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Malcolm Kendrick kilpirauhasen vajaatoiminnan hoidosta

Kilpirauhaspotilaita kohdellaan kuin lapsia
Malcolm Kendrick on skotlantilainen lääkäri.

I am not going into further detail of how T4 binding and conversion in various organs can be affected by stress hormones, inflammation, trauma, adrenal insufficiency, lack of converting enzymes in tissues, and infection of various sorts. I shall just keep this simple by stating that it is possible to have enough T4, even T3 in your bloodstream, but these hormones have reduced ‘bioavailability’. This is not crank ‘woowoo’ stuff. This is real and measurable and you can find studies on this in peer-reviewed medical journals.

En aio puhua sen enempää siitä, kuinka stressihormonit, tulehdukset, traumat, lisämunuaisten vajaatoiminta, muuntoentsyymien puute kudoksissa ja erilaiset infektiot vaikuttavat T4:n sitoutumiseen ja muuntoon eri elimissä . Aion vain sanoa että T4 ja jopa T3 voi olla hyvällä tasolla veressä, mutta näitä hormoneja ei ole tarpeeksi käytettävissä. Tämä ei ole mitään huuhaata. Tämä on todellista, se on mitattavissa, ja siitä on olemassa vertaisarvioituja tutkimuksia jotka on julkaistu arvostetuissa lääketieteen julkaisuissa.

So we have an interesting medical conundrum, do we not? On one hand, doctors are more than eager to prescribe antidepressants at the drop of a hat, based entirely on the patients reported symptoms. No need for any blood tests, and no evidence that they work for the vast majority of people.

Meillä on siis edessämme mielenkiintoinen lääketieteen pulma, vai mitä? Toisaalta lääkärit ovat innokkaasti määräämässä masennuslääkkeitä, pelkästään potilaan kertomien oireiden perusteella. Mitään verikokeita ei tarvita, eikä mitään todisteita että ne toimivat valtaosalla potilaista.

On the other hand, if a patient dares to say that they feel better taking T4 when their blood tests are normal, or if they say they feel better taking a combination of T3 and T4/NDT, they are dismissed as ‘somatising.’ Which is a posh medical way of saying, you are making your symptoms up and we don’t believe you. Equally, if a patient complains of continuing symptoms and that they don’t feel better when they are taking T4 (or T3 and T4) and their blood test results show ‘normal’ they are again accused of ‘somatising’

Toisaalta, mikäli potilas uskaltaa sanoa voivansa paremmin tyroksiinilla, kun heidän laboratorioarvonsa ovat viitteissä, tai hän sanoo voivansa paremmin synteettisellä yhdistelmällä T3 + T4, tai eläinperäisellä lääkkeellä, häntä pidetään somatisoivana”. Tämä on hienostunut lääketieteellinen tapa sanoa että olet keksinyt oireesi, enkä usko sinua. Tai jos potilas valittaa jatkuvia oireita lääkityksestä huolimatta, ja laboratoriokokeet ovat viitteissä, häntä syytetään jälleen ”somatisoinnista”.

The world, my friends, has gone nuts and, in a bitter irony, the medical profession – at least in this area – has become institutionally paternalistic.

Ystävät, maailma on tullut hulluksi, ja katkeran ironista on, että lääkärikunta on ainakin tällä alueella tullut holhoavaksi.

Now I have looked long and hard, and I have found no evidence, from anywhere, that giving T3, in the dose that’s needed, causes any significant medical problems, and I have listened to repeated testimony from people who feel they have greatly improved.

Olen tutkinut asiaa tarkkaan, enkä ole mistään löytänyt minkäänlaisia todisteita siitä, että T3:n antaminen tarvittavalla annoksella aiheuttaisi minkäänlaisia merkittäviä ongelmia, ja olen kuunnellut toistuvia kertomuksia potilailta jotka kokevat saaneensa siitä suuren avun.

I now firmly believe that the medical profession is currently doing these people a great disservice, and that the guidelines on the treatment of ‘hypothyroidism’ are rigid, autocratic, and just plain wrong (for a significant minority).

Uskon nyt vakaasti, että lääkärikunta tekee näille potilaille karhunpalveluksen, ja että kilpirauhasen vajaatoiminnan hoitosuositukset ovat jäykkiä, autokraattisia ja kertakaikkisen vääriä (huomattavalle vähemmistölle).

