Archive for the ‘Thyroid’ Category

Data Record & Assessment Form For Treated Thyroid Disorders (DRAFTT) – Beta Version


Dyslipidemia in subclinical hypothyroidism in an Indian population


Dyslipidemia in subclinical hypothyroidism in an Indian population

Raman K. Marwaha, Nikhil Tandon, M.K. Garg, Ratnesh Kanwar, A. Sastry, A. Narang, Saurav Arora and Kuntal Bhadra

Abstract

Objectives

In view of inconsistent reports on the prevalence of dyslipidemia in subclinical hypothyroidism (SCH), we studied lipid abnormalities in Indian subjects with SCH.

Design and methods

A cross sectional study of 5343 subjects divided in two groups, Group-1 (age ? 18 years) and Group-2 (age > 18 years) was undertaken. They were further subdivided on the basis of their thyroid functional status: Normal (Control); SCH with TSH ? 10.0 mIU/L (SCH-1); and SCH with TSH > 10 mIU/L (SCH-2).

Results

Prevalence of SCH was 14.7%. The only lipid abnormality in children and adolescents was low HDL in subjects with TSH > 10 mIU/L compared with controls. Serum total cholesterol (TC), and LDL cholesterol (LDL) were significantly higher in adults with TSH > 10 mIU/L compared to controls. There were no significant changes in lipid parameters in subjects with SCH having TSH ? 10.0 mIU/L, compared to controls. Serum TSH was positively and FT3 and FT4 were negatively correlated with TC and LDL.

Conclusions

Atherogenic lipid abnormalities were observed in adult subjects with SCH-2 (TSH > 10.0 mIU/L), and not in subjects with SCH-1 who had TSH ? 10.0 mIU/L in Indian population.

Keywords: Subclinical hypothyroidism; Lipid profile; Anti-TPO antibodies

Science direct link to article: http://www.sciencedirect.com/science/article/pii/S0009912011014147

Subclinical Hyperthyroidism_presented at HMAI Congress 2010


HOMOEOPATHIC PERSPECTIVE OF THYROID DISORDERS


R. K. Manchanda1, Archana Narang2, Saurav Arora3, Latika Nagpal3

For Correspondence:
1Deputy Director, Directorate of ISM & H, New Delhi
2Medical Officer, SHMC & H, Nanak Pura, Moti Bagh, New Delhi
3 SRF, SHMC & H, Nanak Pura, Moti Bagh, New Delhi
E mail id: shmc.thyroidclinic@gmail.com

Abstract
Homoeopathy is a unique system of medicine based on individualization and symptom similarity of the patient. It treats every sickness of a man as a whole and individualised entity.The homoeopathic literature is loaded with vast examples of thyroid diseases and their cure with homoeopathy. There are numerous examples of clinical and therapeutic studies done on thyroid disorders but there are few peer reviewed controlled design studies in Homoeopathy. Homoepathic medicines play an important role in immuno modulation at the cellular level and can cure cases of sub clinical & mild hypothyroidism and hyperthyroidism. Homoeopathic Medicines due to their infinitesimal light isotopic forms are capable of penetrating the Hypothalamus-Pituitary Axis. The need of the hour is to carry out scientific, evidence based studies and case documentation to prove the potential role of homeopathy in reversing the functional & immune disturbances of thyroid gland.

Keywords: Homoeopathy and thyroid disorders, research in homoeopathy, autoimmune thyroiditis, goiter, immuno-modulation

FROM THE HISTORY1

Goiter was first described in China in 2700 BC. Da Vinci described thyroid as a thing that is designed to fill empty spaces in the neck. According to Parry – thyroid works as a buffer to protect the brain from surges in blood flow. Roman physicians have reported thyroid enlargement as a sign of puberty. In 500 AD Abdul Kasan Kelebis Abis performed the first goiter excision in Baghdad, the procedure remained unknown. In 1200’s AD advancements in goiter procedures included applying hot irons through the skin and slowly withdrawing them at right angles.  The remaining mass or pedicled tissue was excised. Patients were tied to the table and held down to prevent unwanted movement, but most died from haemorrhage or sepsis. In 1646 AD Wilhelm Fabricus performed a thyroidectomy with standard surgical scalpels, for which he was imprisoned. In 1656 thyroid was first identified by the anatomist Thomas Wharton. In 1808 AD Guillaume Dupuytren performed a total thyroidectomy, but the patient died postoperatively of “shock”. In 1820 AD Johann Straub and Francois Coindet found that use of seaweed (iodine) reduced goiter size and vascularity. In 1830 AD Graves and von Basedow describe a toxic goiter condition they referred to as “Merseburg Triad” – goiter, exopthalmos, and palpitations. In 1866, Samuel David Gross said, “If a surgeon should be so foolhardy as to undertake it [thyroidectomy] … every step of the way will be environed with difficulty, every stroke of his knife will be followed by a torrent of blood, and lucky will it be for him if his victim lives long enough to enable him to finish his horrid butchery.” In 1883, Theodor Kocher while addressing the German Medical Congress stated, “the thyroid gland in fact had a function”. In the same year Kocher’s performed a retrospective review on 5000 career thyroidectomies.  The thyroxine was discovered somewhere in 19th century and a remarkable turning point started with this in management of thyroid disorders by allopathic counterparts.

