty stomach and 4 hoursbefore or after taking other supplements ormedications• Chew or otherwise pulverize the tablets foroptimal resultsIODINE• USDA and WHO recommend 150-300 mcg qd, and not exceed 1 mgqd• Too much or too little iodine intakecan cause problems…encouragelab testing for iodine to eliminateguesswork• Iodine can help prevent conversionof fibrocysts to cancerous form,prevents cretinism, and can helptreat OR cause Hypothyroidism,Hashimoto’s, Grave’s etc… sohealthy levels are important!T2 (DIIODOTHYRONINE)• Was once thought to be anunimportant thyroidmetabolite• Plays a significant role inweight loss…offsets adversefat deposition effects ofinsulin• Speeds the rate at which cellsretrieve and break down fat• Facilitates conversion of T4into T3

Page 11Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.THYROID SUPPLEMENTS“BUYER BEWARE”AN INTEGRATIVE APPROACH TOTREATING THYROID DISORDERS• TREAT THE CAUSE• Identify and correct factors causingincreased/decreased binding of hormone• Identify and correct factors causing poor conversionof T4 to T3• PREVENTION• Diet and lifestyle• FIRST, DO NO HARM• Consider all available forms of thyroid medication,listen to the patient, don’t over or under-doseTREAT THE CAUSEIdentify and correct factors causing increased binding ofhormone• Estrogen, OC’s, Estrogen Receptor Modulators,Porphyria, 5-FU, Tamoxifen, HIV infection, Liverdisease, InheritanceIdentify and correct factors causing decreased bindingof hormone• Glucocorticoids, Androgens, Salicylates, Phenytoin,Acute and Chronic Illness, InheritanceTREAT THE CAUSEIdentify and correct for factors causing poorconversion of T4 to T3• Nutrient Deficiency! Specifically, selenium, Zn, iron,essential fatty acids, Mg, P5P50, B2, B3, Cu,protein (too much or too little), iodine, tyrosine,probiotics, low calorie diet• Obesity• Heavy Metals (cadmium, mercury-chemicallysimilar to iodine!)• HPA Axis Dysfunction: Reduce stress (mental,emotional, physical, environmental)

Page 12Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.PREVENTIONDiet and Lifestyle• Exercise!• Prevents/treats thyroid resistance andincreases receptor sensitivity to thyroidhormones• Increases thyroid hormone secretionPREVENTIONDiet and LifestyleDiet!• Gluten free diet improvesthyroid function• Low inflammatory foods(fresh vegetables, fruits,lean organic proteins,healthy fats)PREVENTIONDiet and LifestyleBalance the stress response• Meditation• Healthy sleep• Low glycemic diet• Laugh, help someone outevery day, practice gratitudePREVENTIONDiet and LifestyleEnvironmental Toxins- The thyroidis particularly sensitive to these!!!!• Potassium perchlorate inhibitsiodine uptake (rocket fuel,fireworks, airbags, contaminateswater in US). Thiocyanates(cigarettes) have same effect.Newborns and infants especiallysensitive!• Pesticides induceglucuronidation of T4 and lowerT4 half life

Page 13Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.PREVENTIONDiet and LifestyleEnvironmental Toxins- The thyroid isparticularly sensitive to these!!!! Lowlevel chronic exposure will oftentrigger Hashimoto’s.• Polychlorinated biphenyls (industrialchemicals banned in ‘75 but still aroundand detected routinely) reduce T4 levels• Bisphenol A (plastics, coating for foodcans, dental sealants) antagonizes T3activation, triggers thyroid resistancePREVENTIONDiet and Lifestyle• Toxicity Questionnaire• Low-toxin lifestyle (organic, chemical free)• Support detoxification mechanisms• 21 Day Medical Purification Program, Juice fast, Waterfast, raw foods, nutrient dense calorie restriction, Junkfood fast, Brassica vegetables, chlorella, spirulina, otherchlorophyll-rich “green foods”FIRST, DO NO HARM• Consider all available forms of thyroidmedication, including desiccatedthyroid, USP• Listen to the patient…are signs &symptoms improving or not?• Avoid over or under-dosing medicationCASE REPORTDebilitating Depression- “Kathy”Kathy is a 53 YO Perimenopausal female whopresented with long standing fatigue (25 plus years)and depression. Hx of antidepressant medication withonly slight improvement in depressive symptoms.Prescribed Synthroid 125 mcg qd w/ no improvement.Labs: TSH 2.5, FT3 1.4, FT4 0.4, 4 salivary cortisolreadings revealed adrenal gland fatigue (all belownormal).PE: no nodules noted, slight generalized bilateralenlargement of thyroid gland

