Saturday, February 25, 2012

Natural thyroid hormones

Many patients ask about natural thyroid hormones.
Are natural thyroid hormones the best treatment for an underactive thyroid?

That question is not simple. Here is my attempt to make this topic clear for those many people, patients and even doctors, who are confused about natural thyroid hormones.

First, underactive thyroid known as hypothyroidism is easily diagnosed. 
That is, once the diagnosis is considered.
Blood tests give the answer. Not hair tests, not saliva tests. 
Blood tests, properly interpreted can confirm or rule out hypothyroidism.

What blood tests? Endocrinologists are the experts on hormones but you don't have to be an endocrinologist to diagnose hypothyroidism. Hypothyroidism is easy to diagnose with a combination of blood tests called thyroid stimulating hormone, abbreviated TSH, and a blood test for free thyroxine.

If both the TSH and the Free thyroxine are in the normal range, there is no hypothyroidism.  The person who says otherwise is either ignorant, confused or a quack or all three.

Some people dismiss the blood tests and claim that they can diagnose underactive thyroid some other way, like using body temperature. 
I caution you to stay away from those folks. They’re bad news!

The TSH is above the normal range in all patients who have an underactive thyroid if their  pituitary and hypothalamus are normal. If there is pituitary disease, the TSH is not reliable for the diagnosis of hypothyroidism. Those relatively few people with pituitary problems should see an endocrinologist for diagnosis and treatment.

The normal thyroid gland makes two main hormones called levothyroxine or T4 

T4 (levothyroxine)

T3 (triiodothyronine)

and triiodothyronine  or T3.  
T3 has 3 iodine atoms while T4 has 4 atoms of iodine as shown above.

Most of the T3 in the body comes from conversion from T4. T4 is present in higher levels in the blood  than is T3. But T3 is more potent.

Everyone can convert T4 to T3, naturally. Humans have an enzyme called a deiodinase that converts  T4 to T3.

The safest way to treat hypothyroidism is to give the pure active form of T4 called levothyroxine. The levothyroxine found in such branded pills as Synthroid, Levoxyl or Tirosint is the same exact chemical that your thyroid makes. Tirosint has no colorants or fillers.

I usually recommend one of these brands because they reliably contain the amount of levothyroxine that we prescribe. Many doctors find the generic levothyroxines to be less reliable. But as with all generics, generic levothyroxine is cheaper.

And when you give pure T4 in pill form your body can naturally make the amount of T3 that it needs. Remember we all convert T4 to T3.

You say wait, how about pig thyroid gland extracts that contain both T4 and T3 like Armour Thyroid?
Isn’t that more natural?

I have several answers to those questions.
·      If you are reading this, you are not a pig. So Armour Thyroid is not too natural for a human.
·      Your body makes the T3 it needs naturally when it gets T4 and giving it a mixture of the two is like my saying I’m smarter than your body and I know how much T3 your body needs so take this pill. The thyroid extract prevents your body from naturally regulating by forcing  T3 into your body instead of allowing your body to make the T3 it needs.
·      T3 lasts a short time in your blood stream so levels of T3 shoot up and down when you take pills that contain T3. See below.
       These fluctuating levels of T3 can cause shakiness and bone and heart problems.
       But when you take T4 alone, T3 is slowly produced over time by your body with smooth stable safe levels of T3 resulting.

Rapid changes in T3 levels in the blood after a single dose
·      Thyroid extract probably would need to be taken at least two or three times daily since the levels of T3 vary so much and T3 has a short half life.
·         People with hypothyroidism in general feel no better with combination T3 and T4 therapies as compared to T4 alone. Multiple randomized, controlled, double blind clinical trials have shown this to be true in  Australia, Canada, and the U.S.  in 2003, in 2004 in Germany, in 2005 in the United Kingdom, and more recently in the U.S..  One small study conducted in Denmark suggested benefit with the combination.
·      There is concern that batches of thyroid extract pills may vary in their content of T3 and T4.
·      Adjustment of the dosage of the thyroid extract by following blood tests can be extremely difficult since the blood levels of the thyroid hormones and TSH vary widely in patients taking thyroid extract.

Remember that the term natural has no agreed upon definition. In my view, the most natural way to give thyroid hormone is to let your body regulate itself as much as possible naturally. By giving levothyroxine alone, you can do that.

But sometimes patients are on T4 therapy with normal levels of TSH and still feel fatigued or otherwise not right. After thorough evaluation, I find that most of these patients will feel better once the right diagnosis is made and treatment is provided.
Thyroid extract is not the answer.

I hope this post has brought some clarity to the question of natural thyroid hormones.