REFERENCES FROM THE LITERATURE2
The homoeopathic literature is loaded with vast examples of thyroid diseases and their cure with homoeopathy. It was the insight of our great masters that they have so beautifully described thyroid related disorders and their management in Homoeopathy. In his great work, Master Samuel Hahnemann has quoted, “What action is exerted on the skin by certain diseases of the glands with an internal secretion (thyroid gland, ovaries, testicles, supra-renal capsules, pituitary gland, etc.) must remain reserved for future research. So much, however, is established to-day to prove that some of these disturbances (Addison’s disease) cause considerable alternations of the skin.” Below are some of the references from the history regarding thyroid disorders and their Homoeopathic cure.

CASE STUDIES PRESENTED SO FAR2

  • Journal of Homoeopathic Clinics, Vol 3, Sep N’1, Case 458, 1869-1870: A 19 years old female with large swelling of the thyroid gland was treated with Bromine3, several times a day following by Calc Carb 3 and was relieved in three weeks of time.
  • International Hanhnemannian Association 1902: A case of thyrotoxicosis was treated by Homoeopathically chosen remedies: China, Lach., Sul.
  • Clinical Illustrations Homoeopathician (A Journal Of Pure Homoeopathy) 1914: presented 3 cases of thyroid enlargement with thyroid dysfunction and were reported cured by Iodum and Baryta carb.
  • International Hahnemannian Association 1919: “Our knowledge of the endocrine remedies is as yet in a formative stage, but the therapeutic use of the ductless glands is steadily growing. We know more of the thyroid gland and of its therapeutic applications, than of any of the other ductless glands.” There is also a case presented which was treated using 2x and 3x trituration of thyroidinum.
  • International Foundation for Homoeopathy: Case Conference Proceedings 1995: A case of primary hypothyroidism aged 30 female was presented by Dr. George Guess.
  • Master F. J. , 1995: A case of a lady aged 51 years with migraine of 15 years standing, hypothyroidism since 10 years and leucoderma since 5 years and a diagnosed as a case of Hypothyroidism was given Staphisgaria.


REFERENECES FROM MATERIA MEDICA
2

  • Blackwood A. L. Manual of materia medica therapeutics: “A normal thyroid has much to do with the function of the ovaries; with a hypothyroid condition, although the ovaries and uterus are normal, menstruation may not appear and the patient becomes obese, the skin dry; should the pituitary show disturbance, the skin will be moist and soft”.
  • American Homoeopath described the concept of Hypothyroidism, cancer and clinical depression.
  • Boericke W. Pocket manual of homoeopathic materia medica: Kali Carb: “Pain in small spot on left side Hypothyroidism”. Thryroidinum: “Marked sensitiveness to cold, Hypothyroidism after acute diseases, i.e. weakness.
  • Grand Georage D. The spirit of homoeopathic medicines: “At times the remedy is suggested by hypertrophied glands or the beginning of goiter. Homeopathic treatment will remedy a slight disorder in the glandular system, but when the disorder is too great, hormonal treatment will be necessary.
  • Lesser O. Textbook of Homoeopathic Materia Medica: “If the alkali and earthy alkali metals, Na, K, Mg, Ca, as cations determine the drug picture, then they shape it as hydrogenoid, cold, sensitive to cold, relaxed torpid lymphatic constitutional types stigmatized along the side of the parasympathetic system. Seen from an endocrine side, they tend toward the hypothyroid side, the function of the lymphocytic apparatus (thymus) is increased.”
  • Master F. J. The bed side Organon of Medicine: “Never give thyroidinum as a routine or specific for all patients who come with thiroid problem.”


REFERENCES FROM REPERTORY
3
There are 32 references in the forms of rubrics and subrubrics given in Synthesis treaure edition. Where as Kents repertory, Murphy repertory and Complete repertory consists of 9, 13 and 37 rubrics in relation of thyroid and other rubrics and vice versa respectively.


THYROID GLAND


DEVELOPMENTAL CONSIDERATIONS
4
The thyroid gland starts developing by 3-4 weeks of gestation, appearing as an epithelial proliferation in the floor of the pharynx. Follicles of the thyroid begin to make colloid in the by 12th week of gestation and thus contribute in development of physical and neurological features. Failure of synthesis of hormones and TSH by thyroid gland may result in arrested or abnormal growth of the fetus. At birth, a cold-stimulated short-lived TSH surge is observed, followed by a TSH decrease until day 3 or 4 of life by T4 feedback inhibition.


FUNCTIONS OF THYROID GLAND6

The thyroid gland is one of the most important endocrine gland which secrets two major hormones, thyroxine and triiodothyronine. It is situated in anterior part of neck just above the lower part of trachea, situated in between cricoid cartilage and suprasternal notch. Normally it is not palpable but may be palpated in conditions in which it is enlarged. Enlargement of the gland may not be a sign of its under or over functioning, but association of goiter with thyroid function status and other investigative modalities helps us to understand disease in a better term. Goiter is assessed by palpation by fingers of both hands for size, consistency and presence of nodules if any.


DIAGNOSING VARIOUS THYROID DISORDERS

The diagnosis of thyroid disorder is primarily done on following points:

  • Complete homoeopathic case taking.
  • Family history of systemic disorders particularly thyroid and autoimmune disorders. It is seen that the individuals who have family history positive of thyroid dysfunction are at more risk of developing thyroid disorders.
  • Consistancy and size of thyroid gland, as it may give us some hint about the underlying pathology, e.g. firm gland are suggestive of hashimoto’s thyroiditis, goiter in high grades can induce pressure symptoms on trachea and other adjacent tissues, painful gland suggests acute or subacute inflammatory condition.
  • Presence of anti thyroid antibodies, may suggest some of the thyroid dysfunction.
  • Other investigations also help in arriving at diagnosis of thyroid disorders. Some of the investigations are: Radio active iodine uptake (RAIU), Technicium scan (Tc Scan), Fine needle biopsy (FNB). These investigations are condition specific and are to be advised as per requirement of the case. The detailed description of these investigative modalities is described later in the following text.

