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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 4
| Issue : 2 | Page : 94-97 |
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Impact of taking thyroxine with herbal brews
George Thomas1, Anulekha Mary John2, Jibily Joy2, Sherin Sarah Mathew2, Alice David3
1 Department of ENT, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
2 Department of Endocrinology, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
3 Department of Medical Research, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| Date of Submission | 24-Sep-2018 |
| Date of Acceptance | 23-Oct-2018 |
| Date of Web Publication | 13-Dec-2018 |
Correspondence Address:
Anulekha Mary John
Department of Endocrinology, Believers Church Medical College Hospital, Thiruvalla - 689 103, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcrsm.jcrsm_32_18
Background/Objectives: Herbal brews other than tea/coffee are becoming popular. We observed that these interfered with absorption of thyroxine. Since no prior studies have examined this, we sought to estimate this interaction effect, if any.
Materials and Methods: This study was conducted among outpatients of a tertiary care hospital in India. Patients on thyroxine replacement were interviewed regarding the drink used with thyroxine. Various herbal brews used were compared against plain water. Thyroid-stimulating hormone was measured and compared.
Results: Total of 121 patients fulfilled the inclusion and exclusion criteria, and 69 (57.0%) patients among them took thyroxine with a herbal brew. Various herbal products included cutch-tree (Karingali) 26 (37.7%), herbal mixture (Dahashamini) 28 (40.6%), and others 15 (21.7%). Risk of not achieving euthyroidism with any herbal brew was 7.6 times high (odds ratio [OR] 7·6 with 95% confidence interval [CI]: 3·1–18·5) as against plain water and was the highest for cutch, OR 12.4 with 95% CI: 4.0–38.0.
Conclusions: Several patients take thyroxine with water brewed with herbal products. Effectiveness of thyroxine was greatly reduced when taken with herbal brews.
Keywords: Cutch, herbal brew, Karingali, thyroxine absorption, uncontrolled hypothyroidism
How to cite this article:
Thomas G, John AM, Joy J, Mathew SS, David A. Impact of taking thyroxine with herbal brews. J Curr Res Sci Med 2018;4:94-7 |
| Introduction | |  |
The thyroid gland located at the base of the neck manufactures hormones that regulate the body's metabolism. There are several different disorders that can arise when the thyroid produces too much (hyperthyroidism) or not enough (hypothyroidism) hormones. These disorders are very common worldwide. In India, there is a significant burden of thyroid disease. A recent report showed that 300 million people in the world are suffering from thyroid disorders and among them, about 42 million people reside in India.[1]
Hypothyroidism is a very common endocrine disorder, and thyroxine is widely used for the replacement of endogenous hormone in hypothyroidism. After oral administration, approximately 70%–80% of thyroxine is absorbed.[2] However, it was observed that several patients did not achieve euthyroid status despite taking an adequate dose of thyroxine, a typical replacement dose of thyroxine being 1.6 mcg/kg of ideal body weight for healthy adults.[3] On further probing, we found that many of them took their thyroxine with water brewed with a herbal product. In India, especially in Kerala, it is common practice to drink water in which these herbs are brewed, rather than plain water. Very often the two are not considered different and are both referred to as “water” colloquially. In clinical practice too, we found that when our patients say they take thyroxine with water, often they mean water brewed with herbs.
Although it is well established that milk, tea, and coffee reduce or delay the absorption of thyroxine,[4],[5] there is no record of the effect herbal brews have on thyroxine absorption. Hence, we sought to study the hypothesis that there is an interaction effect between thyroxine and these herbal brews and to estimate the effect these brews had on thyroxine. Thus, the objectives were
- To find out if there is an interaction effect between thyroxine and herbal brews
- To estimate the effect of herbal brews on thyroxine.
