Category Archives: Heart Problems

Desiccated thyroid in the management of hypothyroidism: Part III

Posted by Thomas Repas, DO, FACP, FACE, CDE January 8, 2009 10:45 AM

Most people would not dream of directing a cardiologist how to perform cardiopulmonary resuscitation during a cardiac arrest. They also would not come in to see the surgeon with a specific outline on how to do the procedure. Most would decline to have their surgery done in the same way and with the same techniques as in the 1970s. Despite this, many intelligent, otherwise reasonable people have no hesitation trying to “teach” me about the thyroid. Many of these same people also request to have their thyroid disorder managed similar to how we did decades ago.

Why is this?

There are several reasons. For one, despite the advances made in technology, scientific knowledge and outcomes over recent decades, modern medicine has failed many patients from a humanistic perspective. It is not too much to expect for questions to be answered and treatment options explained. Everyone desires to be listened to and heard. There is nothing more discouraging than when one’s symptoms are ignored. I have witnessed this myself when I and family members have been patients. It is extremely frustrating. Not surprisingly, some pursue alternative options.

Some believe in a more natural approach towards health. Their goal is to minimize the synthetic, processed and man-made. I actually understand this philosophy very well. My family and I grow a large portion of our vegetables organically. We enjoy the sense of connection with the land and the seasons. We take pride in knowing that we participated in the sustainable production of our food. If someone presented to us a well-crafted, scientifically valid argument as to why there is no benefit to organic vs. conventional gardening, we would smile, nod and keep doing what we are doing. We garden organically as much on philosophical grounds as any other reason.

For me to argue for patients to change someone’s belief system based on science is equivalent to attempting to convince them to change their religion or political party on the same grounds. It would be futile as well as absolutely inappropriate.

Health care is different, however, because there is the potential for harm as well as benefit. I am obliged to inform my patients about the positive as well as negative potential consequences of one option over another. This is true no matter if we are discussing alternative vs. more mainstream therapies. However, I realize that I am only one advisor among many. My duty is to provide the most accurate information possible. Patients are free to choose for themselves how they would like to proceed.

Finally, last week I saw a woman who had been on desiccated thyroid for decades. I explained that we now prefer levothyroxine instead of desiccated thyroid. I also quickly pointed out that her thyroid-stimulating hormone has been perfect, between 0.7 mIU/L and 1.0 mIU/L over the last several years. She had no symptoms; it was difficult for me to argue with success. After discussing and asking her what she wanted to do, she left my office still on desiccated thyroid.

Comment by Tom Repas DO FACP FACE CDE — June 12, 2009 12:24 PM

Hello all – I continue to read the comments posted on this and related threads.

I appreciate everyone sharing their insights and experiences. I haven’t responded to every single posted comment because the sheer volume makes it impossible.

I also get the impression that no matter what else I might add, it would be futile and encourage only further attacks.

I confess to purposely choosing a subject which many are passionate about — and which many of my peers avoid discussing at all.

However, if we take our respective positions, dig our heels in and never talk to those with differing opinions, how will medical care ever progress and improve?

Rather than avoiding talking about such topics, I usually prefer to meet them head on and encourage — not discourage — conversation. I’ll do that even if I know that everyone does not agree with me. I could have written about something or taken a position that everyone agrees with — but that would have been too easy.

Several endocrinologist colleagues have told me I’m crazy for writing about such a sensitive issue and in a way that I know would be sure to make me a target.

They are probably correct — but then I’ve never been known to be one who takes the easiest route, simply because is it easy. Don’t forget, I run ultramarathons in my spare time because marathons are “too easy.”

We might not agree on many things but I appreciate everyone sharing their thoughts, opinions and experiences. It actually has helped me in discussing this issue with patients in my own practice.

You have been heard — loud and clear.

Thank you all again for commenting.

(Please DO NOT accuse me of being patronizing — I sincerely do appreciate your comments, even if they differ from my own).