The ultimate and ground level workers in thyroid-body axis are the two hormones secreted by thyroid gland. These hormones are responsible for various activities in almost the entire body. Every organ and tissue thus needs these hormones (particulary T3) for proper functioning. Thyroid hormones acts by crossing the cell membrane and binding to intracellular receptors (α1, α2, β1 and β2), which act alone, in pairs or together with the retinoid X-receptor as transcription factors to modulate DNA transcription and thus various metabolic and other functions are performed. There are two variants of thyroid hormones circulating in body, free and bounded hormones, as hormones are circulated along the body in protein bounded form. These proteins are majorly thyroid binding globulins (TBG) and less commonly albumin. According to extensive research studies done on this revelas that free hormone assay is more reliable as bounded hormones level may vary in conditions in which there is pooling of TBG in body eg.

•      Pregnancy

•      Estrogen therapy

•      Oral contraceptive pills

•      Acute viral hepatitis

•      Primary biliary cirrhosis

•      Hepatocellular cancer

•      Collagen vascular disease

On the other hand TBG in decreased in

•      Glucocorticoids

•      Androgens

•      Nephrotic syndrome

•      Protein-losing enteropathy

•      Cirrhosis

•      Critical illness/starvation

T4 (thyroxine) is the major circulating hormone whereas T3 is more biologically active. Both T3 and T4 give a feed back to pituatory to release of suppress secretion of TSH. TSH is ultrasensitive to even smaller amouts of circulating T3 and T4 levels, this phenomenon is to be understood at the ground level to understand the diagnosing and follow up cases of thyroid disorders. This can be understood by the following simple yet informative flow chart:

TSH is the one of the most reliable marker of thyroid disorders along with FT4 estimation. Other diagnostic modalities used to diagnose various thyroid dysfunctions are given below with their advantages and desription:

MARKER/INVESTIGATION

BRIEF UTILITY

TSH: Most reliable marker to asses thyroid dysfunction with FT4 as TSH is the precursor of release of FT3 & FT4

Free T3, T4: Circulating un-bounded hormone assays depicts the actual level of thyroid hormones thus prognosis can further be made along with the clinical and confirmed diagnosis.

Antibodies: Anti-TPO, Anti-TSHr: Presence of antibodies may sometime help us to understand the natural history of thyroid functions, as their presence confirms the undergoing pathological conditions.

Thyroid ultrasonography:Thyroid Ultrasonography is done to see the consistency of thyroid gland. It is also done to rule out the presence of nodules. Ultrasonography can also be suggestive of congenital anomalies e.g. absence of one or both lobes of thyroid gland.

RAIU:Scintillation counter measures radioactivity after I123 administration. Uptake varies greatly by iodine status, e.g. Indigenous diet (normal uptake 10%).

Elevated RAIU with hyperthyroid symptoms may be presented in:

·         Graves

·         Toxic goiter

Low RAIU with hyperthyroid symptoms is used to distinguish:

·         Thyroiditis (Sub acute, Active Hashimoto’s)

·         Hormone ingestion

·         Excess I- intake in Graves’

(Jod-Basedow effect)

·         Ectopic thyroid carcinoma (Struma ovarii)

The RAIU technique is also used as a therapy to suppress the hyperactive gland in thyrotoxicosis and hyperthyroidism.

Technetium scan (Tc Scan): Technetium scan is also based on the uptake phenomenon of Tc by thyroid gland which is then use to differentiate various nodules and hyper functioning and hyper active thyroid gland.

Final Needle Biopsy (FNB):FNB is used to study the morphological and pathophysiology of glandular tissue. By this technique we can differentiate various types of carcinomas, dysplasia, and chronic lymphatic infiltration.

SUMMARY

•      TSH is a good screening test to assess thyroid function in an outpatient setting.
•      If TSH is abnormal, the diagnosis is confirmed with thyroid hormone levels.
•      Change in thyroid binding proteins could alter total thyroid hormone levels.
•      99% of thyroid hormones are protein bound.
•      In order to assess the thyroid hormone levels unaffected by the binding proteins, free thyroid hormone levels assessment is more reliable.
•      T4 is the major thyroid hormone in circulation, therefore assessing T4 status alone is usually sufficient to assess the thyroid hormone status.
•      In certain situation, T3 level becomes abnormal without changes in T4, as in T3 thyrotoxicosis where there are elevated levels of T3 along with normal T4 levels and low TSH level.
•      Acute illnesses can alter thyroid function tests without thyroid disease as they tend to increase binding proteins, also TSH can also be influenced by stress and anxiety.
•      Thyroglobulin is a good cancer marker for papillary and follicular cancer after total thyroidectomy.
•      Thyroid antibodies can assess the risk of developing autoimmune thyroid diseases.

SPECTRUM OF THYROID DISORDERS7

GOITER

Chronic enlargement of the thyroid gland not due to neoplasm is called as goiter.

•      Endemic goiter-Areas where > 5% of children of 6-12 years of age have goiter, very common in China and central Africa.

•      Sporadic goiter –Areas where < 5% of children 6-12 years of age have goiter.Multinodular goiter in sporadic areas often denotes the presence of multiple nodules rather than gross gland enlargement.