Hypothyroidism is easily diagnosed and more often than not, easily treated with L-thyroxine only. However, what is being missed by everybody is that over…15% of the thyroid community – millions worldwide – have a normally functioning thyroid GLAND, but the hormone it is secreting is not getting into the cells where it does its work. These are the folk who need T3, in combo. with T4, T3 alone or in NDT. The teaching curriculum makes no mention of the possibility of a non-thyroidal condition where patients suffer the same symptoms and signs of hypothyroidism that may need to be treated with a different medication or hormone. When these patients complain of continuing symptoms when treated with L-T4 monotherapy, many are given an incorrect diagnosis of ME, CFS, FM, depression, functional somatoform disorder – or even old age blah, blah, blah – and sent on their way without further investigation or treatment. This is a serious business, which the RCP and BTA choose to ignore.

Kilpirauhasen vajaatoiminta on helppo diagnosoida ja useimmiten helppo hoitaa tyroksiinimonoterapialla. Mutta yli 15 % kilpirauhaspotilaista, miljoonat, omistavat normaalisti toimivan KILPIRAUHASEN, mutta sen erittämät hormonit eivät pääse toimimaan soluissa. Nämä potilaat tarvitsevat T3:a, joko yhdessä tyroksiinin kanssa, yksinään tai eläinperäisessä kilpirauhasvalmisteessa. Lääkärien koulutuksessa ei kerrota kilpirauhasen ulkopuolisesta ongelmasta, jossa potilaat kärsivät samoista kilpirauhasen vajaatoiminnan merkeistä ja oireista, joita voidaan hoitaa eri hormonivalmisteella. Kun nämä potilaat valittavat jatkuvista oireista tyroksiinihoidolla, monelle annetaan väärä masennus-, krooninen väsymysoireyhtymä- tai somatisaatiodiagnoosi, tai jopa ikääntymisdiagnoosi, bla bla bla, ja heidät lähetetään tiehensä ilman jatkotutkimuksia tai hoitoa. Tämä on vakava asia, jonka lääkärijärjestöt ovat päättäneet jättää huomiotta.

 

Lääketiede – tiedettä vai uskontoa?

Of course the parallels between medicine and religion have always been obvious to anyone who has eyes to see. The patient consultation as confessional. The use of long latin words that the patient cannot understand. The rituals and incantations of medicine have clear parallels with religion. Or would that be the other way round. You could go on and on.

Lääketieteen ja uskonnon väliset yhteneväisyydet ovat aina olleet selkeästi nähtävissä niille, joilla on silmät. Potilaskäynti tunnustuksellisena. Pitkien latinankielisten sanojen käyttö, joita potilas ei ymmärrä. Rituaalit ja loitsut muistuttavat selvästi uskontoa. Tai päinvastoin. Ja niin edelleen.

 It is easy to understand why many aspects of medicine and religion mirror each other. Particularly if we look at one very important aspect of religion. Namely, protection against terrible things happening to you. Humans, once they became aware of their mortality, very rapidly felt the need for protection against an unpredictable and dangerous world. Earthquakes, storms, crop failures, plagues, early death… that type of thing.

On helppo ymmärtää miksi monet lääketieteen ja uskonnon aspektit heijastelevat toisiaan. Varsinkin jos tarkastellaan yhtä uskonnon tärkeää näkökulmaa, suojaamista kamalilta tapahtumilta. Kun ihmiset tajusivat oman kuolevaisuutensa, he alkoivat tarvita suojaa ennalta-arvaamattomilta tapahtumilta ja vaaralliselta maailmalta: maanjäristyksiltä, myrskyiltä, katovuosilta, rutolta, varhaiselta kuolemalta.

Thus, although in many ways, medicine became more scientific, it maintained of the key social functions previously carried out by religion. ‘We can stop bad things happening to you. You do not need to be frightened. If you do as we say’

Lääketiede kehittyi ajan mittaan tieteellisemmäksi, mutta se säilytti sosiaalisen funktion joka aiemmin oli kuulunut uskonnolle. ”Voimme estää pahoja tapahtumia. Sinun ei tarvitse pelätä jos teet kuten sanomme.” 

Primarily, it becomes extremely difficult for you, or the rest of the brotherhood, to admit that you don’t know something? Or that things you have been telling people, or doing, are in fact useless or wrong. Because if you start doing that, you fear you may lose your hard won authority, control and respect. Equally, if patients no longer believe, or trust in you, or your advice, what then? Fear stalks the land.

Lääkärille ja lääkäriveljeskunnalle tulee näin äärettömän vaikeaksi myöntää  ettei tiedä kaikkea. Tai että asiat, joita on kertonut ihmisille, tai tehnyt, ovat todellisuudessa turhia tai vääriä. Jos alat myöntää tätä, saat pelätä auktoriteettisi, hallintasi ja kunnioituksesi menettämistä. Ja jos potilaat eivät enää usko sinua tai luota sinuun tai neuvoihisi, mitä sitten? Pelko vallitsee.

