Download Microsoft Word - Elevating Metabolism with Triiodo-L

TITLE: ELEVATING METABOLISM WITH TRIIODO-L-THYRONINE
CAN SUCCESSFULLY TREAT DIFFICULT OTOLARYNGIC
DISEASES
AUTHOR: Donald T. Levine, MD, FACS
75 North Broadway
Nyack, New York 10960
AFFILIATIONS: ENT Section Chief/Senior Attending at Nyack Hospital,
Nyack, New York
Assistant Attending, Manhattan Eye Ear & Throat Hospital,
New York, New York
1
ABSTRACT
OBJECTIVE: This study demonstrates the effectiveness of metabolic elevation as
a tool to treat a wide variety of ENT disorders that would have otherwise been
incompletely resolved with standard medical therapies.
STUDY DESIGN: A retrospective review of over 500 private practice patients,
selecting 6 representative cases with persistent, difficult, and varied ENT disorders
that were significantly helped or cured utilizing this technique of Triiodo-Lthyronine (T3) metabolic elevation.
METHODS: Institutional Review Board approval for this study was not required.
Patients from my private practice with difficult ENT problems and hypothyroid
symptoms were considered for T3 metabolic elevation. A detailed baseline thyroid
profile is then ordered and gradual metabolic elevation utilizing T3 begins.
Patients are reassessed monthly checking for improvements, side effects, and the
attainment of blood test goals.
2
RESULTS: As the blood testing goals are reached, the patient’s medical problems
are significantly diminished or cured.
CONCLUSION: This specific format of metabolic elevation where the emphasis is
on T3 evaluation and T3 treatment is very effective in treating difficult otolaryngic
diseases.
INTRODUCTION
Low T3 hypothyroidism can cause or aggravate a number of otolaryngic disorders
including otoneurologic diseases (meniere’s syndrome, vertigo); neurologic
problems (neuralgias, headaches, migraine), immune problems (allergies especially to multiple foods or that are difficult to control in spite of standard
therapies; and recurrent infections - stomatitis, sinusitis, bronchitis); and
3
dermatologic problems (hives, urticaria, eczema, dry skin). When these problems
present with typical hypothyroid complaints (excessive tiredness, excessive
coldness, weight gain, hair loss, brittle nails) or there are also problems of
autoimmune disease, chronic fatigue/fibromyalgia, constipation or depression, low
T3 hypothyroidism is likely contributing to or causing the disease.1 These patients
do not adequately convert tetraiodo-L-thyronine (T4) into T3 – the main thyroid
hormone, which is four times stronger than T4 in elevating metabolism. Some of
these patients are already on T4; however, they too, continue in a lowered
metabolic state because of poor peripheral conversion to T3 and the elevation of
reverse triiodo-L-thyronine (RT3), a biologically inactive isomer which dampens
metabolism further. Therefore, traditional analysis which looks only at the
pituitary – thyroid axis, and which analyzes only the thyroid stimulating hormone
(TSH), T4, and T3 uptake is insufficient. Emphasis should be placed more on T3
analysis; and treatment should begin with T3 primarily, since it cannot be
converted into RT3. Testing must measure free T3 (FT3), total T3 (TT3), RT3 as
well as free T4 (FT4), and TSH levels. The laboratory goals corresponding to
maximum wellness in order of importance are: TT3/RT3 ratio between 10-15, FT3
in the upper 20% of the normal range (3.7-4.2), and FT4 in the low end or slightly
below the low end of the range (0.7-0.8).2 TSH is least important since it wasn’t
adequately setting the metabolism anyway.
4
METHOD
When a patient has two or more of the above problems, metabolic elevation as
described is often helpful. Once the above thyroid profile is obtained, the benefits
and side effects are discussed. Cytomel, which is T3 is the preferred treatment
choice because it is the most potent metabolic elevator (T3 is 4 times stronger than
T4); it cannot be metabolized to RT3, which would dampen metabolism; and the
above laboratory goals are most likely to be obtained using Cytomel. Other
treatment choices include Armour Thyroid, which is a combination of T4 and T3.
A 15mg.Tab of Armour Thyroid contains 9mcg. of T4 and 2.25mcg. of T3.
