My Autoimmune Journey: From Pharmacist to Patient. Kirsty T. Washam, PharmD, MBA

Transcription

1 My Autoimmune Journey: From Pharmacist to Patient Kirsty T. Washam, PharmD, MBA

2 Disclosures The speaker has no actual or potential conflicts of interest to disclose in relation to this presentation.

3 Objectives Discuss Explore Define Discuss the prevalence of autoimmune disorders. Explore the patient s despair and anguish managing the challenges of undiagnosed autoimmune disease. Define treatment opportunities for thyroiditis.

4 Introduction

5 Autoimmunity in the United States National Institutes of Health (NIH) > 100 autoimmune conditions affecting 23.5 million Americans American Autoimmune Related Diseases Association (AARDA) Estimates 50 million Americans Many symptoms are generalized and non-specific Joint pain Fatigue Digestive issues

6 Autoimmune Disease Is on the Rise Women 3x more likely to develop autoimmune condition Once you have one, you are at an increased risk of developing additional autoimmune conditions Traditional management of autoimmunity relies on replacement (thyroid, insulin) or immune suppression (corticosteroids, DMARDs) J.F. Bach, The Effect of Infections on Susceptibility to Autoimmune and Allergic Diseases, New England Journal of Medicine 347 (Sep 19, 2002): Copyright Ballantyne S. The Paleo Approach : Reverse Autoimmune Disease and Heal Your Body. Victory Belt Publishing Inc., Simon & Schuster; 2013.

7 Do you know is the leading cause of hypothyroidism worldwide while is the leading cause of hypothyroidism in the United States?

8 Hypothyroidism Primary Most common form Gland dysfunction Hashimoto s is the most common cause Other causes: endemic iodine deficiency, previous thyroidectomy, previous radioablation, medication exposure TSH levels high Secondary Insufficient production of TRH by the hypothalamus or insufficient TSH production by the pituitary TSH levels low Tertiary Deficient TSH secretion due to deficient TRH secretion dxline.info Hypothyroidism - Endocrine and Metabolic Disorders. Merck Manuals Professional Edition.

9 Stephanie L Lee MD. Hashimoto thyroiditis. Practice Essentials, Background, Etiology. Published August 12, Accessed August 20, Hashimoto s Thyroiditis Characterized by destruction of thyroid cells by various cell- and antibody-mediated immune processes The most common cause of hypothyroidism in the US (ages 6+) Incidence 10-15x higher in females Age range years with peak incidence in men years later Increased risk of lipid disorders and papillary thyroid carcinoma

10 Hashimoto s Thyroiditis Risk Factors Changes in sex hormones Infections Medications Exposure to ionizing radiation Excess consumption of iodine Gender Genetic predisposition Hashimoto thyroiditis: MedlinePlus Genetics. medlineplus.gov.

11 Doctors give drugs of which they know little, into bodies, of which they know less, for disease of which they know nothing at all. Voltaire This Photo by Unknown Author is licensed under CC BY

12 Timeline Born via C-section Formula-fed Typical 1990s diet Acne and heavy menstrual cycles Frequent ear infections and strep throat Autoimmunity

13 Symptoms Early, nonspecific symptoms: Fatigue Constipation Dry skin Weight gain More advanced symptoms: Cold intolerance Slowed movement/loss of energy Peripheral neuropathy Memory loss Hair loss Joint pains and muscle cramps

14 Elusive Diagnosis Many patients have difficulty getting a correct diagnosis 45 percent of autoimmune disease patients had been labeled as chronic complainers or were told that they were overly concerned with their health in the earliest stages of their illnesses

15 Complications Goiter Interference with swallowing and/or breathing Heart problems Enlarged heart, heart failure Mental health issues Depression, decreased libido, diminished mental functioning Myxedema coma Rare life-threatening condition that can result from long-term untreated hypothyroidism (requires immediate emergency treatment) Birth defects Babies born to women with untreated hypothyroidism have a higher risk of being stillborn, premature and spending extra time in the NICU Infants born to hypothyroid mothers may have diminished IQ in later life due to underdevelopment of the brain while in the womb Hennessey J, Wartofsky L. Hashimoto s Disease. The Journal of Clinical Endocrinology & Metabolism. 2007;92(7):E1-E1. doi: /jcem

