friday presentations...2018 annual meeting carolinas chapter - american association of clinical...

September 7-9, 2018Kiawah Island Golf Resort

Kiawah Island, SC

2018 Annual Meeting

Carolinas Chapter - American Association of Clinical Endocrinologists

FRIDAY PRESENTATIONS

This continuing medical education activity is jointly provided by the Carolinas Chapter-AACE and Southern Regional Health Education Center

Pseudo-Endocrine DisordersPractical Management Strategies

Michael T. McDermott MDDirector, Endocrinology and Diabetes Practice

University of Colorado Hospital

[email protected]

AACE CarolinasSeptember 7, 2018

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Pseudo-Endocrine Disorders

Reverse T3Syndrome

Wilson’sSyndrome

AdrenalFatigue

Low Testosterone

Low Dose Naltrexone

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Internet Information / Misinformation about Endocrine Disorders is Abundant

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38 y.o. woman self-referred for hormone evaluation because of chronic progressive fatigue. She began feeling fatigue at age 28, about 1 year after the birth of her second child. She also endorses hair loss, inability to lose weight and persistent “brain fog”. She has read the internet and is convinced this is a hormone disorder. She is adamant that this is not due to depression. She has ordered some tests on-line (cycle day 4) and they are abnormal.PMH: Negative Meds: VitaminsPE: BP 129/74 P 74 Ht 5’7” Wt 158 lb. BMI 24.8 kg/m2

General: normal Thyroid: normal Skin: normal

Case History

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38 y.o. woman self-referred for hormone evaluation because of chronic fatigue, hair loss, inability to lose weight, “brain fog”.

Test Results from On-line Orders (Cycle Day 4, 10:00 AM):

TSH 2.1 mU/L (nl: 0.45-4.5) Free T4 1.0 ng/dl (nl: 0.78-1.81)Free T3 2.4 pg/ml (nl: 2.3-4.2) Reverse T3 23 ng/dl (nl: 10-24)TPO Antibodies: negative Tg Antibodies: negativeCortisol 12 ug/dl (nl: 10-20) ACTH 19 pg/ml (nl: 10-50)Testosterone 27 ng/ml (nl: 30-95) Estradiol 101 pg/ml (nl: 27-123)Progesterone < 1.5 ng/ml (nl < 1.5) DHEA 188 ug/dl (nl: 145-395) GH 0.04 ng/ml (nl: 0.05-3.0) IGF-1 57 ng/ml (nl: 60-220)

She asks, “Do I have Wilson’s Syndrome or Reverse T3 Syndrome?

Case History

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http://www.wilsonssyndrome.com/meet-dr-wilson/

https://en.Wikipedia.org/wiki/Wilson%27s_temperature_syndrome

"Wilson’s syndrome" was coined in 1990 by E. Denis Wilson, a physician practicing in Longwood, Florida.

Wilson’s Syndrome

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MTM Adaptation from:Wilson’s Syndrome Website

T4 T3Deiodinases (1 + 2)

Pro-Survival AdaptationChronic T4 to T3 Conversion Reduction

Specific CircumstancesSpecific Individuals

Wilson’s SyndromeProposed Mechanism

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Pro-Survival Adaptation: lowering metabolism to deal with

famines / low food availability at the expense of enzymatic

efficiency. In normal circumstances, the body resumes normal

functioning when food supply is restored and/or stress removed.

This “conservation state” may persist for years and can lead to

chronic fatigue, allergy/immunological problems, and other

“poorly defined” health complaints may become common.

This state may be reset with proper therapy.

Wilson’s Syndrome Website

Wilson’s Syndrome

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Famine Survivors or Their Descendants Scotch / Irish / Russian Ancestry American Indian Ancestry Holocaust Survivors

High Stress Survivors Divorce Death of Loved One Family or Job Stress

Chronic Dieters


Susceptible People

Wilson’s Syndrome

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To This May We Add:

Candida Albicans and Yeast Sufferers

Persons having Hypoglycemia

Persons with Eating Disorders

Persons with Sleep Disorders


Susceptible People

Wilson’s Syndrome

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Use an accurate mercury thermometer.