Synthroid or Levoxyl (T4) would be the least desirable choices since they would
produce RT3 elevations when metabolized. These other metabolic elevators may
be needed later to maintain the FT4 in the low normal range. An autoimmune
Thyroiditis (AIT) work up is ordered initially as well and includes: Thyroglobulin
antibody (TG-ab), Thyroid Peroxidase antibody (TPO), and Thyrotropin Binding
Inhibitory Globulin antibody (TBII/TRAb). AIT is very common and contributes
to thyroid dysfunction including hyperthyroidism, hypothyroidism, and to nodule
formation.
To start, Cytomel 5mcg. is given twice a day (because of its six hour half-life) and
5
on an empty stomach – preferably one hour before breakfast and two hours after
lunch. The second dosage should not be taken before bed or sleep may be
disturbed. Some sensitive patients may need to start on a half of a 5mcg Cytomel
twice a day and eliminate caffeine from their diets. Re-evaluating the thyroid
profile in 3-4 weeks (to allow for equilibration) and 6hrs. after the morning dose is
most important and will provide an average value of FT3 – a better reflection of the
patient’s metabolic state. Heart palpitations, muscle cramping, and heat intolerance
are the main side effects that must be considered before treatment and with each
treatment escalation. Heart palpitations can be managed by reducing the dosages of
Cytomel, eliminating caffeine and other stimulants from the diet, and elevating the
dosages more gradually allowing extra time for equilibration. Supplementing with
O.T.C potassium, slow- magnesium, or quinine can minimize muscle cramping.
Shifting more dosage to the morning and less in the afternoon, if the muscle
cramping occurs mostly at night, may also minimize this side effect. Heat
intolerance may require reducing the dosage or considering other causes such as
low estrogen in menopausal women. Adrenal dysfunction may also need
investigation and treatment for maximum results. Less common side effects are
loss of menstruation, increase in fertility, and headaches (switch to other generic
may be necessary). Escalations of Cytomel advance by a half of a pill (2.5mcg.)
morning first afternoon next. Patients will need a pill cutter. As long as no side
6
effects occur, a new thyroid profile is ordered about a month later and always 6hrs.
after the morning dose. The patient then returns to the office one week after the
blood testing at which time symptom relief, side effects, and blood test results are
reviewed. Side effects may prevent reaching the therapeutic and laboratory goals.
Side effects may also diminish or increase over time on the same dosage. That is
why gradual elevation with monitoring is important. The following cases will
demonstrate the effects of T3 elevation in a variety of difficult ENT disorders.
CASE PRESENTATIONS
J.K. is a 45-year-old female treated over the last 10 years. Originally, she presented
with facial swelling and a history of inhalant allergies (trees, molds, dust), chemical
sensitivities to fragrances and soaps, previous allergy immunotherapy for four
years, courses of prednisone, food sensitivities (was on a yeast/wheat free diet with
some reduction of her urticaria), constipation and bloating, and 2 previous
septoplasties. She also was diagnosed with Hashimoto’s Thyroiditis with
hypothyroidism and was on Synthroid 112mcg. At that time I treated her with
various antihistamines and subsequently re-tested for inhalant and cyclic food
7
allergies. Severe pollen sensitivities and severe food sensitivities to soybean,
chocolate, and tomato were obtained. Wheat and yeast testing were negative!
Upon eliminating these foods and treatments with antihistamines, steroid sprays,
and steroid cream she improved. She declined further immunotherapy. She then
returned to my office 4 years later complaining of dizziness, decreased hearing,
stuttering, aural fullness in her right ear, right forehead pain, and mental confusion.