•      Familial

Etiology:

1.                   Hashimoto’s thyroiditis

•      Early stages only, late stages show atrophic changes

•      May present with hypo, hyper, or euthyroid states

2.    Graves’ disease-Due to chronic stimulation of TSH receptor

3.      Diet -Brassica (cabbage, turnips, cauliflower, broccoli),Cassava,Lithium prevents release of hormone, causes goiter in 6% of chronic users

4.      Neoplasm

5.      Chronic Iodine excess-Iodine excess leads to increased colloid formation and can prevent hormone release.If a patient does not develop iodine leak, excess iodine can lead to goiter.

THYROID NODULES

•      Prevalence

–     Palpable: 4-7%

–     Non-Palpable:  >50%

–     Cancer in nodules:  5%

•      Women affected more than men

•      Most subjects are euthyroid and/or asymptomatic

•      Prevalence is less than 1% with thyrotoxicosis

•      Historical Red Flags are defined as:

–     Male

–     Extremes of age (<20 or >65)

–     Rapid Growth

–     Symptoms of local invasion (hoarseness, dysphagia, neck pain)

–     History of radiation to the head or neck dispose an individual to develop nodules

–     Family history of Thyroid Cancer or Polyposis

SOLITARY THYROID NODULE

•         More likely to be malignant in men, patients over 60 and patients with a h/o head or neck irradiation are at more risk.

•         No growth for years almost always indicative of benign nodule as it is not a  nodule that appears suddenly (likely a cyst or adenoma hemorrhage)

•         Malignant nodule develops in weeks to months.

•         Virtually all patients with thyroid carcinoma are euthyroid as are those with benign nodules. Nodule of >1.5 cm are usually detectable on examination and are confirmed in the Ultrasonography. Lifetime risk for developing a nodule is 5-10%. Studies show 50% of people during autopsy has either single or multiple nodules. 5-10% of clinically detectable hypofunctioning (cold) nodules can be malignant. The laboratory/Imaging techniques used are: TSH, Calcitonin, Ultrasound, FNB for characterization of Nodules, Nuclear Scan to see whether nodule is “Hot” or “Cold.” If FNB is suggestive of malignancy then surgery is advised, and if it is supscpicious or negative then a follow up of few months is given to the patient with repeat investigations. In case there are Indeterminant reports then FNB is repeated, if still indeterminant, surgery is recommended.

PRIMARY HYPOTHYROIDISM

Definition – disorder of the thyroid gland causing decreased thyroid hormone production and secretion. It is the most common disorder of thyroid dysfunction. The factors attributed to these are:

•         Worldwide – iodine deficiency is most common cause.

•         Iodine depleted areas – chronic autoimmune thyroiditis is commonly present in these areas.

•         Associated with elevated serum cholesterol, CPK, AST and LDH

SECONDARY HYPOTHYROIDISM

Definition – It is caused by decreased thyroidal stimulation by TSH.

•          Also referred to as central or hypothyrotropic hypothyroidism.

•          Caused by either pituitary or hypothalamic diseases.

•          Very uncommon.

•          TSH is usually low or inappropriately normal.

Symptoms of hypothyroidism

It includes – Fatigue, lethargy, mental impairment, depression, cold intolerance, hoarseness, dry skin, decreased perspiration, weight gain, decreased appetite, constipation, menstrual irregularities, arthralgias, and parasthesias.

Signs

Slow movements, slow speech, hoarseness, bradycardia, dry skin, non-pitting edema, hyporeflexia, delayed relaxation of reflexes are some of the signs of hypothyroidism.

N. B.: Older patients tend to have fewer signs and symptoms of hypothyroidism and those they have tend to be less specific.

Diagnosis

  • Low FT4, High TSH (Primary, antibodies estimation suggested)
  • Low FT4, Low TSH (Secondary or Tertiary, TRH stimulation test, MRI)

HASHIMOTO’S THYROIDITIS

  • It is the most common cause of hypothyroidism.
  • It is due to action of auto- antibodies to TPO, TBG thus by inhibiting/diminishing the production and secretion of thyroid hormones.
  • Commonly presents in subjects from 30-50 yrs, female affected more than males.
  • It is usually non-tender and asymptomatic.
  • Lab values

· High TSH

·            Low T4

·            Anti-TPO Ab, Anti-TBG Ab

SILENT THYROIDITIS (POST-PARTUM THYROIDITIS)

Silent thyroiditis is termed post-partum thyroiditis if it occurs within one year of delivery.Patient comes with Hyperthyroid symptoms.Soon there is progression to euthyroidism followed by hypothyroidism for up to 1 year.Later on Hypothyroidism generally resolves.

SUBACUTE THYROIDITIS (DEQUERVAIN’S, GRANULOMATOUS)

It is the most common cause of painful thyroiditis.It often follows a URI.FNA may reveal multinuleated giant cells or granulomatous change.

Course

–     It starts with pain and thyrotoxicosis (3-6 weeks) followed by asymptomatic euthyroidism.

–     Then there is period of Hypothyroid state.(weeks to months)

–     It is followed by phase of recovery (complete in 95% after 4-6 months).

Diagnosis

–     Elevated ESR

–     Anemia (normochromic, normocytic)

–     Low TSH, Elevated T4 > T3, Low anti-TPO/Tgb

–     Low RAI uptake (same as silent thyroiditis)

–     Graves’ disease may occasionally develop as a late sequellae

ACUTE THYROIDITIS

Causes:

–     68% Bacterial (S. aureus, S. pyogenes)

–     15% Fungal

–     9% Mycobacterial

It May occur secondary toPyriform sinus fistulae, Pharyngeal space infections, Persistent Thyroglossal remnants, Thyroid surgery wound infections (rare) and in HIV.