Take your temperature every 3 hours beginning

3 hours after you get up.

Average the readings over several normal days.

If average body temperature is > 1 degree below

normal, you may have Wilson’s Syndrome.


Wilson’s SyndromeTesting Protocol

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Cycling body temperature up to the normal range using the

proper thyroid (T3) supplements, then cycling down again.

Cycling is repeated several times until the body temperature

remains at normal level after stopping T3 supplements.

Typically this may take 3-4 cycles. In difficult cases, it has taken

as many as 11-12 cycles.

Using the wrong ratios can exacerbate the syndrome.


Wilson’s SyndromeTreatment Protocol

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Check YourTemperature

Order YourOwn Lab Tests

Find a ProviderWho Treats

Wilson’s SyndromeWilson’s Syndrome Website

Wilson’s Syndrome

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No scientific evidence supports theexistence of Wilson’s Syndrome.

ATA Website: www. Thyroid.Org

Wilson’s SyndromeATA Public Statement

Unsafe

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(1988) A 50-year-old woman died of an arrhythmia and heart attack while on excessive amounts of thyroid hormone prescribed by Wilson.

(1992) the Florida Board of Medicine accused him of "fleecing" patients with a "phony diagnosis". The Board of Medicine and Wilson agreed to a 6-month suspension of Wilson's medical license, after which Wilson agreed to attend 100 hours of CME, submit to psychological testing, and pay a $10,000 fine before resuming practice.

(1992) Wilson also agreed not to prescribe thyroid medication unless the Board of Medicine determined that the medical community had accepted "Wilson's Syndrome" and his treatment.

Reference: State of Florida, Department of Health. February 12, 1992. Final Order Number: DPR9200039ME

Wilson’s Syndrome

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Wilson’s Syndrome

http://www.wilsonssyndrome.com/meet-dr-wilson/

(2012) Since I’ve published my book there has been growing interest in and mention of Reverse T3, and the use of T3 in the treatment of low thyroid symptoms. For example, many thyroid-related health sites, books, fitness trainers, physicians, spokespeople, and businesses, tout the importance of peripheral conversion of T4 to T3 and/or Reverse T3 (RT3) and the usefulness of T3 in the treatment of low thyroid symptoms in patients with normal thyroid blood tests.

Over twenty years ago, I received a lot of opposition both from mainstream and alternative medicine circles. Now, it’s great to see that my ideas are being embraced and disseminated more and more.

Best regards,Denis Wilson, MD (June 21, 2012)

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Reverse T3 Syndrome

www.stopthethyroidmadness.com17

Reverse T3 Syndrome

NDT: Natural Desiccated Thyroid18

FactT3 has 100 x Higher Affinity for the

Thyroid Receptor Compared to RT3.

Schuster LD, Schwartz HL, Oppenheimer JH.J Clin Endocrinol Metab 1979; 48:627-32

Reverse T3 SyndromeProposed Mechanism

T3

RT3

ThyroidReceptor

RT3

RT3 CompetesWith T3 for Binding to

T3 Receptor

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If Only I Had a Little More T3!

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A 47 year old woman has been experiencing fatigue for about 15 years but complains of “total exhaustion” progressively over the past year. She does not sleep well but does not snore. Appetite is poor. Mild weight gain (5 lb) in the past year. Cannot exercise due to fatigue. She had a test for “adrenal fatigue”, says it is positive and requests treatment for this condition.PMH: Mononucleosis at age 18 Meds: Occasional prescription pain medicationPE: BP 128/70 P 80 Ht 5’8” Wt 157 lb.