16 A Pill for Every Ill

17 When the Student is Ready, the Teacher Appears Thyroid Function Tests: TSH Thyroperoxidase (TPO*) antibodies Thyroglobulin (TG) antibodies* Free T4 Free T3 Reverse T3 *10-15% of patients with Hashimoto s may be antibody negative

18 Root Cause Approach

19 Addressing Underlying Causes Genetic susceptibility Infections & environmental triggers Intestinal permeability

20 The Five R Approach to Healing Hashimoto s Remove Repair Replace Reinoculate Rebalance Iodine* Infections Fluoride Toxins Inflammatory foods Stress Healing diet Protomorphogens L-glutamine B 12 Zinc Selenium Thyroid hormone Digestive enzymes +/- bile acids Vitamin D Probiotics Ferments Adrenal support Polyphenols LDN Wentz I, Nowosadzka M. Hashimoto s Thyroiditis : Lifestyle Interventions for Finding and Treating the Root Cause. Izabella Wentz; 2015.

21 Remove Iodine* Infections Fluoride Toxins Inflammatory foods Stress

22 Iodine* Controversial Thyroid sensitive to both insufficient and excessive amounts Iodine deficiency leading cause of hypothyroidism worldwide but excessive iodine intake has been associated with increased risk of autoimmune hypothyroidism May trigger thyroiditis/have a toxic effect on thyroid May increase thyroid antibodies (TPO-Ab and TG-Ab) Bülow Pedersen, I., Laurberg, P., Knudsen, N., Jørgensen, T., Perrild, H., Ovesen, L., & Banke Rasmussen, L. (2007). An increased incidence of overt hypothyroidism after iodine fortification of salt in Denmark: A prospective Søkilde Pedersen, I., Knudsen, N., Carlé, A., Vejbjerg, P., Jørgensen, T., Perrild, H., Laurberg, P. (2011). A cautious iodization programme bringing iodine intake to a low recommended level is associated with an increase in the prevalence of thyroid auto

23 Infections Big 3 Epstein-Barr virus Yersenia enterocolitica H. pylori Bacterial Viral Fungal Parasitic Blackard, J. T., Kong, L., Huber, A. K., & Tomer, Y. (2013). Hepatitis C virus infection of a thyroid cell line: Implications for pathogenesis of hepatitis C virus and thyroiditis. Thyroid: Official Journal of the Am Gaitonde, D.Y., Rowley, K.D., Sweeney, L.B., & Eisenhower, D.D. (2012). Hypothyroidism: An update. American Family Physician, 86(3), International Journal of Dermatology, 42(3),

24 Kheradpisheh, Z., Mirzaei, M., Mahvi, A. H., Mokhtari, M., Azizi, R., Fallahzadeh, H., & Ehrampoush, M. H. (2018). Impact of drinking water fluoride on human thyroid hormones: A case-control study. Scientific Reports, 8(1), Fluoride Suppresses thyroid hormone Increases plasma TSH Fluoridated drinking water, fluoride toothpaste/dental treatments, medications (fluoroquinolone antibiotics, voriconazole) Office of Dietary Supplements - Fluoride. ods.od.nih.gov.

25 Toxins Bisphenol A (BPA) Binds thyroxine receptor Increases serum T4 Water bottles, can liners, thermal receipts, medical devices Mercury Blocks conversion of T4 into T3 (5 deiodinase) Inhibits TPO enzyme Dental amalgams, Thimerosol Phthalates Endocrine disruptor PVC plastics, personal care products Brent G. A. (2010). Environmental exposures and autoimmune thyroid disease. Thyroid: Official Journal of the American Thyroid Association, 20(7), Nishida, M., Muraoka, K., Nishikawa, K., Takagi, T., & Kawada, J. (1989). Differential effects of methylmercuric chloride and mercuric chloride on the histochemistry of rat thyroid peroxidase and the thyroid peroxidase activity of isolated pig thyroid cells. Journal of Histochemistry and Cytochemistry, 37(5), Ghassabian, A., & Trasande, L. (2018). Disruption in thyroid signaling pathway: A mechanism for the effect of endocrinedisrupting chemicals on child neurodevelopment. Frontiers in Endocrinology