Diagnosis:

–     Warm, tender, enlarged thyroid

–     FNA to drain abscess, obtain culture

–     RAIU normal (versus decreased in DeQuervain’s)

–     CT or US if infected TGDC suspected

Recovery is usually complete

RIEDEL’S THYROIDITIS

It is a rare disease involving fibrosis of the thyroid gland

Diagnosis:

–     Thyroid antibodies are present in 2/3

–     Painless goiter  “woody”

–     Open biopsy often needed to diagnose

–     Associated with focal sclerosis syndromes (retroperitoneal, mediastinal, retroorbital, and sclerosing cholangitis)

THYROTOXICOSIS

Definition – refers to clinical syndrome of hyper metabolism resulting from increased serum concentration of T4 and/or T3, regardless of cause. Not synonymous with hyperthyroidism. Hyperthyroidism – increased thyroid hormone biosynthesis and secretion by the thyroid gland.

Symptoms – nervousness, fatigue, weakness, increased perspiration, heat intolerance, tremor, hyperactivity, palpitation, change in appetite, weight change, menstrual irregularities.

Signs – hyperactivity, tachycardia, atrial arrhythmia, systolic hypertension, stare, eyelid retraction, tremor, hyperreflexia, muscle weakness.

*Older patients – have fewer signs and symptoms of sympathetic activation and more cardiovascular dysfunction.

GRAVES’ DISEASE

It is the most common cause of thyrotoxicosis in the industrialized world.It is Autoimmune condition with anti-TSHr antibodies.Onset of disease may be related to severe stress which alters the immune response.

Diagnosis:

–     TSH, T4, T3 to establish toxicosis

–     RAIU scan to differentiate toxic conditions

–     Anti-TPO, Anti-TSAb, FT3 if indicated

RAIU in Hyperthyroid States

High Uptake

Low Uptake

Graves’

Sub acute Thyroiditis

Toxic MNG

Iodine Toxicosis

Toxic Adenoma

Thyrotoxicosis factitia

HOMOEOPATHIC MANAGEMENT

There are various types of thyroid disorders which we commonly encounter in our day to day practice. These disorders are attributed at different levels, viz:-

  • Dynamic- Euthyroid autoimmune thyroiditis.
  • Functional- initial stages of autoimmune/hashimoto thyroiditis, Subclinical hypothyroidism and Subclinical hyperthyroidism.
  • Patho-physiological- Goitre, Hashitoxicosis, Chronic lymphocytic infiltration of thyroid, Non-malignant Nodules.
  • Pathological- Hypothyroidism, Graves’ disease, Thyrotoxicosis.
  • Descructive- Malignancies, toxic nodules.

The understanding of these levels helps us to define the prognostic and management plan for the individual. Also it helps us to define the therapeutic guidelines to treat a case of thyroid dysfunction. If we clearly perceive this concept we can avoid claiming false cures, as we cannot go against nature’s law of cure. If destruction has started we can only stop its progression, but cannot revive new cells. Once destruction has set in and the functional units of gland are non functional, no medicine can revive it or grow it, but on the other hand medicine will save rest of the cells. This is the reason why we encounter many patients in our practise who do not respond to best selected homoeopathic remedies according to Homoeopathic principles. This occurs in cases where there is either disease has progressed to non revertible changes or there is/are some other obstacles to cure. These obstacles to cure can be:

  • Other systemic disorders e.g. Diabetes mellitus, Hypertension, Metabolic syndrome, dyslipidemia etc
  • Autoimmune disorders e.g. SLE, vitiligo,
  • Any history of previous thyroid disorders e.g. hashimoto thyroiditis, thyroid nodules, autoimmune thyroiditis, etc
  • Other endocrinal disorders e.g. PCOS, prolactinoma, Cushing syndrome, etc.

Association of thyroid dysfunction with these disorders make the condition what we read in Organon as “Complex diseases”. The treament plan of these cases is done according the laws embedded in Organon of Medicine8.

In aphorism 3 of Organon of Medicine8 fifth edition, Hahnemann states that, “If the physician clearly perceives what is to be cured in diseases, that is to say, in every individual case of disease (knowledge of disease, indication),……” the first homework to be done by a physician is to understand the disease and its component, then only he can see the finer shades of individulization, difference between common and uncommon symptoms, understaning an individual as a whole and not a diseased part or organ, diagnosis and prognosis of this state etc. The natural history of any disease helps us to manage a disease and to intervene it with judicial employment of medicines. For example cases in which irreversible pathological changes have occurred, remedies having specific actions in low to moderate doses are usually advised. In cases where there are dynamic or functional abnormalities remedies with moderate to high potency are advised.

LEVELS OF PREVENTION OF THYROID DISORDERS:

PRIMORDIAL PREVENTION

Health promotion:

Educate the family regarding lifestyle measures, good food habits, positive attitude to be inculcated in young child

Specific protection:

•      Regular exercise

•      Desirable BMI

•      Health promotive measures and attitude

•      Identifications and elimination of exciting or precipitating factors, if any.

PRIMARY PREVENTION

•      Early diagnosis and treatment.

•      Reinforce primary and preventive measures.

•      Identifications and elimination of exciting or precipitating factors, if any.

SECONDARY PREVENTION

Aggressive reinforcement of:

•      Primary and secondary risk intervention.

•      Secondary prevention: lipid profile within normal limits

•      Aggressive and effective control of disease.