She was diagnosed with a learning disability; was seeing a speech and language
pathologist; and had 3 separate head injuries as a child. The first was nasal trauma
causing her deviated nasal septum. The second trauma to her right forehead
resulted from her running into the edge of a door. The third occurred to her right
eye and orbit from a baseball (no fracture). Audiometry revealed a mild high
frequency hearing loss in her right ear at 8K Hz. and minimal Eustachian tube
dysfunction in her right ear. CT scans, MRI’s, and neurologic work up were
normal. She again was treated with antihistamines, steroid nasal sprays, and
decongestants with some lessening of her symptoms. She declined
immunotherapy. She returned to my office 2 years later complaining of dizziness
of various intensities even when stationary. She denied vertigo. She had been
diagnosed with auditory processing problems; still had mental confusion; a very
poor memory, and took very detailed notes during our consultation. She worked as
a computer consultant! Repeat MRI was normal and repeat audiogram revealed
8
only a mild hearing loss at 8K Hz. Discrimination scores were 100% bilaterally
and impedance testing revealed no middle ear congestion. She then returned to my
office one year ago because of allergic congestion despite antihistamines and
decongestants. Though she was on Synthroid 100 mcg, she was still cold, had dry
skin, and stated she had some unexplained weight gain. I ordered a thyroid profile,
which revealed a TT3/RT3 - 3.32, FT3 – 2.9, TT3 – 80, TSH - .912, FT4 – 1.47
and confirmed her AIT. I diagnosed her with low T3 hypothyroidism. Over the
next year I elevated her free and total T3 and reduced her reverse T3 by decreasing
her Synthroid dosage and by giving her increasing amounts of Cytomel. Her
symptoms improved dramatically. Her mental confusion abated by “75%!” Her
energy level remains high. She is no longer dizzy. Her allergies have improved by
“80%” with improved tolerance to inhalants and foods. She has no further
neuralgias, and is no longer cold. Her latest thyroid profile demonstrated TT3/RT3
ratio – 12.3, FT3 – 3.2, FT4 – 0.75, TSH – 0.49.
She’s currently on Synthroid 50mcg AM and Cytomel 10mcg. BID. I will monitor
her every four months for now. We may recheck her food allergy end points and
adrenal hormone status in the future. Her quality-of-life is significantly improved.
J. M. is a 48-year-old female who I saw for the first time 6 years ago. At that time
she complained of hives (worse pre-menstrual, with weather changes, and stress),
9
frequent headaches, and nasal congestion. She was cold sensitive, had difficulty
losing weight, some tiredness, and some hair loss. Zyrtec helped to treat the hives
but not completely. Inhalant testing revealed only mild sensitivities to dust, cats
(she had 2), short ragweed, and delayed reaction to candida (the other 19 molds
were negative). Skin endpoint titration food allergy testing demonstrated mild
sensitivities to chicken, egg, rice, wheat and a pronounced sensitivity to strawberry.
She subsequently avoided these foods and treated outbreaks with Fexofenedine 180
or Cetirizine. Thyroid testing at that time revealed FT3-294, TSH- 2.37, and FT40.99. Over the next 6 years I have transitioned her from Synthroid to Armour
Thyroid and finally to Cytomel. She is now on Fexofenedine 180, Cytomel
17.5mcg. BID. Her current thyroid profile reveals TT3/RT3 ratio – 8.88, FT3 –
336, FT4 – 0.8, TSH-0.43. She has rare hives now, no nasal congestion, no
headaches or hair loss. She states her energy level is excellent but has some
coldness still. She has no side effects. I plan to try to get her TT3/RT3 ratio
between 10 and 15 and the FT3 into the upper 20% of the normal range. She will
need additional Cytomel, some T4 if her FT4 drops below 0.7, adrenal work-up,
and further monitoring.
D. D. is a 48-year-old woman first seen 3 years ago. She was referred for a lip
biopsy because of a persistent lower lip non-healing ulcer. For fifteen years she
10
10
had suffered from lip, tongue, and cheek sores which would appear, stay for a very
long time, and heal while new ones would appear in previously healed spots and in
new areas. She had been to many physicians, oral surgeons, and chiropractors and
was on many supplements. She had a previous biopsy, which diagnosed these
lesions as pemphigoid and had been on topical and systemic steroids – all of which
helped somewhat. She also had low body temperature, low energy, and some hair
loss. Instead of biopsing this particular lesion (which I doubted would have made
any difference) I ordered a thyroid profile and upon its review decided to raise her
metabolism with Armour Thyroid. This did help to reduce the severity and the
frequency of the lesions, but they weren’t eliminated and we hadn’t reached her lab
goals. On Cytomel 7.5mcg BID; her lab values wereTT3/RT3-9.5, FT3-4.2, FT40.67, TSH-.415, which was closer to the ideal but still not perfect. She now had
rare lesions of short duration. On Cytomel 7.5mcg. BID plus Armour Thyroid
15mcg. BID, she has no lesions and no side effects. Her blood values reflecting
this are TT3/RT3 – 11.43, FT3 – 4.5, TSH - .141, FT4 - .65, TT3 – 144, RT3 .126. We will follow up in two months to check for symptoms, side effects, and
her new blood values.