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Desiccated thyroid in the management of hypothyroidism: Part II

Posted by Thomas Repas, DO, FACP, FACE, CDE January 6, 2009 09:49 AM

http://www.endocrinetoday.com/comments.aspx?rid=35766

Most board-certified endocrinologists avoid desiccated thyroid in the management of hypothyroidism for additional reasons.

Desiccated thyroid preparations contain an approximately 4:1 ratio of thyroxine (T4) to triiodothyronine (T3), whereas the normal human thyroid has of a ratio of 11:1. These preparations result in supraphysiologic levels of T3 in the two to four hours after ingestion. This is due to the rapid release of T3 from thyroglobulin and the immediate almost complete absorption of T3.

In my own practice, I have seen numerous individuals referred to me on desiccated thyroid with fully suppressed thyroid-stimulating hormone. This is because the dose was titrated based on symptoms or clinical findings rather than biochemical assays. Some have had anxiety, insomnia, tremulousness, heat intolerance and other symptoms clearly due to iatrogenic hyperthyroidism. The long-term consequences of hyperthyroidism are not benign. Nevertheless, many have absolutely refused to allow me to decrease their dose, despite my concerns.

With hormone therapy, just as too little is unacceptable, too much is also unacceptable. More is not always better.

Some alternative care practitioners claim that standardized laboratory testing is unreliable. They use other methods to justify their approach such as basal body temperature measurement, testing of tendon reflexes and how the patient generally feels subjectively.

Although thyroid hormone certainly has effects on metabolism, in order for there to be a consistently measurable increase in body temperature, many patients must be rendered hyperthyroid. There are many other factors that affect basal body temperature, not only the thyroid. In addition, there is wide intra-individual variation in body temperature. Body temperature varies depending on time of day and how it is measured. “Normal” body temperature should not be defined as 98.6º F ± 0º, just as we do not define “normal” TSH as exactly 1.00 mIU/L. Normal is a range, not a single value. Using basal body temperature to modify the dose of thyroid HT is imprecise and not supported by the scientific evidence. It is the same with measurement of reflexes and other non-specific clinical findings.

Regarding symptoms and the subjective feeling of wellness, that is problematic. My goal is not only to prevent and treat disease, but for all of my patients to feel better on whatever therapy we have chosen. The problem here is that there are innumerable reasons to feel poorly, often with identical symptoms to hypothyroidism, and yet not due to thyroid dysfunction.

Too many times have I seen other medical diagnoses missed, because every symptom a patient had was attributed to their thyroid and no further evaluation was done. It is easier and less time consuming to write a prescription than it is to think, ask questions and most important of all … to listen.

Sometimes we need to tell patients what they need to hear, even if it is not what they would like to hear. This should be done as kindly and tactfully as possible, but it must be done nonetheless.

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Stop the Government Takeover of Medicine!

http://www.hotzehwc.com/en/art/258/

We do not want politicians rationing our medical care and telling people that they are somehow too old or too sick for treatment. We do not want politicians deciding which treatments will be available, and which will not.

Whom do we trust more: our doctors or our politicians? Of course we trust our doctors more than our politicians. We must keep and defend our freedoms, starting with our most fundamental freedom to choose the medical care that we need most.

The bill that is passing through the House committees is a complete government takeover of medicine that will restrict our choices and lower the quality of care. HR 3200, misleadingly entitled “America’s Affordable Health Choices Act of 2009,” takes away the choice and control that Americans have today over their medical treatment. People will be told under the bill that abortion is covered at taxpayer expense, but some life-saving or life-enhancing treatments are not.

The Obama bill imposes a “public option” that will define which treatments will be allowed. Your access to bio-identical hormones will probably be rejected by the public option, and that could squeeze out even private access to these helpful treatments.

The bill would force people to buy insurance they do not need, and which will not cover what we do need. Taxpayers will be forced to buy that insurance for those who cannot, at a trillion-dollar expense that will bankrupt the government.

The bill requires that government investigate “self-insured employers not being able to pay obligations.” This means government will audit and harass small business owners until they pay for insurance they cannot afford.