TERTIARY PREVENTION

•      Disability limitation

•      Rehabilitation

TREATMENT GUIDELINES FOR PHYSICIANS

Although it has been a matter of debate regarding the exact guidelines to treat various thyroid disoders especially diseases which are in their subclinical states, a general line of treatment can be sought out if one knows the basic facts about thyroid disorders. Moreover one needs to be updated regarding the latest techniques and research going on. For a very long period of time the subclinical hypothyroidism and subclinical hyperthyroidism conditions were treated as full blown cases of hypo or hyper thyroidism. As the studies in these areas advanced, it was seen that one needs to clearly define the line and justification of treatment. Treatment only upon biochemical anomaly and in absence or minimal symptoms needs to be justified and scientfically reasoned. Also the term subclinical sometime seems arbitrary when there are symptoms but biochemically anomalies are minimal and vice versa. Thus a physician’s discretion at this point of time should be critical and justified.

As Hahnemann has rightly said that there are patient in disease and not the disease in patient.  Therefore, a holistic approach is needed to treat the patients. A detailed case taking with psyco somatic approach should be adapted during the case taking. It should include investigation of emotional and psychological factors such as stress, repressed emotions, mental shock, grief, anger, dreams, delusions, and all other factors affecting the mind along with past, family history and intellectual and physical aspects of the patient. Hahnemann in aphorism 2nd has stated that, “The highest ideal of cure is rapid, gentle and permanent restoration of the health, or removal and annihilation of the disease in its whole exten.” Such a choosen remedy on the basis of individualization as stated in aphorism 7 works at deeper levels especially on pituatory hypothalamic axis and sets right the basic imbalance of hormones in the body.

In cases of sub clinical & mild hypothyroidism and hyperthyroidism Homoeopathic treatment has been found to be very efficacious. Homoeopathic Medicines have their impact on Hypothalamus-Pituitary Axis. Homoeopathy can delay the progression of malfunctioning of the thyroid gland. As the thyroid and its hormones effects each and every organ of the body including mental and physical growth, early detection and treatment with Homoeopathy in children can lead to prevention of complications. As homoepathic medicines are selected on the basis of constitution of the patient, it plays an important role in immuno modulation at the cellular level and therefore helps in annihilation of auto antibodies. Theses are the observations which authors have drawn during the past years in OPD at INMAS, NHMC & SHMC.

WHEN TO CONSULT AN ENDOCRINOLOGIST

For Patients with:

•         Grave’s disease

•         Multinodular goiter

•         Single palpable nodule

•         Central disease (pituitary or hypothalamic)

•         Patients resistant to therapy

STUDIES ON HOMOEOPATHY AND THYROID DISORDERS

There are numerous examples of clinical and therapeutic studies done on thyroid disorders, examples of which are discussed in short in historical perspective elsewhere in this article. Following are some of the peer reviewed controlled design studies in Homoeopathy apart from clinical and therapeutic studies.

  • Does a homeopathic ultramolecular dilution of Thyroidinum 30cH affect the rate of body weight reduction in fasting patients? A randomised placebo-controlled double-blind clinical trial. (Homeopathy, 2002; 91(4):197-206 (ISSN: 1475-4916) Schmidt JM; Ostermayr B, Krankenhaus für Naturheilweisen, Munich, Germany.9
  • Homeopathically prepared dilution of Rana catesbeiana thyroid glands modifies its rate of metamorphosis. (Homeopathy, 2004; 93(3):132-7 (ISSN: 1475-4916) Guedes JR; Ferreira CM; Guimarães HM; Saldiva PH; Capelozzi VL
    Laboratory of Molecular Pathology, University of São Paulo School of Medicine, SP, Brazil.10
  • THYROIDINUM, A PROVING (HYGANTHROPHARMACOLOGY). J Am Inst Homeopath.  1964; 57:201-7 (ISSN: 0002-8967) PANOS M; ROGERS R; STEPHENSON J.11
  • Pharmacologic and alternative therapies for the horse with chronic laminitis. Vet Clin North Am Equine Pract.  1999; 15(2):495-516, viii (ISSN: 0749-0739) Sumano López H; Hoyas Sepúlveda ML; Brumbaugh GW.
    Departamento de Fisiología y Farmacologiá, Facultad de Medicina Veterinaria y Zootecnia, Universidad Nacional Autónoma de México, México DF, México.12
  • To evaluate the efficacy of homoeopathic treatment in sub clinical hypothyroidism (SCH). A single blind case control 18 months follow-up pilot study at NHMC & Hospital and Institute of Nuclear Medicine & Allied Sciences, Delhi, India under Dilli Homoeopathic Anusandhan Parishad (DHAP) revealved remarkable results about management of children on subclinical hypothyroidism.13

In continuation of this scientific spirit another research study on, “Effect of Homoeopathic treatment on natural history of autoimmune thyroiditis” is undergoing at Dr. B. R. Sur Homoeopathic Medical College, Hospital & Research Centre, Nanak Pura, Moti Bagh, New Delhi (Govt of NCT of Delhi) in collaboration with Institute of Nuclear Medicine & Allied Sciences (INMAS), Timarpur, Delhi – 54 (under ministry of Defence). The project is under EMR scheme of AYUSH.

ACKNOWLEDGEMENT

The authors express their thankfulness to Maj. Gen. Dr. R. K. Marwaha, Addl. Director, Institute of Nuclear Medicine, Timarpur, Delhi, Dr. V. K. Khanna, Ex-Principal, NHMC & H, Defence colony, New Delhi and Dr. V. K. Chauhan, Principal SHMC & H, Nanak Pura, Moti Bagh, New Delhi for their timely support, help and guidance. The authors are also thankful to the staff of INMAS-Mr. Kuntal Bhadra, Mr. Baig, and Mr. Satwir Singh for their assistance in various activities at screening, investigations and OPD setups.