W. N. is a 74-year-old male who came to me because of a right head pain centered
in the right orbit and radiating posteriorly made worse by straining or bending. No
11
11
previous treatments with antibiotics or pain medications helped. CT scans of the
sinuses and brain were negative. He had a history of cluster headaches 40 years
ago and tried these medications again without success. He was on Synthroid
125mcg. a day for hypothyroidism but was still excessively cold. He denied any
tiredness. His initial thyroid profile demonstrated TT3/RT3-6.25, FT3-299, FT41.7, TSH-0.31, and elevated Thyroid peroxidase and thyroglobulin antibodies. I
continued his Synthroid dose and started him on Cytomel 5mcg BID. He
developed nervousness, heart palpitations, headaches, and muscle spasms 2 days
later. I halved the dose of Synthroid and Cytomel and then increased his Cytomel
back up to 5 mcg BID once his side effects stopped. With a gradual transition to
Synthroid 75mcg AM, Cytomel 10mcg AM/7.5mcg PM and Synthroid 75mcg.AM
his blood work is as follows: TT3/RT3-9.67, FT3-351, FT4-1.0, TSH-0.17. He
states that his head neuralgia (and even his sciatica) is “90% improved”; he is no
longer cold, has great energy (which has been noticed by his family and friends);
he’s back to gardening and his constipation is gone. He is being tested for allergies
and uses Azelastin and Mometasone for intermittent congestion and will continued
to be followed and treated metabolically and for allergies.
S. B. is 72-year-old female who has been treated in my office over the last four
years for recurrent and chronic sinusitis. She has been on many antibiotics,
12
12
sometimes for long durations and courses of prednisone especially when her
infections were complicated by bronchitis. She’s had sinus CT scans which
demonstrated only clearing of acute congestion and slight mucosal thickening.
Other medications have included Montelukast, Azelastin, Advair Diskus 250/50,
and guaifenesin. She’s been tested for inhalants (positives only for ragweed,
aspergillus and Johnson grass smut mold in delayed reactions only). Nasal cultures
showed different pathogens and were sometimes negative. She has a history of
Raynauds as part of CREST Syndrome, hypothyroidism with AIT, fibromyalgia,
GERD, and hypertension. Medications included norvasc, Atenolol, Pepcid, and
Ecotrin. Low T3 hypothyroidism was suspected. Her thyroid profile three years
ago on 112mcg. levothyroxine demonstrated TT3/RT3-5.2, FT3 – 267, FT4 – 1.4,
TSH-1.99. Over the next 18 months I transitioned her to Synthroid 50mcg. and
Cytomel 10mcg. BID. On this dosage her thyroid profile demonstrates the
following: TT3/RT3-12, FT3 – 370, FT4-.8, TSH-0.53, TT3-156, and RT3-13.
She has not had any further infections now for 2 years, has more energy, less
coldness, less allergy, less Raynauds, and less dry skin. She has had no side effects
and rarely needs her allergy and asthma medications.
D. I. is a 57-year-old female with complaints of severe cervical neuralgia (despite
multiple negative workups and therapeutic modalities), headaches, seasonal and
13
13
perennial allergies, and recurrent eustachian tube dysfunction despite treatment with
Loratadine-D24, Mometasone spray, and analgesics with only some transient help.
Symptoms of excessive tiredness and excessive coldness were elicited, so a thyroid
profile was obtained which revealed TT3/RT3 - 7.88, FT3 – 299, FT4 – 1.2, TSH –
3.93, TT3 – 126. She is now on Cytomel 10mcg. AM, 7.5mcg. PM, Synthroid
25mcg. AM. She has minimal neuralgia, minimal allergies, and is no longer tired or
cold. Her latest T – profile is TT3/RT3 – 11.93, FT3 – 381, FT4 –
0.9, TSH – 0.59, TT3 – 179. She is extremely happy and working full time again
teaching singing and dance lessons.