The government will dictate the health benefits that must be included by insurance as a condition of being able to participate in the Health Insurance Exchange. The private insurance will have no reason to differ from the public option, and private insurance will soon disappear.

Families with special needs could be hit hardest by this new health bill. In America children with cystic fibrosis live an average of 37 years, but under nationalized health care the life expectancy for this condition is only 27 years in Ireland. That’s because government-run health care does not cover many special-needs conditions, and there is not enough of a private market to fund such care after the government takes over.

The Senate bill’s summary authorizes “home visits” supposedly to “improve immunization coverage.” Americans don’t want government knocking on their doors to demand proof of vaccination.

No one expects the U.S. Post Office to be innovative, and it isn’t. In fact, Post Offices are shortening their hours because they can’t make ends meet. The Post Office did not develop Federal Express, cell phones, and the internet. Do we want medical care in our nation to become like the Post Office? Do we want to kiss goodbye to medical innovation, like possible cures for cancer and other life-saving medical treatments?

Keep the government out of medical care and let the free market work its magic. Return the money to patients so that private medicine can develop the new cures.

The bottom line is that the Obama health care bill gives almost total control to government politicians and bureaucrats to deny you medical care you need. Everyone must say “no” to this government takeover of medicine.

What you can do now:

Go to http://www.house.gov/ and type in your zip code in the upper-left corner to find the Congressman representing you. When their name pulls up, click on it to get to their website. There should be a tab for their district office.

Please call, email, or visit your Congressman while they are in recess this month so they know how you feel about Obama’s plan. Attend town hall meetings in your district like this one, where an ordinary citizen received a thunderous applause for saying: “I look at this health care plan and I see nothing that is about health or about care. What I see is a bureaucratic nightmare, senator. Medicaid is broke, Medicare is broke, Social Security is broke and you want us to believe that a government that can’t even run a cash for clunkers program is going to run one-seventh of our U.S. economy? No sir, no.”

http://www.foxnews.com/politics/2009/08/03/audience-shouts-sebelius-specter-health-care-town-hall-philadelphia/

We have a window of opportunity to make our voices heard! Thank you for speaking out!

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Armour Thyroid Medication Reformulation Part II

http://www.hospitalsoup.com/health-conditions/thyroid/armour-thyroid-medication-reformulation-part-ii

When Forest Labs changed how Armour Thyroid Medication was formulated, there apparently was no announcement made to physicians, pharmacists or patients taking the drug. Forest has not responded to my request for information or an interview regarding this issue although their Pharmaceutical Customer Service Telephone Number (866-927-3260) states that there are “unexpected production delays” with certain strengths of Armour Thyroid.

When my hypo-thyroid symptoms re-appeared after getting my thyroid prescription refilled, and it was the second time that this had happened, I went online to research possible causes. And imagine my amazement when I discovered I was not the only one having difficulty with the new Armour. I found hundreds of other patients with similar stories reporting brain fog, tiredness, muscle and joint pain, hair falling out, feeling cold, weight gain. All symptoms I was all too familiar with and which were associated with improper levels of thyroid hormone in my body.

According to sources who have been able to speak to someone at Forest Labs, the laboratory changed the fillers in Armour Thyroid. The changes that were reported to have been made include the following: increasing cellulose (this has made Armour more difficult to dissolve), and reducing the amount of dextrose (which was the ingredient which gave it a slightly sweet taste). The “active component” of Armour has said to have remained the same.

Why you must stay vigilant regarding any medications that you take: Medications are made up of “active ingredients” which is the actual part of the tablet containing the specific “medicine” and in-active ingredients which can be flavors, fillers, and dyes. This is why you may have a brand name medication that is similar to a generic version of a drug, but generic versions may work differently for individuals. Because all of us are unique in how we respond to medications, certain fillers or non-active components of a medicine may help or hinder your body from absorbing or responding to a particular medication. That is one reason why in certain cases some physicians will not allow substitution of a generic drug for a brand name, or perhaps vice-versa. In the case of the Armour reformulation it has nothing to do with generic vs. brand names but it is important to understand how fillers, dyes and flavors can effect your response to a medication. From the hundreds of e-mails I’ve received from thyroid patients who had read my first post regarding Armour Thyroid’s reformulation it appears that there are many of us whose bodies are not responding properly to the medication change.