(Orthostatic VS negative) Complete exam normalLab Report: Full Day Salivary Cortisol Profile –

Adrenal Fatigue

Case History

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Adrenal Fatigue

Normal

Adrenal FatigueSalivary Cortisol Profile

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Adrenal Fatigue Website28

Adrenal Fatigue Website29

Sometimes I Just Can’t Keep Up 30

“Adrenal support with real adrenal”

Adrenal Support Products

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“Made from raw, cold-processed bovine glandular tissue”

“Raw Adrenal Glandular

Concentrate”

“Natural glandular”

“Blend of glandulars, herbs, vitamins and

more”

Adrenal Support Products

? 38

I Feel So Good on Adrenal Support!

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Mayo Clinic Adrenal Fatigue Website40

Hormone Foundation (Endocrine Society) Fatigue Website41

Primary Adrenal InsufficiencyDiagnosis

Serum Cortisol and Plasma ACTH

Cortisol < 5 ug/dl and ACTH > 2 x ULN - Supportive

ACTH Stimulation Test (250 mcg)

Peak Cortisol (30 or 60 min.) < 18 ug/dl - Diagnostic

Bornstein S, J Clin Endocrinol Metab 2016; 101:364-89

Salivary Cortisol Profiles Have Never Been Validated

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SerumCortisol

ug/dl

Time (Minutes) After ACTH 0 30 60

10

20

30Normal

Partial Adrenal Insufficiency

Complete Adrenal Insufficiency

Primary Adrenal InsufficiencyACTH Stimulation Test

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Stage 1: Plasma Renin Activity (PRA) / Normal Plasma Aldosterone (PA)

Stage 2: Stage 1 plus Cortisol Response to ACTHStage 3: Stage 2 plus Plasma ACTHStage 4: Clinically Overt Adrenal Insufficiency

Adrenal Functional Impairment Occurs in 4 Stages

Debellis A, J Clin Endocrinology Metab 1993; 76:1002-7

Primary Adrenal InsufficiencyStages of Development

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Bornstein S, J Clin Endocrinol Metab 2016; 101:364-89Ospina NS, J Clin Endocrinol Metab 2016; 101:427-34

ACTH Stimulation TestMeta-Analysis: Primary Adrenal Insufficiency

Sensitivity: 92% (CI: 81-94%)

Specificity: Not Estimable

Good But Not Perfect

Data Insufficient to Analyze Secondary Adrenal Insufficiency

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Oltmanns K, J Intern Med 2005; 257:478-80

On Fentanyl Off Fentanyl

Secondary Adrenal InsufficiencyOpioid Induced – Central ACTH Inhibition

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A 53 year old man referred for management of his testosterone therapy. He has noted fatigue and low motivation for the past year. Libido / sexual function are normal. He is a former college hockey player. He has 10-14 alcohol drinks/week. A recent evaluation by his PCP was normal, including TSH and Testosterone. He visited a “Low T” clinic and was given an injection of testosterone pellets. PE: BP 148/88 P 76 Ht 6’3” Wt 226 lb.

General: normal Thyroid: normal Skin: normalLabs: Testosterone 1,173 ng/dl (nl: 220-780)

Case History

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Testosterone Pellet Therapy for Men

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Testosterone Boosting Supplements

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Testosterone Boosting Supplements

Same Photos on Website for:Everlasting T

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A 58 year old woman called to ask about recent growth of dark hair on her chin and upper lip. She has had fatigue and low libido for 4 years since her divorce. She visited a local “practitioner” and was given an injection of testosterone pellets. Meds: Levothyroxine 88 mcg dailyPE: BP 133/65 P 66 Ht 5’4” Wt 154 lb.

General: normal Thyroid: normal Skin: dark terminal hair on chin and upper lip

Labs: TSH 1.7 mU/LTestosterone 2,138 ng/dl (nl: 20-80)

Case History

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Testosterone Pellet Therapy for Women

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Testosterone Pellet Therapy for Women

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65 y.o. man - email through EHR patient portal:“Recently I increased my thyroid dose from 200 mcg to 300 mcg daily due to various symptoms including fatigue, periodic dizzy spells, headaches, constipation, worse acne and hoarseness. My symptoms improved. Because of your previous warnings, I reduced my dose back to 200 mcg and all the symptoms returned. So I increased the dose back to 300 mcg with improvement again. Please renew my prescription for 300 mcg.”

