Chinese Medicine Management of Hyperthyroidism
By Professor Ni Qing
Guang anmen Hospital, China Academy of Chinese Medical Sciences, China
Compiled and Translated by Dr. Greta Young Jie De
Hyperthyroidism occurs due to excessive production of thyroid hormone by the thyroid gland. Signs and symptoms vary from person to person and may include irritability, muscle weakness, sleeping problems, a fast heartbeat, heat intolerance, diarrhoea, enlargement of the thyroid, hand tremor, sweating and weight loss. The commonest cause is Graves’ disease which accounts for between 50% and 80% of hyperthyroidism. Hyperthyroidism is under the scope of "Ying Bing" mainly attributed to emotional stress and improper diet resulting in qi stagnation, phlegm congelation blended with blood stasis and manifested as a nodule in the neck. Early onset is generally an excess pattern due to the liver and heart yin deficiency with hyperactive yang, and over time the disorder develops from excess to deficiency characterized by yin and qi deficiency.
Chinese medicine diagnosis can be based on the following: (1) Aversion to heat, sweating; heart palpitations, weight loss despite insatiable hunger; anxiety and getting angry easily; protruding eyes (proptosis) and other related-hyperthyroidism symptoms. (2) Laboratory test:Serum thyroid hormone as indicated by elevated T4 and T3 and a suppression of TSH. (3) MRI and radionuclide examination are helpful for the diagnosis and differential diagnosis of this disease.
(1) Yin Deficiency with Hyperactive Yang
Patients presenting with this syndrome may have any of the following features:discomfort of the neck or swollen eyes; aversion to heat, excessive sweating; anxiety and irritability; heart palpitations, heart vexation and insomnia; tremour of hands and tongue; frequent bowel movement; dark urination, red and parched tongue and a rapid and forceful pulse. This pattern is more prevalent with early onset of hyperthyroidism with the patient suffering from weight loss, enlarged thyroid, protruding eyes and increased heart rate of 90/min; Increased TT4; FT3, FT4 and decreased TSH and can be accompanied by abnormal liver function tests with leukopenia.
(2) Liver and Kidney Yin Deficiency
Patients presenting with syndrome may have any of the following features: discomfort of neck and subjective feeling of swollen eyes, feverish sensation over the five centres, low grade fever, malar flush; chest and rib-side distended pain; weak and aching lumbar and knees; blurred vision, or male nocturnal emission and impotence for male and amenorrhoea for women; red tongue with scant tongue coating, and a wiry, thready and rapid pulse. This is a pattern associated mainly during dosage reduction of medication manifested as swollen thyroid and proptosis. Thyroid function tests: TT3; TT4, FT3; FT4 are in the normal range with low TSH. This can be accompanied by reduced WBC or anaemia.
(3) Qi and Yin Deficiency
Patients presenting with syndrome may have any of the following features: discomfort of neck and swollen eyes; fatigue, shortness of breath, no desire to talk; distended epigastrium and abdomen or poor appetite; dry and parched throat; vexation, thirst with desire to drink, spontaneous and nocturnal sweating, insomnia, forgetfulness; weak and achy lumbar and knees; vertigo, tinnitus; feverish sensation over the five centres; dry bowel; dark urination, atrophied tongue with dry and scant tongue coating and a deficient pulse. This is generally associated with the maintenance and treatment period characterized by swollen thyroid, proptosis with normal thyroid function. TR-Ab and TS-ab are positive.
Chinese Medicine Theory and Treatment Principle:
The onset of hyperthyroidism can be attributed to both interior and exterior factors with the interior factor due to congenital deficiency coupled with emotional stress, and the exterior factor due to an attack by pathogenic toxin resulting in the impaired functions of the heart, liver, spleen, kidney, qi and blood with ensuing pathological byproducts such as phlegm-damp, blood stasis, fire and wind. Thus, the pathology is a complex pattern of deficient root causes and excess symptoms. In terms of development of the disease, it can be differentiated as acute phase, remission phase and recovery phase. Treatment principle should incorporate herbs to regulate the immune system and to relieve inflammation. During the acute phase, treatment should integrate both western and Chinese medicines to fast track improvement of symptoms. During the remission phase treatment should also integrate western and Chinese medicines with an additional consideration of minimizing the side effects of western medication using Chinese medicine, whereas in the recovery phase, Chinese medicine is focused on consolidating the treatment efficacy.
Treatment Based on Syndrome Differentiation
(1) Yin Deficiency with Hyperactive Yang
Treatment principle: Nourish yin and sedate yang; transform phlegm and reduce the nodule (Ying)
Formula: E Jiao Ji Zi Huang Tang modified (Chong Ding Tong Shu Shang Han Lun).
E Jiao 10g; Ji Zi Huang 1 piece; Sheng Di 15g; Bai Shao 30g; Nu Zhen Zi 15g; Shou Wu 15g; Tian Ma 10g; Gou Teng 20g; Ye Jiao Teng 30g; Fu Ling 15g; Sheng Mu Li 30g (Decoct first); Zhe Bei Mu 15g; Shi Jue Ming 30g; Ling Ci Shi 15g (Decoct first); Zhi Gan Cao 6g.
For anxiety and being easily upset, add Long Dan Cao; Xia Ku Cao 15g;
For vertigo, add Bai Ji Li 15g;
For proptosis and redness in the eyes, add Cao Jue Ming 15g; Qing Xiang Zi 15g;
For enlarged thyroid (>11 degree), add Xia Ku Cao 30g; Xuan Shen 15g.