This is why, if you are a patient who feels that your treatment has not worked as you were told it would, or should, you will not find an eager audience for your complaints within the medical profession. Equally if you question or refuse the sacrament, sorry treatment, your doctor is likely to become very angry with you.

Tämän vuoksi potilas joka tuntee ettei hoito ole toiminut niin kuin sen kerrottiin toimivan, tai sen pitäisi toimia, et löydä innostuneita kuulijoita valituksillesi lääkärikunnan sisältä. Samoin jos kyseenalaistat tai kieltäydyt sakramentista, anteeksi hoidosta, lääkärisi tulee todennäköisesti suuttumaan sinulle.

Additionally, if a doctor cannot discover what is causing your symptoms, or they have no tests to diagnose you, you are likely to be told that there is nothing actually wrong with you. The medical profession cannot easily admit to ignorance. In such situations, the only explanation that can be countenanced is that ‘you are making it up.’ Unexplained symptoms become ‘somatisation’. Side effects from drugs, such as statins, are due to ‘nocebo’ effects.

Jos lääkäri ei vielä löydäkään syitä oireillesi, tai jos hänellä ei ole olemassa laboratoriokokeita diagnosoimaan vaivaasi, sinulle todennäköisesti sanotaan että olet täysin terve. Lääkärikunta ei osaa myöntää tietämättömyyttä. Silloin ainoa selitys on että ”olet keksinyt kaiken”. Selittämättömistä oireista tulee ”somaattisia häiriöitä”. Lääkkeiden, kuten statiinien, sivuvaikutukset ovat ”noceboa”.

A million reasons will be found as to why the treatment has not worked in your case. Or why you got worse. The only explanation that cannot be allowed is that the doctors are completely wrong, and do not know what they are talking about.

Löytyy miljoona syytä siihen, miksi hoitosi ei ole toiminut. Tai miksi olosi huononi. Ainoa selitys jota ei voida sallia on, että lääkärit ovat täysin väärässä, eivätkä tiedä mistä puhuvat.

If you find a whole group of patients who feel that their condition is not being treated well, and you band together to get the medical profession to think again, you will run up against a brick wall. You will simply be written off as cranks, and dismissed. The priesthood does not take kindly to being exposed as wrong.

Jos löytyy kokonainen potilasryhmä jonka mielestä heidän sairauttaan ei hoideta hyvin, ja potilaat liittyvät yhteen saadakseen lääkärikunnan miettimään asiaa uudestaan, he törmäävät seinään. Ryhmä tullaan leimaamaan hankalaksi ja mitätöimään. Papisto ei pidä siitä, että heidät paljastetaan vääriksi papeiksi.

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2014 in review

The WordPress.com stats helper monkeys prepared a 2014 annual report for this blog.

Here’s an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 27,000 times in 2014. If it were a concert at Sydney Opera House, it would take about 10 sold-out performances for that many people to see it.

Click here to see the complete report.

How to deal with patients who have used T3 medication in Finland

This is a letter from the leading endocrinologist at the Tampere University Hospital to all public medical practitioners in the Pirkanmaa health care district. I’ve heard that this has happened in other districts as well. Please share. And please comment!

How to deal with therapeutic problems in hypothyroidism, and patients who have used T3 medication

The number of remissions to the Tampere University Hospital concerning therapeutic problems in hypothyreosis and especially the use of T3 have soared. We ask the remitting physician to note the following, when assessing the need for a remission to special medical care.

1. Is the patient hypothyroid? When, by whom, and on what grounds has the diagnosis been given, or the care initiated?

Hypothyreosis is diagnosed or ruled out by measuring S-TSH and S-T4V (free T4). If the results indicate a mild, subclinical hypothyreosis, it’s advisable to repeat the S-TSH after 1-3 months, and at the same time measure the S-TPO antibodies. If they are positive, the subclinical hypothyreosis may be treated. Thyroxin® can be tested in subclinical hypothyreosis if TSH is repeatedly higher than 4 mU/L. In people over 70 years of age, subclinical hypothyroidism should not generally be treated. Hypothyreosis should be treated, if S-TSH is ≥ 10 mU/L. For pregnant women and women who plan to get pregnant, thyroxine treatment should be started, if TSH ≥ 2,5 mU/L.
Functional medicine practitioners offer reverse T3, rT3 tests from abroad for a high price. This is not needed in clinical practice, because rT3 is an inactive thyroid metabolite.

