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ARE BIOPHOSPHENATES REQUIRED FOR SOME PEOPLE?

QUESTION: I have a fairly unique problem, however, regarding bisphosphonates. I MUST take them. I had my thyroid removed due to cancer in 2005. Since then, Levoxyl has caused rapid osteoporosis, which I never had prior to my thyroid cancer surgery (I never took Levoxyl before 2005). Since I am 100% dependent on Levoxyl, and Levoxyl causes (first) osteopenia, and then osteoporosis, there is no way out. I have consistently taken (and still do) proper doses of Calcium, Vitamin D, and Magnesium, but it did not prevent the rapid erosion of my bone mass. So, perhaps for those who still have thyroid glands and can get by with just Calcium, D and Magnesium, your article is accurate. But for those dependent on Levoxyl, what are our choices? Do you have any comments or ideas on this?

ANSWER: Levoxyl is levothyroxine. Other brand names include Euthyrox, Levothroid, Synthroid, Tirosint, and Unithroid. It is also referred to as T4.

Levothyroxine is ONE of the thyroid hormones. The thyroid hormones, thyroxine (T4) and triiodothyronine (T3), are produced by the thyroid gland. An important component in the synthesis is iodine. The major form of thyroid hormone in the blood is thyroxine (T4). The ratio of T4 to T3 released in the blood is roughly 20 to 1. Thyroxine is converted to the active T3 (three to four times more potent than T4) within cells. These are further processed to other thyroid hormones such as iodothyronamine (T1a) and thyronamine (T0a).

I am not mentioning these to show off, but to emphasize that there are more than one thyroid hormone. All of them are naturally present and have functions for our health. Loss of the thyroid gland is not to be taken lightly. Unlike some other hormones (estrogen, testosterone, for example), other parts of the body are not know to efficiently produce or alter thyroid. That's why people need to use a supplement.

I've done some searching about the relationship between levothyroxine and osteoporosis. A December 2003 medical journal review article conducted a systematic review of the effects of replacement levothyroxine therapy on bone mineral density (story). The review included 63 studies (3,279 patients) from 1990 to 2001. The reviewers said that all of the studies were either limited and/or controversial. Thirty one of them showed that there was no effect on bone mineral density. I am not trying to argue against your comment that "LEVOXYL = OSTEOPOROSIS". That suggest that the relationship is proven. My research suggests that this isn't exactly correct.

If levothyroxine is associated with bone mineral loss then I suggest it might also be related to the fact that levothyroxine is just one of a myriad of thyroid hormones that the thyroid gland produces for the body. It is entirely like that all of the thyroid hormones working in harmony provide the benefits AND protect us from adverse reactions - such as bone loss (if that actually happens).

Until levothyroxine came to the market patients were using naturally extracted forms of thyroid. They were obtained from (mostly) porcine thyroids - a byproduct of the meat packing industry. The most common brand was Armour Thyroid (a product made with thyroid glands from the Armour meat packing business).

Part of the marketing of levothyroxine (primarily the brand called Synthroid) was to point out that there could be batch-to-batch variances between one shipment of thyroid glands and another. No such variance was likely when a doctor would prescribe a drug made under the strict controls of a drug maker. Keep in mind that drug companies are allowed to sell products that vary by as much as 10% between batches - and even between tablets in a single batch (or lot number). I've long held that the variance issue was more marketing hype than actual fact.

The discussions about the usefulness of levothyroxine have continued for decades. Still, nobody has come to a firm conclusion about it. Personally, I think that if a person has lost their thyroid completely they would probably do best by replacing the thyroid hormones with a more complete supplement. Thyroid extract doses seem very reasonable to me. Replacing just T4 seems less efficient. I am not concerned about the potential for variances. They happen in all doses of every drug.

It is not impossible for patients and doctors to adjust dosing when needed. In fact I know of a patient who has her compounder adjust the T3 and T4 content of a commercial product (Naturthroid). Her doctor and her know quickly when the combination is not correct. The pharmacist uses the assay provided by the manufacturer and adjusts the commercial version by adding T3 and/or T4 to achieve the proper balance, The pharmacist then packages the corrected dose in a capsule. Compounding pharmacist have access to pure forms of T3 and T4 and it is not uncommon for us to make preparations that contain them in the proper ratio. It is more time consuming for the patient and the doctor than merely prescribing one of the commercial T3 drugs, but sometimes it takes more effort.

Thyroid replacement can be looked at in the same way one might consider what kind of prosthetic limb would be best. I saw a commercial about a young woman who replaced a lost leg with one that would allow her to jog - something she was passionate about. It looked like some sort of outer space gadget and didn't look at all like a real leg and foot. It met her needs. Other people might want something that looks more natural. Heather Mills comes to mind (she was one of the celebrity performers on the U.S. TV series "Dancing with the Stars" in 2007.). Her dancing scores might well have suffered if she hit the dance floor with titanium tubes and springs instead of a natural looking limb. Yes, T4 is probably fine for many people. If it isn't there are other alternatives. As I mentioned earlier, I think a more complete thyroid is superior to just one of the hormones. This seems particularly important when the thyroid gland has been completely lost.

Finally, it seems odd to me that a person would need one drug to offset the negative effects of another. Why not just use a different approach? Yes, it is common practice (sometimes referred to as poly-pharmacy), but does that mean it's correct? I'm reminded of the old adage, "if everyone in your class jumped off the bridge would that make it ok for your to jump too?". Just because it is common for doctors to prescribe a drug to offset the effects of another doesn't mean it is good practice - just that everyone else is doing it. After thinking about that for over 35 years I have concluded that it is inappropriate - and that better techniques are possible. The vast majority of health practitioners disagree with my conclusions.

There are many reasons that I have issues about bisphosphonates. I don't think there is any good reason for anyone to take it. There is insufficient evidence that it actually works the way it is claimed. I used the recent FDA comments to highlight just how potentially dangerous those drugs can be. However, I will not tell anyone to disobey their doctor's orders to take it. That is between patient and doctor.

All of the above is a long-winded explanation for two points. It is not proven that using T4 CAUSES osteoporosis. It is clear to me that all bisphosphonates are dangerous.

The Effect of Levothyroxine Therapy on Bone Mineral Density: A Systematic Review of the Literature. R. Schneider, C. Reiners Clinic for Nuclear Medicine, University of Würzburg, Würzburg, Germany. Published in  Exp Clin Endocrinol Diabetes 2003; 111: 455-470 DOI: 10.1055/s-2003-44704

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