DISCUSSION
Low T3 hypothyroidism is the primary cause for lowered metabolism. T3 is the
major elevator of metabolism and is 4 times more potent than T4. It acts by
binding to the nuclear membrane, DNA, mitochondria, and endoplasmic reticulum
inside all cells.3 T3 is also stored as it is bound to thyroglobulin in the blood. TT3
is a measure of the bound T3 plus the FT3. Intracellular T3 is in equilibrium with
extra cellular T3 both free and bound forms. T4, which is stored in the thyroid
gland follicle and bound to thyroglobulin, can be considered a pre-hormone. It
must be converted to T3 in order to significantly elevate metabolism. This occurs
14
14
peripherally in all tissues of the body. The 5’deiodinase enzyme cleaves off one of
the iodines on the 4-iodinated thyronine molecule to activate it. In many
individuals whether it be from stress, aging, illness, or cortisol, there is insufficient
conversion (inhibition of 5’deiodinase enzyme) and the T3 levels fall below a level
needed to sustain adequate function of that particular system. The 5- deiodinase
enzyme activity is increased causing T4 conversion to RT3 (reverse T3), which has
4
no metabolic activity and dampens metabolism. In these individuals disease
processes begin and healing processes are compromised. The well known
hypothyroid symptoms of coldness, tiredness, hair loss, brittle nails, weight gain,
recurrent infections are often present when elicited. Many patients have been in a
lowered metabolic state for such a long time that they do not think of their coldness
or tiredness as something out of the ordinary. Some of these patients are depressed
because of their inability to function and are on antidepressants as a result.
Sometimes the typical hypothyroid symptom may be masked by other disease
states. For instance coldness may be masked by menopausal symptoms of hot
flashes. Tiredness might be attributed to aging, poor sleeping, OSAS, chronic
sinusitis, or anemia. Women seem to be effected more than men. Probably this is
related to the metabolic enhancing effects of testosterone of which are ten times
greater in men than women. The trigger points for a patient’s symptoms can occur
with relatively small decreases in their metabolism.
15
15
CONCLUSION
All of these 6 patients had significant improvements in their quality of life after T3
elevation. All 6 exhibited problems with their immune system. Each patient had
different manifestations – some affecting their ears (dizziness), skin (hives,
urticaria, dryness, hair loss), nervous system (brain fog, neuralgia), respiratory
(allergy, airway obstruction), GI tract (stomatitis, constipation), and constitution
(coldness, lethargy, depression). Low TT3/RT3 and FT3 levels make allergy
control much more difficult. Difficult ENT conditions can persist even in patients
on T4 supplementation. Optimizing a patient’s metabolism with T3 using the above
criteria is a powerful tool, which can successfully treat difficult ENT problems.
Other medical problems often resolve along the way resulting in a superior quality
of life and excellent patient compliance. This technique will greatly enhance your
ENT practice, as you turn difficult patients into grateful ones.
16
16
REFERENCES
1
. Wilson, E. Dennis. Wilson’s Syndrome The Miracle of Feeling Well, 3rd ed., Orlando:
Cornerstone Publishing Company, 1996. p. 20-21.
2. McDaniel, Alan. Personal communication.
3. Werner and Ingbar’s The Thyroid: A Fundamental and Clinical Text, 6th.ed., edited by
Braverman, Utiger, J. B. Lippincott Co.; 1991, p.145.
4. Ibid, pp. 358-360.
17
17
1
. Wilson, E. Dennis. Wilson’s Syndrome The Miracle of Feeling Well, 3rd ed., Orlando:
Cornerstone Publishing Company, 1996. p. 20-21.
2
. McDaniel, Alan. Personal communication.
3
. Werner and Ingbar’s The Thyroid: A Fundamental and Clinical Text, 6th.ed., edited by
Braverman, Utiger, J. B. Lippincott Co.; 1991, p.145.
4
. Ibid, pp. 358-360.
18
18