“By the way, I have read on the internet that low dose naltrexone can cure Hashimoto’s thyroiditis. My naturopath agreed. Can you please call in a prescription for that also?”

Case History

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Low Dose Naltrexone

Proposed to Treat:Cancer, Crohn’s Disease, HIV, Multiple Sclerosis, Parkinson’s Disease, Alzheimer’s Disease, Amyotrophic Lateral Sclerosis, Autoimmune Thyroid Disease. 56

Low Dose Naltrexone

Publication: Smith J. Low dose naltrexone therapy improves active Crohn’s disease.Am J Gastroenterol 2007; 102:820-8.

Background: Endogenous opioids and opioid antagonists have been shown to play a role in healing and repair of tissues.

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Low Dose Naltrexone

Smith J. Low dose naltrexone therapy improves active Crohn’s disease.Am J Gastroenterol 2007; 102:820-8.

Cro

hn’s

Dis

ease

Act

ivity

Inde

x

Parker CE. Low dose naltrexone for induction of remission in Crohn’s disease.Cochrane Database Syst Rev 2018, April 1;4:CD010410. doi:10.1002/14651858.CD010410.pub3 “Insufficient evidence to allow any firm conclusionsRegarding the efficacy and safety of LDN for patients with active Crohn’s disease.58

Low Dose Naltrexone

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Low Dose Naltrexone

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Low Dose Naltrexone

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61 y.o. woman email through HER patient portal:“I reviewed my test results. Things look about the same except for the FT3 - it seems to be decreasing. I am having problems staying awake during the day again. I was going to write and let you know that I am in need of taking more Provigil to stay awake during the day. I am currently prescribed 200 mg in a.m. and 200 mg at noon. I am having a very hard time waking up in the morning and am wanting to fall asleep on my feet all the time. I took an extra 200 mg which really helped. I still need Zolpidem at night to fall asleep. When I checked my T3 I was wondering if that is what is wrong. I know I need more of something.”

Case HistoryChronic Fatigue Syndrome

Previously Treated With:Levothyroxine, Liothyronine, Dexamethasone, Dextroamphetamine, Modafinil

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How Should We Approach the Patient

with a Pseudo-Endocrine Disorder?

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Patients with Pseudo-Endocrine DisordersAre Equally Important and Deserve Our

Full Attention and Compassion


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Fix My Thyroid, Adrenal, or Pituitary Condition

What the Patient Says:

Please Help Me!

What the Patient Means:


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The Patient’s Quality of Life is PoorAnd He/She is Frustrated

It’s an Honor that She/He Entrusts You With an Opportunity to Help Her/Him


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Can you play a role in improving this patient’s quality of life?

Can you help this patient even if there is no apparent endocrine disorder?


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Listen Attentively

Always Provide Honesty, Encouragement, and Compassion

Examine Your Patient

Offer Additional Testing, if Appropriate

Pseudo-Endocrine DisordersRecommendations

Admit that Current Testing Options Have Some Limitations

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Stand Out Above the Crowd

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Support Supplements – No Proven Benefit

Hormone Replacement Therapy – Avoid Unless

Deficiency Documented.

Good SleepHabits

RegularExercise

GoodNutrition

StressReduction

DepressionManagement

IllnessTreatment

Pseudo-Endocrine DisordersRecommendations

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“Many Endocrinologists are Trained but not Educated.”

Comment I Found on Internet

I Strongly Disagree.But We Must All Be Lifelong Learners.

Never Stop Learning!71

It’s An Exciting Time to be an Endocrinologist!

There is So Much Still to Learn.

And So Many People We May Be Able to Help!

Parting Thoughts

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Thank You

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