26 Inflammatory Foods Gluten Associated with autoimmune thyroid disease May increase anti-tpo levels in individuals with celiac disease Wheat, rye, barley Dairy Proteins can trigger inflammation Lactose intolerance is common Eggs Protein (lysozyme) in egg whites can cross the gut barrier and carry foreign proteins with it causing inflammatory response Egg whites high incidence of allergy-related symptoms Soy Link to autoimmune thyroid disorders High in lectins and phytic acid Liontiris, M.I., & Mazokopakis, E.E. (2017). A concise review of Hashimoto thyroiditis (HT) and the importance of iodine, selenium, vitamin D and gluten on the autoimmunity and dietary management of HT patients: Points that need more investigation Manzel A, Muller DN, Hafler DA, Erdman SE, Linker RA, Kleinewietfeld M. Role of Western Diet in Inflammatory Autoimmune Diseases. Current Allergy and Asthma Reports. 2013;14(1). doi: /s

27 Stress Slows thyroid hormone production Negative feedback loop between cortisol, hypothalamus and pituitary Reduces T4 to T3 conversion High stress converts more T3 into reverse T3 (RT3) instead of free T3 (FT3) Makes thyroid receptors less sensitive Release of cytokines makes thyroid receptors less sensitive to thyroid hormones Damage Chronic inflammation damages tissues, triggering stress response Inflammation Immune system response to infection Stress Reactivates latent infections Stojanovich L, Marisavljevich D. Stress as a trigger of autoimmune disease. Autoimmunity reviews. 2008;7(3): doi: /j.autrev McCray CJ, Agarwal SK. Stress and Autoimmunity. Immunology and Allergy Clinics of North America. 2011;31(1):1-18. doi: /j.iac

28 Repair Healing diet Protomorphogens L-glutamine

29 Healing Diet Emphasis on whole foods/minimally processed foods Focus on inclusion of healing foods Bone broth, gelatin, ferments Balance blood glucose Increased intake of healthy fats and proteins Possible options: Paleo, Autoimmune Paleo (AIP), Low FODMAP, GAPS diet Abbott, R. D., Sadowski, A., & Alt, A. G. (2019). Efficacy of the autoimmune protocol diet as part of a multidisciplinary, supported lifestyle interventio

30 Protomorphogens* Extracts of nucleic acids of cells Type of glandular supplement Can be used when a gland is over- or under-active Examples: liver, thyroid and lung glandular provides support to corresponding gland in the body

31 Chang WK, Yang KD, Shaio MF. Effect of Glutamine on Th1 and Th2 Cytokine Responses of Human Peripheral Blood Mononuclear Cells. Clinical Immunology. 1999;93(3): doi: /clim L-glutamine Glutamine is the most abundant and versatile amino acid in the body The rate of glutamine consumption by immune cells is similar or greater than glucose Reduces intestinal inflammation Decreases intestinal permeability Kim MH, Kim H. The Roles of Glutamine in the Intestine and Its Implication in Intestinal Diseases. International Journal of Molecular Sciences. 2017;18(5):1051. doi: /ijms Cruzat V, Macedo Rogero M, Noel Keane K, Curi R, Newsholme P. Glutamine: Metabolism and Immune Function, Supplementation and Clinical Translation. Nutrients. 2018;10(11):1564. doi: /nu

32 Replace B 12 Zinc Selenium Thyroid hormone Digestive enzymes +/- bile acids Vitamin D

33 B12 Symptoms of deficiency can mimic hypothyroidism Fatigue Mood changes/irritability Poor memory/cognition Depression Hashimoto s patients have a high incidence of B12 deficiency Drug-induced nutrient depletion, decreased absorption Supplement with methylcobalamin Adenosylcobalamin and/or hydroxycobalamin may be appropriate for patients with certain genetic mutations Ness-Abramof R, Nabriski DA, Braverman LE, Shilo L, Weiss E, Reshef T, et al. Prevalence and evaluation of B12 deficiency in patients with autoimmune thyroid disease. Am J Med Sci Sep;332(3):