| Materials and Methods | | |
After the study proposal was designed, it was presented before the Institutional Review Board, Believers Church Medical College Hospital, and the Ethical Committee (Institutional Ethics Committee [Regn. No: ECR/1098/Inst/KL/2018], Believers Church Medical College Hospital, Kerala, India) for approval. The study was commenced after obtaining approval from the above authorities. STROBE criteria for observational case–control study were used. The study was done during the period from February to August 2017. Healthy adult outpatients with primary hypothyroidism were selected. They were ambulant and were on adequate dose of thyroxine according to ideal body weight. All selected patients were regular and compliant with thyroxine intake. Those with any condition which could possibly alter thyroxine requirement or absorption, such as thyroid malignancy, pregnancy, sick euthyroid status, subclinical hypothyroidism, central hypothyroidism, and surgeries; serious comorbid illness such as gastrointestinal disorders, malabsorption, and hepatic, renal, or cardiac impairment; and psychiatric illness, that could possibly interfere with requirement or absorption of thyroxine, and those on concomitant medication such as cholestyramine, sucralfate, calcium, iron, and aluminium hydroxide which have been shown to reduce its absorption[2] were excluded from the study. Patients, who fulfilled the inclusion criteria, were selected. Consent was obtained from each patient or subject after full explanation of the purpose and nature of all procedures used. All patients were interviewed in detail about the type of drink taken with thyroxine, timing, compliance, and dose of thyroxine. History of hypothyroidism and anthropometric details was taken. Thyroid function test (immunochemiluminometric assay) was performed in all patients. Those who did not maintain at least 30 min gap between medication and first drink or meal were excluded from the study. All details were entered into a pro forma.
Statistical methods
Potential risk factors to achieving euthyroidism were examined using mean, standard deviation, and proportions. Considering thyroxine taken with plain water as a reference, the odds of not achieving euthyroidism with 95% confidence interval was calculated for those who took thyroxine with herbal brew. Comparison of different herbal brews was also performed.
| Results | | |
There were 169 patients who fulfilled the selection criteria during the study period. However, only 121 had maintaned an adequate time gap before the next meal or drink. Of these, a total of 69 (57.0%) patients took thyroxine with herbal brew. They were further distributed as 26 (37.7%) who took thyroxine with cutch tree (Karingali), 28 (40.6%) with the herbal mixture (Dahashamini), and 15 (21.7%) with other herbs.
Mean ± standard deviation (SD) thyroid-stimulating hormone (TSH) of those who had achieved euthyroidism was 2.5 ± 1.5 μIU/ml. However, in those whom euthyroidism was not achieved, the mean ± SD of TSH was 19.7 ± 27.4 μIU/ml which was much higher, with wide variation. The dose of thyroxine too varied accordingly, with 80.7 ± 22.0 mcg for those in whom hypothyroidism was controlled, and 105.4 ± 42.6 mcg for those whom it was not.
Other potential risk factors for not achieving euthyroidism (summarized in [Table 1]) did not show statistically significant differences between the two groups. The proportion of men was low. More than two-thirds of the participants were obese in each group, and cause of hypothyroidism was autoimmune thyroid disease in more than 50% of patients in each group. There were no other differences between these groups other than the fact that most patients consumed thyroxine with a brewed herb in the group that did not achieve euthyroidism with the standard dose.
Overall, the risk of not achieving euthyroidism for those who took thyroxine with any herbal brew was 7.6 times as high (odds ratio [OR] 95% confidence interval [CI]: 7.6 [3.1–18.5]) as those who took it with plain water [Table 2].
A gradient in risk of not achieving euthyroidism was seen with the various types of herbal brews. On the top of the gradient was cutch tree (Karingali) that showed a very high risk of not achieving euthyroidism. The risk was 12.4 times higher (OR [95% CI]: 12.4 [4.0–38.0]) than those who took with plain water.
| Discussion | | |
Herbal products are becoming more and more available these days and are easily accepted by the public due to the various claims of “magical” nonchemical, natural cure advertised in the mass media. Several of these products are available through online shopping portals. In an era when scientific research and meticulous drug trials are needed before a new drug can be marketed, advertisers of natural remedies require no legal approval and hold no responsibilities. The advertisements of several natural products claim to have a miracle cure and preventive action against even lifestyle diseases. Some of the herbal preparations that are described in this study are considered so. Moreover, since these herbal products are believed to be “devoid of adverse effects,” the doses at which they are taken are much higher than what is recommended by the packet inserts.
The most common brew is made of dried and powdered core of wood, flower, or tender stem of cutch tree,[6] called Karingali, in Malayalam, the native language. Another common herbal preparation available commercially is a mixture of several natural products. Cutch tree or Karingali is also a part of this preparation called “Dhahashamini.” Other ingredients include the following: Bark and seeds of Sappan wood,[7] also known as, Indian redwood, referred to as Pathimugham; leaves and seeds of Basil,[8] also known as Sacred Basil or Holy Basil,and referred to as Tulsi; Cumin seeds (Cuminum cyminum)[9] and related Black cumin (Bunium persicum), referred to as Jeera; dried flower buds of Cloves,[10] referred to as Grambu; seeds and leaves of Coriander,[11] referred to as Malli; roots of Vetiver,[12] commonly referred to as Ramacham, Khus, or Usirah; and seeds of Ajwain,[13] referred to as Ayamodhakam. Less common herbal brews include those that are made of only one or at most two of the following herbs: Basil, cumin, cloves, curry leaves, ajwain, coriander, green tea, guava leaves, and cinnamon was grouped as others.