(2) Liver and Kidney Yin Deficiency
Treatment principle: Nourish and tonify the liver and kidney; transform phlegm and reduce nodules (Ying)
Formula: Chai Hu Jia Long Gu Mu Li Tang (Shang Han Lun) + Er Zhi Wan (Yi Fang Ji Jie) modified.
Chai Hu 10g; Bai Shao 30g; Nu Zhen Zi 15g; Han Lian Cao 15g; Sheng Long Gu 30g (Decoct first); Sheng Mu Li 30g (Decoct first); Yu Zhu 15g; Sang Shen 30g; Ling Ci Shi 15g (Decoct first); Zhi Gan Cao 6g.
For qi deficiency and fatigue, add Tai Zi Shen 30g; Sheng Huang Qi 15g;
For swollen thyroid (>II degree), add Bie Jia 15g; Xia Ku Cao 30g; Ju Ye 15g; For insomnia, add Chao Zao Ren 15g; Wu Wei Zi 10g; He Huang Pi 30g;
For heart palpitations, add Bai Zi Ren 15g; Gan Song 10g;
For nocturnal sweating, add Ye Jiao Teng 30g; Fu Xiao Mai 30g; Xian He Cao 15g;
For tremor, add Mu Gua 30g; San Qi Fen 6g (to be added to the decoction).
Patentformula: Xiao Yao Wan 3g, three times daily.
(3) Qi and Yin Deficiency
Treatment principle: Augment qi and nourish yin, transform phlegm and reduce nodules (Ying)
Formula: Sheng Mai San (Bei Ji Qian Jin Yao Fang) + Si Jun Zi Tang (Tai Ping Hui Min He Ji Ju Fang) modified.
Tai Zi Shen 30g; Sheng Huang Qi 15g; Mai Dong 10g; Wu Wei Zi 15g; Sheng Di 15g; Chai Bai Zhu 20g; Sheng Mu Li 30g (Decoct first); Xia Ku Cao 15g; Chen Pi 10g; Zhi Gan Cao 6g
For excessive sweating, add Fo Xiao Mai 30g; Bie Tao Gan (Dried peach) 15g;
For sloppy stool, omit Sheng Di, and add Chao Bian Dou 15g; Sheng Yi Ren 30g;
For thirst, add Wu Mei 15g; Tian Hua Fen 15g; Shi Hu 15g;
For heart vexation, add Bai He 15g; Chao Zhi Zi 15g;
For enlarged thyroid (>II degree), add Bai Jie Zi 15g; Zhe Bei Mu 30g.
Patent formula: Sheng Mai Capsule, 4 capsules three times daily.
TCM Treatment of Complications
- Proptosis: Gua Lou, Fu Ling, Bai Shao, Chuan Xiong improve the micro-circulation; Mu Li can improve blood circulation and is an effective herb to address proptosis; Dan Shen candilate the arterioles, increase the blood perfusion of the microcirculation, thereby reduce the microvascular resistance, and hence promote the blood circulation and improve the symptoms of hyperthyroidism. Bai Ji Li, Gou Teng and Zhen Zhu Mu can inhibit the hyperactivity of liver yang and target proptosis due to phlegm bind.
- Heart palpitations: Ren Shen, San Qi, Ku Shen, Shan Za, Bai Zi Ren and Suan Zao Ren can regulate cardiac arrhythmia thereby improving heart vexation and heart palpitations due to hyperthyroidism.
- Anxiety and irritability: Mu Li can heavily sedate and calm the heart shen and help reduce mood swing and emotional upset.
- Aversion to heat, and excessive sweating: Huang Qi can improve the immune system thereby reducing the sweating. Wu Wei Zi is sour and astringent and can also astringe sweating. Modern research has found that it can increase white blood cells and enhance the liver to expel toxin.
- Insomnia: Suan Zao Ren, Ye Jiao Teng, He Huan Pi and Bai Zi Ren nourish yin and calm the heart shen.
- Frequent bowel movements: This can be attributed to spleen qi deficiency and treatment principle is to augment qi and tonify the spleen. Fu Ling, Ze Xie, Shan Yao, Shi Liu Pi, Bai Pian Dou and Lian Zi Rou etc. may be used.
- Tremour: Use herbs to sedate the hyperactive liver and extinguish endogenous wind such as Gou Teng, Chan Tui, Mu Gua, Sheng Long Gu, Mu Li and Bie Jia etc.
- Elevated Transaminase: Long-term oral intake of anti-thyroid drugs may lead to liver damage. The severity of symptoms of liver damage in hyperthyroidism is closely related to thyroid hormone levels. Extract of Bai Shao can reduce serum levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) and restore liver cell functions. These actions have been demonstrated in animal studies in which serum concentrations of ALT and AST were reduced by glycoside of Bai Shao, thus providing liver protection. Similarly, Dang Gui can also reduce serum alanine and aspartate aminotransferases, and promote liver cell regeneration.
- Leukopenia: Hyperthyroidism combined with leukopenia are under the scope of “Deficient Detriment” in Chinese medicine. Clinical manifestations are dizziness, drowsiness, fatigue, etc., which are related to the side effects of anti-thyroid drugs. Ren Shen can enhance the immune function as well as having a significant effect on raising white blood cells which in turn can prevent leukopenia.
Benefit of Combining Chinese Medicine with Western Medication:
- It was found that the combined treatment can substantially improve symptoms associated with hyperthyroidism.
- Co-treatment with Chinese medicine reduces the effective dosage of western medication and side effects of western medication.
- Chinese medicine provides management of proptosis.
- Improvement of liver function: Chinese medicine can significantly lower the elevated blood levels of liver function enzymes.
- Combining Chinese medicine will shorten the course of treatment of the disease.