2. The patient doesn’t feel better on Thyroxin® test therapy

According to the recommendations for care of subclinical hypothyroidism (TSH > 4 mU/L and free T4 is normal), a test treatment on thyroxine is done for 3 months, and after that a check, whether the symptoms have disappeared, is done. It’s fairly common, albeit not according to recommendations, that a test therapy is done at low values in euthyreosis (TSH and free T4 within range but low). If the symptoms continue during the test, or symptoms of thyrotoxicosis show up (palpitations, sweating, irritability, muscle weakness), the test should be terminated. Other reasons and solutions should be looked for to the original symptom, which is most often fatigue, weight gain or ”brain fog”. The most common causes are problems related to control of life, like stress, too much work, sleeplessness, lack of exercise, problems with eating schedules, overweight). Factors like sleep apnea, depression, hypercalcemia, diabetes, anaemia, vitamin B12 deficiency and electrolytic imbalances should also be checked.

3. The patient has had treatment for ”Wilson’s syndrome”

Functional medicine practitioners issue T3-medications for reasons that aren’t based on medical scientific evidence. The sole use of synthetic triiodothyronine (T3, trade names Liothyronin® and Thybon®) leads to thyrotoxicosis. Because the half life of T3 is short (around 24 hours), the problem with T3 treatment is the huge diurnal variation in T3 concentration. Typically the patient is in thyrotoxicosis for 3-4 hours after taking the T3 preparation. Thyrotoxicosis makes the patient tired, and causes arrythmia, irritability and sweating. In the morning, before the morning medications, the TSH, free T4 and free T3 values are typically low. Especially for pregnant women, or women who plan to get pregnant, T3 therapy is connected to the risk for the fetus to be hypothyroid and mentally retarded, because T3 does not surely penetrate the placenta, and the fetus is depending on the mother’s thyroxine during the development of the brains. Any T3 administration without medical grounds shall be terminated. There’s no need to gradually lower the dose. Pregnant women can be administered 25 – 50 µg of Thyroxin® to protect them from short term hypothyreosis. Because the T3 preparations work for a short time only, the patient’s own HPT axis will recover quickly. The thyroid function tests should be done after a month, and are usually normal. Then the original symptoms should be assessed, the reason that the patient visited a functional medicine practitioner in the first place.

4. The patient is hypothyroid because of autoimmune thyroiditis, thyroid surgery, or RI treatment, but is dissatisfied with the thyroxine replacement therapy

The recommended care for hypothyroidism is Thyroxin® monotherapy. Levothyroxine has a long half life (around one week), and stable T3 levels are obtained in the tissues through deiodination. Thyroxin® is taken once daily. Iron and calcium tablets should not be taken simultaneously with Thyroxin®, because these preparations lessen the uptake of Thyroxin®. Acid blockers and estrogen preparations raise the need for thyroxine. Most patients feel well on T4, as long as the dose is correct. The dose is correct, when the patient feels well, TSH is around 1 mU/L, and free T4 is in the reference range. Some patients feel best mentally, when free T4 is in the upper range and TSH is low. Free T3 must not rise above the reference range in this case. The most suitable levels can be individually assessed by measuring the thyroid function tests 6 weeks after raising the dose. Senior patients’ TSH should be in the upper part of the range. Subclinical hyperthyreosis makes the patients prone to osteomalasia and heart and blood vessel morbidity.

5. NDT (trade names Armour Thyroid and Thyroid) should not be used for the treatment of hypothyreosis

Synthetic combination therapy T4 + T3 may be tested on patients, who have a proven diagnosis of hypothyroidism, and who have not benefitted from correct doses of T4. Other possible reasons for fatigue must first be ruled out. In such situations a three month test therapy on T4 + T3 should be done by an internist or an endocrinologist, who is knowledgeable in thyroid illnesses. Combination therapy is not recommended for pregnant women and people with arrythmias. The risk in combination therapy is thyrotoxicosis caused by a too large dose. This can be seen as low TSH.

Literature:
2012 European Thyroid Association Guidelines: The Use of L-T4 + L-T3 in the Treatment of Hypothyroidism. Wiersinga WM, Duntas L, Fadeyev V, Nygaard B, Vanderpump MPJ. European Thyroid Journal 2012: 1:55–71.
2012 Clinical Practice Guidelines for Hypothyroidism in Adults: Co-sponsored by American Association of Clinical Endocrinologists and the American Thyroid Association. Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah-Pollack R, Singer PA, Woeber KA. Endocrine Practice 2012. Thyroid 2012: 22.
2013 ETA Guideline: Management of Subclinical Hypothyroidism. Pearce S, Brabant G, Duntas L, Monzani F, Peeters R, Razvi S, Wemeau JS. Eur Thyroid J 2013;2:215–228
Kilpirauhasen vajaatoiminnan yhdistelmähoito (Combination therapy of hypothyroidism, in Finnish). Niskanen L. Suomen Lääkärilehti 2013; 13/14.