Friday, February 17, 2012

Is Kava Safe?

Is Kava safe?

Kava has been promoted as a natural herbal supplement to relieve anxiety and help with mood and sleep.

But is Kava really effective for these problems? Is Kava safe?

The scientific name of Kava is Piper methysticum. Kava is a plant native to the South Pacific. Like all dietary supplements or nutraceuticals or herbal products, a lot of money is made from their sale. That includes kava.

This also means that those many companies promoting or selling kava would like you to believe that kava works great and is perfectly safe.

But is kava safe or effective? New evidence is in.

Kava might be effective but the data and studies to suggest this are very limited. The chemicals in kava that may reduce anxiety are called kavalactones. The chemical structure is shown below.
Only kava preparations that have a high concentration of kavalactones seem to be effective in some studies. 

One fairly recent trial that showed benefit was only 3 weeks long. 
Clearly more placebo-controlled, randomized clinical trials would need to be done to prove effectiveness of kava.

Outside of effectiveness, there is now no question that some formulations of kava can cause liver damage or liver failure. And other side effects can occur such as headache, dizziness, and stomach upset.

Kava has are over 200 varieties called cultivars. It appears that some cultivars of kava are safer from a liver standpoint than cultivars. And some parts of the plant are best not used to prepare kava extract.

It is thought that the likelihood of liver injury may be less likely if the intake of kavalactones is kept below 250 milligrams per day. But this remains to be clearly proven in clinical trials. Many questions remain about kava and liver damage. 

And I am not sure I would want to volunteer for one of those clinical trials with kava. There are definitely safer approaches to treat depression or anxiety. 
I would be anxious just worrying about my liver if I were taking kava.

And several countries have banned or restricted sale of kava products. 
In fact, 10 years ago, the  FDA issued a consumer advisory for supplements containing kava.
But kava supplements are still  readily available in many countries including the U.S..

I say avoid kava altogether. When it comes to kava supplements in the U.S., there is no way to know for sure what you are getting in the kava pills you buy.

So if you take herbal supplements, read the label before buying or swallowing the pills. 
Natural does not mean safe. And that includes supplements that come from kava.

Your Diabetes Endocrine Nutrition Group

Saturday, February 11, 2012

Better Drugs for Type 2 Diabetes

Not all treatments for Type 2 Diabetes are the same. A recent study again  demonstrated the problems that can arise with drugs called sulfonylureas. These drugs  are commonly used for treating Type 2 Diabetes. They are also one of the class of drugs most commonly causing emergency hospitalizations. 

The best thing about this class of drugs is that they are cheap. But there are better drugs for Type 2 Diabetes.

There are many drugs in the sulfonylurea class. The most commonly used in the U.S. are glyburide, glimepiride and glipizide.

Notice they all end in “ide”. Although that happens to rhyme with “died” sulfonylureas are not that bad. That is if they are used with caution.

But as shown in this recent study, this class of drugs called sulfonylureas, is a frequent cause of emergency admissions to the hospital.


Because sulfonylurea drugs can cause low blood glucose called hypoglycemia.
In too many cases,  this hypoglycemia is so severe the person may lose consciousness.
After all, your brain (and mine) needs glucose to function.

The risk of hypoglycemia is especially a problem with glyburide for those persons who have reduced kidney function. As we all get older, we lose kidney function.
Loss of kidney function from kidney damage is more likely over time in those with diabetes especially if they have had poor glucose control.

Glyburide and its breakdown products, called metabolites, are eliminated by the kidneys. So that means, in people with reduced kidney function, glyburide hangs around longer to lower the blood glucose. Hypoglycemia is even more of a  problem in people who might miss a meal or not eat enough.

These facts explain why many of those having a medical emergency because of sulfonylureas were the elderly.
Glyburide is the worst drug among the 3 listed above in this class.
In general, I stay away from glyburide for my patients.

Sulfonylureas also tend to cause weight gain. And sulfonylureas also do not seem to keep the glucose under control for a long period of time. In other words, in many people, sulfonylureas seem to lose their effect over time.
There are better drugs for Type 2 Diabetes.

Metformin is also low cost but does not tend to cause hypoglycemia or weight gain. Some doctors stop metformin when it is not necessary. See my previous post on this topic.

About 10-15 percent of people cannot tolerate metformin because of diarrhea. In general, the slow release or XR,  formulation of metformin is better tolerated.

But even when people are taking  metformin, many need more than just metformin to control their blood glucose.

Fortunately, there are now many options.
But these other options cost more. Many though have advantages over the  sulfonylureas.