34 Zinc Symptoms of deficiency Poor wound healing Impaired taste/smell Thin, brittle nails Essential for thyroid function Assists with conversion of T4 to T3 Supplement with zinc Be aware of inverse relationship between Cu/Zn Betsy, A., Binitha, M., & Sarita, S. (2013). Zinc deficiency associated with hypothyroidism: An overlooked cause of severe alop

35 Gärtner R, Gasnier BC, Dietrich JW, Krebs B, Angstwurm MW. Selenium supplementation in patients with autoimmune thyroiditis decreases thyroid peroxidase antibodies concentrations. J Clin Endocrinol Metab. 2002;87(4): doi: /jcem Selenium Trace element Thyroid tissue has the highest concentration of selenium in the body Assists with conversion of T4 to T3 Study showed 40% reduction in TPO antibodies 200 mcg x 90 days Mazokopakis EE, Papadakis JA, Papadomanolaki MG, et al. Effects of 12 months treatment with L-selenomethionine on serum anti-tpo Levels in patients with Hashimoto s thyroiditis. Thyroid Jul;17(7):

36 Thyroid Hormone Standard of care Replacement therapy to replace the function of a thyroid gland that is underactive or has been surgically removed Suppression therapy to prevent further growth of thyroid tissue Goal of treatment is to replicate a normally functioning thyroid T4 (levothyroxine), T4 (liothyronine), NDT (natural desiccated thyroid), compounded T3/T4 and OTC supplements Thyroid Hormone Treatment. American Thyroid Association.

37 Digestive enzymes +/- Bile acids Most people with Hashimoto s/hypothyroidism have hypochlorhydria Difficulty digesting proteins can lead to Food sensitivities Gut infections (H. pylori, Yersinia, parasites, SIBO) Digestive enzymes help break down proteins and enhance ability to digest fiber and starches Bile acids assist with fat absorption Supplement options include betaine with pepsin, systemic enzymes, pancreatic enzymes, gluten/dairy digestive enzymes Achlorhydria: Background, Pathophysiology, Etiology. emedicine. Published online November 4,

38 Vitamin D Low levels of vitamin D have been linked to autoimmune conditions Vitamin D has been shown to decrease both TPO-Ab and TG-Ab In Hashimoto s patients being treated with levothyroxine, vitamin D was linked to a decrease in thyroid autoimmunity Testing for vitamin D levels is more widely available and accepted Recommend supplementation based upon patient lab results, if available General dosing recommendation is 2000 IU daily Wang, J., Lv, S., Chen, G., Gao, C., He, J., Zhong, H., & Xu, Y. (2015). Meta-analysis of the association between vitamin D and autoimmune thyroid disease. Nutrients, 7(4), Krysiak, R., Szkróbka, W., & Okopień, B. (2017). The effect of vitamin D on thyroid autoimmunity in levothyroxine-treated women with hashimoto's thyroiditis and normal vitamin D status. Experimental and C Mazokopakis, E.E., Papadomanolaki, M.G., Tsekouras, K.C., Evangelopoulos, A.D., Kotsiris, D.A., & Tzortzinis, A.A. (2015). Is vitamin D related to pathogenesis and treatment of Hashimoto's thyroiditis? Hellenic Journal of Nuclear Medicine, 18(3),

39 Reinoculate Probiotics Ferments

40 / Probiotics Play a role in peripheral conversion of T4 to T3 ~20% of this happens in the intestines Gut microbiome influences availability of essential nutrients Iodine, copper, iron for thyroid hormone synthesis Selenium and zinc for conversion of T4 to T3 Vitamin D for regulating immune response Dysbiosis has been reported in autoimmune thyroid disease as well as thyroid carcinoma Supplements Saccharomyces boulardii beneficial yeast that competes with pathogenic bacteria and yeasts that cause dysbiosis Spore-based probiotics can increase bacterial diversity and improve SIBO Knezevic J, Starchl C, Tmava Berisha A, Amrein K. Thyroid-Gut-Axis: How Does the Microbiota Influence Thyroid Function? Nutrients. 2020;12(6):1769. doi: /nu