REFERENCES

1.      V. Leoutsakos, A short history of the thyroid gland, Dept of Surgery Athens University School of Medicine, Athens, 115 27 Greece

2. Encyclopedia Homeopathica, Version 2.2.

3.RADAR 10, Apex Version.

4. Thyroid gland development and defects, Kratzsch J, Pulzer F., Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital, Paul-List-Str. 13-15, D-04103 Leipzig, Germany.

5. Grant’s Atlas of Anatomy, Twelfth edition, Anne M. R. Agur

6. Guyton & Hall Textbook Of Medical Physiology 11th_Edition

7. Harrisons textbook of medicine, 17th edition.

8. Organon of Medicine, Samuel Hahnemann, 5th edition, Publisher B. Jain.

WEB REFERENCES:-

  1. http://www.sciencedirect.com
  2. http://www.ncbi.nlm.nih.gov/pubmed/15287432
  3. http://www.ncbi.nlm.nih.gov/pubmed/14178448
  4. http://www.find-health-articles.com/rec_pub_10472124-pharmacologic-alternative-therapies-horse-chronic-laminitis.htm
  5. http://www.delhihomeo.com/clinical_hypothyroidism.htm

RESEARCH IN HOMOEOPATHY: PRESENT AND FUTURE PERSPECTIVE


Published in Homoeopathi Heritage, a publication from the house of B Jain publishers in June 2010 issue


Dr Archana Narang M.O. (T), Dr Saurav Arora (SRF), Dr Latika Nagpal (SRF)

Dr. B. R. Sur Homoeopathic Medical College, Hospital & Research Centre,

Nanak Pura, Moti Bagh, New Delhi 110021

shmc.thyroidclinic@gmail.com

Research is an endeavour to discover answers to intellectual and practical problems through the application of scientific method.

CITATIONS FROM THE ORGANON

  • Experimentation is for one of the two purposes, observation for induction, or verification of inductions. Experimentation is analysis, deduction, analytic deduction…….We observe by contrast.
  • “….not, however, to construct so called systems, by interweaving empty speculations and hypotheses….
  • “…..cease to deceive suffering mankind with mere talk, and begin now, instead, for once to act, that is, really to help and cure.”

ABSTRACT

Research is a necessity in the ever growing era of modern science and we are now more prone for criticism and authenticity. Research and science is nothing new to us, we have been rooted on these grounds since the “Apple” fall on “Newton’s head”. Hahnemann was one of the four epochal figures in the history of practice of medicine. His experiment with materialistic doses of cinchona bark is theroot of logical thinking. From Hahnemann’s era we have been scientific, logical and philosophical. We need upgradation in the field of homoeopathy to compete in today’s world and to make ourselves more strong, clear and confident. Many a times we are questioned about our principles and methods of practice. To answer all the queries, we must prepare ourselves so strong that our existence doesn’t go in vain. The hard work of our forefathers has brought us where we stand today. The need of hour is scientific research, and this doesn’t mean only test tubes and laboratories, but it is a step ahead of it. Research can be done in numerous ways. The right research depends upon our insight and aims. There is a researcher and a scientist in every one of us, the need is to bring it to the front and think logically, the same way our master taught us. This article will try to touch the latest research methodologies in Homoeopathy, keeping in mind the basis of our philosophy.

INTRODUCTION

A basic research process can be defined as, “An inquiry process that has clearly defined parameters and involves discovery and creation of knowledge for testing, building, revision, confirmation, refutation of knowledge and theory by means of investigation of a problem for local decision making”. The first basic thing Hahnemann did to prove, there exists a science beyond the materials, was by means of experimentation and observation, observing it to the levels of criticism and analysing it to the depths of history. Research not only means noting down the observations and findings but to analyse them and to reach to a conclusionwhich is the landmark for future research.

OBJECTIVES OF RESEARCH

The purpose of research is to discover answers through the application of scientific procedures. Until and unless we are not clear about our objectives we cannot lead to a fruitful finding. The objectives can be:

  • To gain familiarity with a phenomenon or to achieve new insights into it – Exploratory or Formulative Research. This kind of research is key point to our trials regarding the action of remedies onto various systems in our body.
  • To portray accurately the characteristics of a particular individual, situation or a group – Descriptive Research, i.e., drug pictures, disease pictures, individualized case studies, research regarding group studies.
  • To determine the frequency with which something occurs or with which it is associated with something else – Diagnostic Research, i.e., action of various remedies in specific conditions and vice versa.
  • To test a hypothesis of a causal relationship between variables – Hypothesis-Testing Research, i.e., clinical trials of (new or old) drugs on conditions which were not appeared drug proving but were benefitted in therapeutics, for example action of certain remedies on cancers.

CHARACTERISTICS OF A GOOD RESEARCH

A good research has some characteristics associated with it, without these it is nothing but a bundle of papers on table. The characteristics help us to learn the simple meaning of research methodologies. These characteristics also help us to understand the outcomes of such research; it is likewise applying a constitutional remedy to an individual. The purpose of the research should be clearly defined. The process which we are planning to adopt should be detailed. Once we have decided upon the area we want to work research protocol should be thoroughly made and planned. To make the protocol scientific and unbiased high ethical standards should be applied. If any limitations to the study are present they should be clearly defined and accepted. Once data is collected its proper analysis should be done by an expert, such as bio statistician. Logic is to be applied to every possible test to validate the data collected and conclusions reached. The outcomes of research should be presented with rationale and truthfulness and once the analysis is properly done the justified conclusions should be drawn from it and should be published for other’s benefit.

So, the linear research process consists of:

TYPES OF RESEARCH

There are numerous ways by which we can do research activities. The type of research depends upon our aim. There can be a mixed type of research on one topic also. The common types are:-

·         Descriptive: as in description of drugs and their Symptomatology.