The GLP-1 mimetics are superb choices. They do not cause low blood sugar and tend to be as effective as the sulfonylureas and they promote modest weight loss, not weight gain. Of the GLP-1 mimetics, Victoza is a once a day drug. Newly available,  Bydureon is once a week. Byetta is twice daily.

In another class is Actos. Actos remains an excellent choice for many patients and it should be generic and therefore lower cost by the fall of this year. Like any drug, Actos has its pluses and minuses but it does tend to maintain glucose control over a long period of time and does not cause hypoglycemia.

And there are 3, soon to be 4, drugs called DPP 4 inhibitors. These drugs are less effective than the GLP-1 mimetics and, unlike the GLP-1 mimetics do not tend to promote weight loss. Currently the 3 available drugs in the U.S. are marketed as Januvia, Onglyza and Tradjenta. None of these causes hypoglycemia.

Cycloset and Welchol are two very different drugs for Type 2 Diabetes. Cycloset has unique properties. See a previous post.
WelChol lowers cholesterol and glucose.

All these drugs are in many ways better drugs for Type 2 Diabetes than those sulfonylureas: glimepiride and glipizide and surely glyburide. Glyburide, I think should be avoided.

Then there’s insulin. When used skillfully, insulin is great medicine.

All medicine needs to be tailored to the individual.
No one medication or dosage is best for everyone.
I am pleased that we have increasing options and better drugs for those suffering with Type 2 Diabetes.
If the all goes well, more are coming.
But remember, healthy eating and exercise can be highly effective.

Your Diabetes Endocrine Nutrition Group

Friday, February 3, 2012

Can Type 1 Diabetes Be Reversed?

Can Type 1 Diabetes be reversed?

I sure hope so. But we all got more disappointing news this week.

Unlike the more common Type 2 Diabetes, Type 1 Diabetes is an autoimmune disease. Type 1 Diabetes had been called juvenile onset diabetes but Type 1 Diabetes can start at any age. So the term Type 1 is used now.

About 5% of people with diabetes have Type 1 Diabetes.
Insulin injections are required for control of blood glucose and insulin is needed for survival.

Type 1 Diabetes is a challenging disease to treat.
Type 1 Diabetes is a challenging disease to live with.

Type 1 Diabetes is caused by destruction of the insulin producing cells.
These beta cells are attacked by the immune system.
Studies performed to see if Type 1 Diabetes can be reversed are typically focused on reducing the immune attack on the beta cells.

These studies on Type 1 Diabetes involve people with Type 1 Diabetes who have been recently diagnosed.
Early on, after diagnosis of Type 1 Diabetes, the pancreas is still making some insulin. But years after the diagnosis, most people with Type 1 Diabetes make virtually no insulin.
At that point, there are very few of those beta cells left. Most are destroyed by the continuing attack from the immune system.

The aim in these trials of Type 1 Diabetes is to help the beta cells continue to make insulin.

Our site participated in a previous trial for newly diagnosed persons with Type 1 Diabetes. 
Sadly, that trial failed. We were all so very disappointed: our staff, the study participants, all others with Type 1 Diabetes and the company.

But all of those in the medical community and those with diabetes continue to hope that a safe effective treatment might keep insulin production going for those with Type 1 Diabetes.

Maintaining some of the body’s own insulin secretion can be very helpful. Control of the blood glucose is easier. And better control means a lower risk of diabetes related complications, like eye, nerve and kidney problems.

Sure we would all wish for normal sugars without the need for any insulin injections. That  would be  a cure for Type 1 Diabetes. But stopping the immune assault  on the beta cells would help continue some insulin secretion. Some insulin secretion is better than none, as long as the treatment is relatively safe.

And now our site is  participating in another study for recently diagnosed Type 1 Diabetes. This study involves adults only. We hope that this will bear fruit. The data thus far are quite promising. But as I said, we've been disappointed before! We can still hope and continue the research.
You can learn more about this international, multi-center trial here.

Until those results are in, keeping blood sugar under excellent control is the way to go.
There is no question that excellent blood glucose control helps beta cells make more insulin.

And now there are  better tools to help people with Type 1 Diabetes get under good control with a low risk of hypoglycemia.

Endocrinologists can offer our patients continuous glucose monitoring systems, insulin pumps and insulin treatment with better insulin.

There are clearly smart ways to use insulin. And there are not so smart ways.
We advise patients to "take it like you make it".
In other words, insulin is best used in the way the pancreas might normally make insulin.
See a previous post to learn more about taking insulin sensibly.

Please stay in control. Stay in touch. And feel free to leave a comment or question.

Your Diabetes Endocrine Nutrition Group