Page 14Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.CASE REPORTDebilitating Depression-”Kathy”Initial Tx Plan: Nature-Throid 1/2 grain qd ic, Adrenocort 2 caps qd.Gluten free diet, exercise daily for 30 min. High quality vit/minsupplement (4 hours after thyroid). Repeat thyroid labs every 6 weeksuntil nml and symptom resolution.Depression symptoms resolved and fatigue improved by 50% onceshe reached Nature-Throid 2 grains qd ic. We then tested for, andtreated her progesterone deficiency which further improved thefatigue.3 YR f/u- Pt remains on Nature-Throid 2 grains qd ic…lab levelsand sx are healthy. Next step is to test urinary iodine and treataccordingly (pt has fibrocystic breasts)CASE REPORTWeight Gain, Fatigue, BP, LDL-”Gail”Gail is a 61 YO postmenopausal woman presenting w/fatigue, constipation, and weight gain around midsection.Long history of elevated BP 140/95 and LDLnon-responsive to prior treatments. Health conscious,raw vegan lifestyle. Work stress.Came into office after receiving full physical by highlyreputable concierge physician. All results returnednormal. Had also been tested for thyroid (TSH only)and was told she was “normal.”Reflex test and comprehensive thyroid lab panel, bloodnutrient test, organic acids test and cortisol readings.CASE REPORTWeight Gain, Fatigue, BP, LDL-”Gail”Results reveal delayed reflex, Very High Levels ofTPOAb (first time patient ever tested!), normal (notoptimal) TSH, FT4, FT3, selenium and Zn deficiency,intestinal dysbiosis, and severe cortisol deficiency(adrenal fatigue). Dx: Hashimoto’s thyroiditis, nutrientdeficiencyTx plan: Nature-Throid 1 grain qd ic, adrenal supportformula (herbal adaptogenic blend) 2 caps bid,increase protein intake, selenium 200mcg qd (alternatew/ 1 brazil nut qd), Zn glycinate 50 mg qd, probiotics,acupuncture & meditation for stress relief.CASE REPORTWeight Gain, Fatigue, BP, LDL-”Gail”• 1 Yr Follow Up…• Pt required an increase in Nature-Throid to 1.5 gr qdic when she was under tremendous stress at work andTPO levels rose. Energy levels stable, BP has gonedown to 130/80, LDL wnr, reflex test normal, she noweats some animal protein in diet, has a more slender &healthy waistline, and she is religious about taking herthyroid medication. Patient stable.• TPOab levels stabilized. Still mildly elevated. Repeatthyroid and cortisol every 6 months.

Page 15Innovative Strategies for Optimizing Thyroid Function© 2010 Pharmaceutical Education Consultants, Inc. unless otherwise noted. All rights reserved.Reproduction in whole or in part without permission is prohibited.RESOURCESPRACTITIONERS• http://thyroid.org/professionals• The Hormone Handbook by Dr. Thierry Hertoghe, MD• Internationalhormonesociety.org• Nature-throid.com• Thyroidmanager.orgPATIENTS• The Complete Idiot’s Guide to Thyroid Disease by Dr. AlanChristianson and Hy Bender• Stopthethyroidmadness.com• CIGThyroid.comThank You!Dr. Gina’s contact info: HealthBridge Medical Center 366 San MiguelDr. Suite 209 Newport Beach, CA 92660frontdesk@healthbridgehealing.com (949) 715-9321www.healthbridgehealing.com & www.healthbridge.tvNotesNotes