41 Ferments Pickles Sauerkraut Kimchi Kombucha Kefir Yogurt Rezac S, Kok CR, Heermann M, Hutkins R. Fermented Foods as a Dietary Source of Live Organisms. Frontiers in Microbiology. 2018;9. doi: /fmicb De Santis S, Cavalcanti E, Mastronardi M, Jirillo E, Chieppa M. Nutritional Keys for Intestinal Barrier Modulation.Frontiers in Immunology. 2015;6. doi: /fimmu

42 Rebalance Adrenal support Polyphenols LDN

43 Adrenal support HPA axis dysfunction may be the reason many thyroid patients don t feel better despite being treated for hypothyroidism Fatigue Brain fog Depression Decreased memory B vitamins, vitamin C, magnesium Adaptogens Ashwagandha Reishi Licorice Maca Stefano Mariotti, Paolo Beck-Peccoz. Physiology of the Hypothalamic-Pituitary-Thyroid Axis. Nih.gov. Published August 14,

44 Polyphenols Compounds that give fruits & vegetables their color and taste Polyphenol-rich foods Dark chocolate Red wine Spices Potent anti-inflammatory Regulate immunity Supplements Epigallocatechin gallate (EGCG) Resveratrol Curcumin Capsaicin This Photo by Unknown Author is licensed under CC BY Khan H, Sureda A, Belwal T, et al. Polyphenols in the treatment of autoimmune diseases. Autoimmunity Reviews. 2019;18(7): doi: /j.autrev

45 LDN Antagonizes some TLR receptors Reduces production of pro-inflammatory cytokines Suppresses cascade inflammation Central and system effects as TLR receptors are present on microglial cells, mast cells, and macrophages Blocks opiate receptors for a brief period Increases natural production of antiinflammatory endorphins Upregulates opiate receptors Has direct effect on some cell proliferation rates Dosing mg QHS Side effects Vivid dreams Increased thyroid sensitivity Li Z, You Y, Griffin N, Feng J, Shan F. Low-dose naltrexone (LDN): A promising treatment in immune-related diseases and cancer therapy. International Immunopharmacology. 2018;61: doi: /j.intimp

46 Let food be thy medicine - Hippocrates (maybe)

47 Acute Illness

48 Chronic Disease

49 Pharmacists on the Frontlines Underutilized, despite training & experience Medication experts, that can do much more than just dispense medication Increase quality of care Improve patient outcomes Decrease cost CDC. How Pharmacists Can Improve Our Nation s Health. Centers for Disease Control and Prevention. Published February 28,

50 Functional Medicine Expand role as advisers and counselors Spend more time with patients and offer more personalized service Personalized care without third-party intervention Why Pharmacists Have Begun Embracing Functional Medicine. Pharmacy Times. Accessed August 21,

51 Take-Aways Ask why patients are experiencing symptoms Learn ways to support root cause healing Connect with other likeminded professionals

52 Self-Reflection What can you do to start helping your autoimmune patients?

53 Inspiration without implementation is just entertainment Pamela Shaw

54 Additional References/Resources Stephanie L Lee MD. Hashimoto thyroiditis. Practice Essentials, Background, Etiology. Published August 12, Accessed August 20, Ballantyne S. The Paleo Approach : Reverse Autoimmune Disease and Heal Your Body. Victory Belt Publishing Inc., Simon & Schuster; Wentz I, Nowosadzka M. Hashimoto s Thyroiditis : Lifestyle Interventions for Finding and Treating the Root Cause. Izabella Wentz; Fasano A. Leaky gut and autoimmune disease. Clin Rev Allergy Immunol. Feb 2012;42(1):71-78 Drugreport. The 50 Most Commonly Prescribed Drugs in America And Their Average Price. DrugReport.com - Reporting on Dangerous Drugs, Defective Medical Devices & Harmful Products. Published March 23, Autoimmune and Immune-Mediated Diseases. National Institutes of Health (NIH). Published December 8, Accessed August 21, Diagnosis Tips. Autoimmune Association. Accessed August 21, CDC. How Pharmacists Can Improve Our Nation s Health. Centers for Disease Control and Prevention. Published February 28, Why Pharmacists Have Begun Embracing Functional Medicine. Pharmacy Times. Accessed August 21,