If you are taking Armour Thyroid and have comments about this issue please enter your thoughts below. Let me know if you are experiencing any problems or if the medication is still working for you. One way to tell if you have the “old” Armour or new formulation is that the old formulation had a stronger smell, whereas the new one is less pungent. If you’ve taken Armour before you will understand.

In the next installment, I’ll explain what thyroid medication I am now using, and the good news is that I am slowly getting back to my old self, and the hypo-thyroid symptoms are slowly disappearing.

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T3 Thyroid Hormone Helps with Major Depression Treatment

Mary Shomon

http://thyroid.about.com/cs/thyroiddrugs/l/blt3depression.htm

April, 2003 — Israeli experts have found that as many as half of all patients experiencing unipolar and non-psychotic major depression do not respond to initial selective serotonin reuptake inhibitor (SSRI) antidepressant treatment. As a result, the researchers have developed a formula of progressively increased doses of prescribed antidepressant drug, usually Prozac (fluoxetine). And those who are unresponsive also receive triiodothyronine (T3), from 25 to 50 micrograms per day.

In research reported on in the International Journal of Neuropsychopharmacology, 81 patients were started on fluoxetine 20 mg; and 9 patients received paroxetine, and at four weeks, 74 completed treatment, and at that time, 44 0– or 48.9% — responded to the regimen. An additional 5 patients (16.6%) responded when the SSRI dose was raised to 40 mg two weeks. Patients who did not respond to SSRI treatment were evaluated at the onset to be far more depressed.

T3 was added, and found to be effectiver among 10 out of 16 women patients (62.5%), but was not effective in any of the 9 male patients who received it. Although values were within the normal range, patients who responded to T3 had higher serum thyroid-stimulating hormone (TSH) levels than those who did not.

The researchers speculate that the effect of T3 may be related to thyroid function even within the normal range.

Source: “Algorithm-based treatment of major depression in an outpatient clinic: clinical correlates of response to a specific serotonin reuptake inhibitor and to triiodothyronine augmentation” Int J Neuropsychopharmacology 2003;6:41-49.

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Thyroid Hormone Helps Treatment-Resistant Bipolar Depression

Kimberly Read & Marcia Purse

http://bipolar.about.com/b/2009/08/07/thyroid-hormone-helps-treatment-resistant-bipolar-depression.htm

You’ve tried 10, 12, even 14 or more medications for your bipolar depression and they just haven’t worked well enough. Well, maybe your doctor should consider adding another type of treatment altogether. The thyroid hormone triiodothyronine – better known as T3 – has been shown to be effective for treatment-resistant depression in patients with bipolar disorder.

A study published in the Journal of Affective Disorders was a chart review of about 160 patients, mostly with bipolar II disorder, who had tried an average of 14 different drugs for their depression, who were given T3 from 2002 to 2006. The results were impressive: a whopping 84% of the patients experienced improvement, and 33% full remission. Not one experienced a switch into mania. Although the doses were higher than normal for many patients, the researchers report that the medication was well-tolerated, although 16 patients (10%) dropped out because of side effects.

The authors do point out that a chart review study has its limitations, but this is still exceedingly hopeful news for those of us whose depression stubbornly hangs on.