It is intriguing to see that such innocuous habits of patients like brewing their drinking water with easily available herbs could cause such an impact on one's therapy. Cutch tree, which contains the active ingredient catechin, is very commonly brewed with drinking water in houses, restaurants, and at many social gatherings. Catechin is also found in the tea flavonoids.[14] This one product alone has 12.4 times higher risk of not achieving euthyroidism when compared to those who took with plain water. Whether this is because of interference with the absorption of thyroxine or if it has any other effect on the functioning of the thyroid gland is something that requires further study. Chandra et al.[14] have shown an effect of catechins on thyroid physiology in rat models and had shown that there was a decreased activity of thyroid peroxidase and 5'-deiodinase I enzymes. Decreased levels of serum T3 and T4 along with the significant elevation of TSH were noted in his study. In this study, catechin seems to have the highest impact on thyroxine. The effects seen could be related to thyroxine absorption alone, or there may be other effects on the thyroid hormone synthesis and action, which needs to be elucidated. There is also a need to see if catechin and related compounds are capable of inducing thyroid autoimmunity or block the hormone action at the receptor level.
It is interesting that though the herbal mix also contains cutch tree products, the risk of not achieving euthyroidism is much lower at only 6.9 times more than when taking thyroxine with plain water. It is highly likely that the other ingredients may be interacting with cutch tree product, and at least one of those ingredients may actually be beneficial.
The wide variation in risk, as observed by the wide confidence intervals, is probably due to the wide variation in the concentration of these brews. Since these herbs are usually homegrown, the dose at which they are taken varies widely. Even if a packaged version is used, they are taken at a much higher dose than is recommended on the packaging since they are considered “healthy.” It would also be interesting to study the effect of catechin at varying doses. Further animal studies may help to tease out the various questions this study has raised.
There are several dietary substances considered and proven to be goitrogens[15] by virtue of their antithyroid actions at several steps in thyroid hormone synthesis. Some substances such as soy products can also aggravate thyroid problems by reducing T4 absorption or interfering with thyroid hormone action or by increasing autoimmune thyroid disease.[16] Many a time the absorption of the drug becomes erratic and unpredictable when taken with other dietary or herbal substances. It is not easy or pleasant to give too many dietary restrictions to a patient. However, simple instructions such as taking thyroxine with plain water and the need to keep at least 30 min time gap before the next drink or meal can achieve euthyroidism at a more physiologic dose of thyroxine. Such instructions can avoid transient thyrotoxic symptoms related to high dose and the frustrations of erratic TSH values.
This study highlights the importance of patient education. Educating the patient is as important as prescribing the right medication. Even when thyroxine is consumed with plain water, if an appropriate time gap is not observed before the next drink, TSH may not get normalized.[17] Thus, looking at the effect of the various types of brews on time gap may also be relevant.
Further study is warranted to follow-up those patients who took herbal brew after changing the drink to plain water to see how the TSH improves and whether dose can be brought down.
| Conclusions | | |
In summary, this study has helped us to identify that herbal drinks are very common and that many of them interfere strongly with thyroxine absorption. When TSH is not adequately normalized as expected with the dose of thyroxine, the physician must probe into the drink that is taken along with the medication. Further studies to decipher the action of catechin compounds in cutch tree bark on the endocrine system and to examine the effect of changing the concomitant drink to plain water is required.
New Knowledge Added by this Study:
- Herbal drinks are replacing plain water in households
- The increasingly common practice of herbal brews can interfere with thyroxine absorption.
Implications for Clinical Practice or Policy:
- Patients must be advised to take thyroxine with plain water, on an empty stomach
- When TSH is not adequately controlled, an inquiry should be made about the concomitant drink.
Acknowledgments
All our patients and laboratory services of Believers Church Medical College Hospital (BCMCH), Dr. Pramod Thomas, Department of Biostatistics, BCMCH.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]
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