Pseudo-Endocrine Disorders Practical Management Strategies 2018 Michael T. McDermott MD Director, Endocrinology and Diabetes Practice University of Colorado Hospital Michael.mcdermott@ucdenver.edu
Internet Information / Misinformation about Endocrine Disorders is Abundant
Pseudo-Endocrine Disorders Wilson s Syndrome Reverse T3 Syndrome Adrenal Fatigue Cortisol-Related Diabetes Mifepristone Treatment for Type 2 Diabetes
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 PE: Case History Meds: Vitamins BP 129/74 P 74 Ht 5 7 Wt 158 lb. BMI 24.8 kg/m2 General: normal Thyroid: normal Skin: normal
Case History 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: negative Cortisol 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?
Wilson s Syndrome "Wilson s syndrome" was coined in 1990 by E. Denis Wilson, a physician practicing in Longwood, Florida. http://www.wilsonssyndrome.com/meet-dr-wilson/ https://en.wikipedia.org/wiki/wilson%27s_temperature_syndrome
Wilson s Syndrome 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 Susceptible People 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 Wilson s Syndrome Website
Wilson s Syndrome Susceptible People To This May We Add: Candida Albicans and Yeast Sufferers Persons having Hypoglycemia Persons with Eating Disorders Persons with Sleep Disorders Wilson s Syndrome Website
Wilson s Syndrome Testing Protocol 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 Syndrome Website
Wilson s Syndrome Proposed Mechanism T4 Deiodinases (1 + 2) T3 Pro-Survival Adaptation Chronic T4 to T3 Conversion Reduction Specific Circumstances Specific Individuals MTM Adaptation from: Wilson s Syndrome Website
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. Wilson s Syndrome Treatment Protocol Using the wrong ratios can exacerbate the syndrome. Wilson s Syndrome Website
Wilson s Syndrome ATA Public Statement No scientific evidence supports the existence of Wilson s Syndrome. Unsafe ATA Website: www. Thyroid.Org
Wilson s Syndrome (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 (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) http://www.wilsonssyndrome.com/meet-dr-wilson/
Did I hear you right?
Wilson s Syndrome Check Your Temperature Order Your Own Lab Tests Find a Provider Who Treats Wilson s Syndrome Wilson s Syndrome Website 2018
Reverse T3 Syndrome www.stopthethyroidmadness.com
Reverse T3 Syndrome NDT: Natural Desiccated Thyroid
Reverse T3 Syndrome Reverse T3 Dominance Syndrome (Alternative Name) Theory Reverse T3 (RT3) competes with T3 for thyroid receptor (TR). High RT3 prevents T3 binding to TR: hypothyroid symptoms. Fact T3 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
If Only I Had a Little More T3!
Case History 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 medication PE: BP 128/70 P 80 Ht 5 8 Wt 157 lb. (Orthostatic VS negative) Complete exam normal Lab Report: Full Day Salivary Cortisol Profile Adrenal Fatigue
Adrenal Fatigue Salivary Cortisol Profile Normal Adrenal Fatigue
Adrenal Fatigue Website
Adrenal Fatigue Website
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Mayo Clinic Adrenal Fatigue Website
Hormone Foundation (Endocrine Society) Fatigue Website
Primary Adrenal Insufficiency Diagnosis 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 Salivary Cortisol Profiles Have Never Been Validated Bornstein S, J Clin Endocrinol Metab 2016; 101:364-89
Primary Adrenal Insufficiency ACTH Stimulation Test Serum Cortisol ug/dl 30 20 10 Normal Partial Adrenal Insufficiency Complete Adrenal Insufficiency 0 30 60 Time (Minutes) After ACTH
ACTH Stimulation Test Meta-Analysis: Primary Adrenal Insufficiency Sensitivity: 92% (CI: 81-94%) Good But Not Perfect Specificity: Not Estimable Bornstein S, J Clin Endocrinol Metab 2016; 101:364-89 Ospina NS, J Clin Endocrinol Metab 2016; 101:427-34
Primary Adrenal Insufficiency Stages of Development Adrenal Functional Impairment Occurs in 4 Stages Stage 1: h Plasma Renin Activity (PRA) i / Normal Plasma Aldosterone (PA) Stage 2: Stage 1 plus i Cortisol Response to ACTH Stage 3: Stage 2 plus h Plasma ACTH Stage 4: Clinically Overt Adrenal Insufficiency Debellis A, J Clin Endocrinology Metab 1993; 76:1002-7
Secondary Adrenal Insufficiency Opioid Induced Central ACTH Inhibition On Fentanyl Off Fentanyl Oltmanns K, J Intern Med 2005; 257:478-80
48 year old man self-referred for treatment of Type 2 Diabetes Mellitus. His PCP told him that she was told Mifepristone (Korlym) is a new and very effective treatment for type 2 diabetes. He would like to be started on this new medication. You check with your local pharmacies. The cost for this medication is: $13,737.60 for 30 days $164,848 for one year Case History You want to know what is the data for efficacy in type 2 diabetes. And where did this advice come from?
Diabetes in Cushing s Syndrome Treatment with Mifepristone Mifepristone (Korlym) is approved for people with Cushing s syndrome who have type 2 diabetes or glucose intolerance. Mifepristone blocks the glucocorticoid receptor and thereby blocks cortisol action on tissues. Fleseriu M. J Clin Endocrinol Metab. 2012;97(6):2039-2049
Diabetes in Cushing s Syndrome Treatment with Mifepristone Glucose AUC Oral Glucose Tolerance Test Fleseriu M. J Clin Endocrinol Metab. 2012;97(6):2039-2049
Diabetes in Cushing s Syndrome Treatment with Mifepristone HbA1C HOMA-IR Fleseriu M. J Clin Endocrinol Metab. 2012;97(6):2039-2049
Pseudo-Endocrine Disorders Patients with Pseudo-Endocrine Disorders Are Equally Important and Deserve Our Full Attention and Compassion
Pseudo-Endocrine Disorders What the Patient Says: Fix My Thyroid, Adrenal, or Pituitary Condition What the Patient Means: Please Help Me!
Pseudo-Endocrine Disorders The Patient s Quality of Life is Poor And He/She is Frustrated It s an Honor that She/He Entrusts You With an Opportunity to Help Her/Him
Pseudo-Endocrine Disorders 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?
Pseudo-Endocrine Disorders Recommendations Listen Attentively Examine Your Patient Offer Additional Testing, if Appropriate Admit that Current Testing Options Have Some Limitations Always Provide Honesty, Encouragement, and Compassion
Stand Out Above the Crowd
Pseudo-Endocrine Disorders Recommendations Good Sleep Habits Stress Reduction Regular Exercise Depression Management Good Nutrition Illness Treatment Support Supplements No Proven Benefit Hormone Replacement Therapy Avoid Unless Deficiency Documented.
Comment I Found on Internet Many Endocrinologists are Trained but not Educated. I Strongly Disagree. But We Must All Be Lifelong Learners. Never Stop Learning!
Parting Thoughts 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!
Thank You