·         Analytical: as in analysing already proved drugs for new spheres of actions.

·         Conceptual: as in making new treatment concepts in different diseases.

·         Empirical: research based on experience or observations.

·         Quantitative: as in drug standardization.

·         Qualitative: as in action of different potencies in different conditions.

·         Applied: as in application of remedies in specific conditions.

·         Fundamental: as in clinical proving, clinical verifications and collaborative research.

·         Diagnostic: as in action of various remedies in specific conditions and vice versa.

RESEARCH METHODOLOGY IN HOMOEOPATHY

Following are the few areas worth discussing regarding research in Homoeopathy:

·         Drug standardization: Aphorism 122, “In these experiments – on which depends the exactitude of the whole medical art, and the weal of all future generations of mankind – no other medicines should be employed except such as are perfectly well known, and of whose purity, genuineness and energy we are thoroughly assured.” This drug standardization is conducted to ensure quality, genuiness, and authenticity of raw drugs and to evaluate the safety and efficacy of drugs. Physico chemical standardization studies include ash values, extractive values, colour reactions, physical constants of mother tinctures and thin layer chromatography (TLC) profiles of extracts and mother tinctures. Pharmacogonostic studies include morphology, anatomy, histochemistry, powder-microscopy and prelimiary chemical tests. Pharmacological tests include toxicity studies, antifertility activity, motor activity, hypoglycemic effects, Blood Pressure, CNS toxicity study etc.

  • Homoeopathic pathogenetic trials (HPTs): Human pathogenetic trials or commonly known as Drug Proving is the core activity we aim for. This goes in accordance with our philosophy and laws to know the effect of medicines on healthy human beings. Drug proving technique has been the same since the first time it was introduced by Hahnemann some 200 years ago. In the recent times the process and methodology of HPTs has improved greatly. The techniques have been unified to record and process the results of HPTs.
  • Clinical research: Clinical research is one of the major research activities in Homoeopathy in the past few years. The concept of “Evidence based medicine” is propagated through clinical research everywhere, and is welcomed everywhere. Councils, institutions, agencies, associations and physicians are now coming together in clinical research activities to promote Homoeopathy as “Evidence” based science. In the past few years many clinical research papers have been published in peer reviewed journals. The aim of the clinical research process is to gather scientific data at one place and to support & propagate Homoeopathy as evidence based science.
  • Clinical verification: To make clinical proving and research more authentic and scientific, clinical verifications are done at multicentric levels. This helps us to gain finer shades of remedies in terms of ethnicities, climates, populations etc.
  • Collaborative and fundamental research studies: Collaboration component of research is necessary to explore more on ground level. Collaborative studies are critically analysed and presented to larger masses of other fields. Further there are many areas where Homoeopathy is new as a science, thus collaborating with other institutes and individuals helps Homoeopathy to be rooted to those areas. This generates waves of new dimensions and horizons. Collaboration also provides us with the latest techniques and methods which otherwise are difficult to approach in day to day practice. Many of the research studies are done with renowned institutes like AIIMS, ICMR, BHU, INMAS etc.

SUMMARY AND CONCLUSION

Homoeopathy, the rational art of healing is based on scientific fundamental principles. As we all know that in today’s world research is an imparative part of any science, so for further development of homoeopathic practices and for the affirmation of the fundamental principles on which Homoeopathy is based, we have to focus on research oriented activities in our system of medicine. To strengthen the scientific base, improving Homoeopathic practice and verifying the clinical efficacy, research in Homoeopathy should be carried out and encouraged.

Research in Homoeopathy should aim at making Homoeopathy more effective and reliable in wider range of conditions. Research should improve the practice of Homoeopathy and at the same time evolve methods to make it easier to practice. We can achieve scientific credibility only by collecting clinical evidences for the efficacy of our drugs in various clinical conditions.

Sometimes it is very difficult for many of us to correlate scientific attitude with homoeopathy we are doing at our clinics and hospitals. Most of the time, we are afraid of the complexity of research, funding issues, absence of proper data collection, difficult access to published studies; online resources, and many more unaswered issues. Our aim towards research is very clear, to cure and benefit our patients, to become more scientific, to gather data, to grow stronger on philosophical and logical grounds.All practicing Homoeopaths can contribute to the progress of Homoeopathy by making data of their clinical experiences, by applying drugs on large number of cases and writing down the outcomes carefully. We can also identify the most reliable indications of each drug on which prescriptions can be made even while working at bedside in IPDs, OPDs or in our clinics. Every one of us can contribute to the data verification, repertory verification and proving the efficacy of drugs of our Materia Medica. Unbiased observation and data verification has been emphasised by, Hahnemann in aphorism 6 of Organon of Medicine, “The unprejudiced observer is well aware of the futility of transcendental speculations…..”

REFERENCES

1.      Organon of Medicine, Vth Edition.

2.      Directorate General of Health Services (DGHS). Ministry of Health and Family Welfare, Govt. of India. Good clinical practices for clinical research in India, 2006.

3.      Central council for research in Homoeopathy. Workshop on research methodology and standardization, 2006.

AOBUT THE AUTHORS

  • Dr Archana Narang (MD) is Medical Officer (T) at NHMC and is currently working as Co-Investigator in a research project on Thyroid disorders by CCRH at INMAS (Ministry of defense) & SHMC (Govt of Delhi). The author has many papers published at National & International level to her credit.
  • Dr Saurav Arora and Dr Latika Nagpal are working as Senior Research Fellow at SHMC.in
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