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Depression Explored, With Dr. Barry Durrant-Peatfield

http://thyroid.about.com/b/2003/11/19/depression-explored-with-dr-barry-durrant-peatfield.htm

Having just read the tragic news item from India about the depressed thyroid lady who committed suicide and preparing as I am at present a lecture about thyroid and depression, which I shall shortly give to London’s Insitute of Optimum Nutrition’s Mind Conference, I felt it might be appropriate to remind people of the strong link and frequency of depression and hypothyroidism…

Depression causes untold misery and destroys lives. Perhaps one in five people will suffer from it sometime in their lives. A huge industry has arisen around the treatment of depressive illness and psychiatrists are gainfully employed in their thousands. Whether it is more widespread than it was is perhaps difficult to answer. There are more of us to be depressed; we have more to be depressed about, and we are more likely to seek help. But there certainly seems to be more people troubled by depression and the great panoply of antidepressant medication tells its own story.

Before having a look at thyroid deficiency and its link to depression, we should learn a bit about it, and how it is caused and why. People who are depressed are sad, unmotivated most of the day and are usually worse in the morning. They sleep poorly, and wake up tired; they feel worthless, they have a poor self-image. They may eat more or less and put on or lose weight. Sir Winston Churchill used to call it his Black Dog. In his case, as with many, it was self-limiting: probably an extra cigar and brandy banished itâ?¦

There are two sorts of depression fundamentally: the exogenous kind, which is the result of circumstance, and the endogenous form, an illness from within ourselves. It is the second form we are to deal with. Maintenance of mood resides in part of the brain called the hippocampus. Here brain cells release neurotransmitter hormones, which are taken up by receptors; the amount released and the number of receptors responding, governs whether we are depressed or not.

Probably the most important of these mood neuro transmitter substances are serotonin and noradrenalin, and treatment is directed at preventing the decay of these substances at the receiving nerve endings. This is what Monoamine Oxidase Inhibitors (MAOIs) antidepressants, Tricyclic antidepressants and Selective Serotonin Reuptake Inhibitors (SSRIs) do. However, thyroid hormone deficie ncy acts on the receptor sites and hastens the recycling of these neurotransmitters at the nerve endings or reduces the amount being secreted. The result is that the neurotransmitters that are responsible for maintaining mood do not work at optimum efficiency. Depression then takes over.

It has been estimated that more than one third of people suffering from depression are hypothyroid. Some are in hospital. They receive, over long periods, antidepressants of one sort or another when actually the problem is deficiency of thyroid hormones. It is simply that no one thought of thyroid deficiency as a cause when their illness began; or the simplistic tests failed to reveal it.

Any patient suffering from depression should be routinely assessed for hypothyroidism. There should be no exceptions; half to one third will be found to be hypothyroid, and as a result of treatment, their depression will begin to lift in weeks. Conventional medicine will turn with little thought to psychotropic antidepressants. The problem with these is that they are sometimes difficult to stop taking. Of the SSRIs, Seroxat in particular has a poor reputation in this respect; Prozac has attracted unfavourable reports and moreover contains a fluoride compound. Tricyclic antidepressants (eg Tryptizol, Imipramime) often have unpleasant sedating side effects, and the MAOIs (eg Parnate, Nardil) clash with a number of drugs and foodstuffs. St John’s Wort is an altogether simpler and safer alternative.

Hypothyroidism should not be considered in isolation. It is more than likely that there are other deficiencies at work and cortisol, testosterone, oestrogen, DHEA and progesterone deficiencies should be looked for and corrected. It is now clear that nutrition plays a much greater role in mental illness than conventional medicine would have us believe.

The brain and its neurotransmitters simply don’t work properly without the proper raw materials. An obvious one is that there should be a constant, even supply, of its fuel glucose. Hypoglycaemia is certainly associated with depression. The essential amino acids must be provided for the manufacture of the protein neurotransmitters; so must essential fatty acids, especially the omega 3 group, which make up the structure of the brain and the neurones releasing the neurotransmitters. The vitamin B complex, folic acid, vitamin C are needed to allow the amino acids to form complex proteins and the other mineral micronutrients have to be there.

Get the nutrients right (also ensuring thyroid manufacture and uptake), provide thyroid supplementation if required, perhaps as naturally as possible from glandular extracts, and we can fight the black tide of mind altering drugs that threatens to overwhelm so many of us.

Kind regards,

Barry Peatfield

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