1. DR. AMAL MOHAMMED OBEID MD DIRECTOR OF TRAINING IN PROPHETIC MEDICAL CHAIR CLINICS Cupping therapy (hijama) and auto immune thyroid disease

2. Research team Dr. Amal M. obeid: prophetic clinics Prof Faiza Qary: endocrinology Dr Ahmad Ajamy: Radiology Dr M. Amine: medical statistics Prof Soad Jaoni: chair president Prof Sawsan Rohaim: chair vice presedent Ms Zakia Abdullsattar: senior nurse Mrs ofilia: laboratory

3. 1- THEORY. 2- OBJECTIVES. 3- METHOD. 4- OUT COMES. 5- CONCLUSION. Points to be discussed

4. Hashimoto thyroid disease Auto immune thyroid disease characterized by TPO: Thyroid peroxidase antibody TG: anti thyroglobulin antibody Resulting in lymphocytic infiltration of the thyroid gland which cause it to decrease its function partially or completely.

5. Normal thyroid gland Hashimoto thyroid disease histologically

6. Current medical management Thyroxin supplementation, life long treatment Prognosis Varying degrees of fibrosis and thyroid enlargement Risk of the developing other auto immune conditions Increased risk of thyroid lymphoma (rare).

7. THE EFFECT OF ADDING HIJAMA (CUPPING THERAPY) TO THE CURRENT MEDICAL MANAGEMENT OF PATIENTS WITH AUTO IMMUNE THYROID DISEASE. Study Objective

8. TO START WITH A SMALL PILOT STUDY AIMING FOR DESIGNING AN ACCURATE PLAN FOR A BIGGER STUDY plan

9. EVIDENCE BASED MEDICINE Why Hijama for hashimoto thyroiditis

10. Hashimoto pathogenesis Evidence based medecin Immune dysfunction Thyroid inflammation Hijama proofed +ve effect on non thyroid immune conditions (Ahmed SM et al) Proofed anti inflammatory effect of hijama (Mohammed Sharif et al ) theory

11. ACCORDING TO THE PATHOLOGICAL PROCESS Where to perform hijama

12. Pathologically (Chistiakov DA et al)

13. HYPER OR HYPO VASCULARITY +/- CERVICAL LYMPH NODE ENLARGEMENT Ultra sound

14. Where to place our cups Thyroid gland (for anti inflammatory effect) Enlarged LN as demonstrated by Ultra sound Sternum ( bone marrow stimulation)

15. study design Design: Case-control pilot study Data collection method: prospective Population: Hashimoto female patients > 19 and < 65 y/o, Setting: King Abdulaziz University Hospital Period: From 1/1/2014 to 1/6/2015

16. Study design Pilot interventional prospective study Total n=23 ( 9 intervention & 14 control) 9 patients referred by endocrinology department for hijama and each one was on the same dose of thyroxin through out the study. 13 patients were found from hospital filing system Ethical committee approval and patient consent forms were don.

17. Study groups N=23 Usual treatment + 3 Hijama same thyroxine dose Group 1 (intervention) n=9 Usual treatment ≈3 m. follow up Group 2 (control) N=14

18. Out comes of interest Primary outcome:- TPO & TG Thyroid anti body level Secondary outcomes:- TFT :- TSH, T4, T3. Prolactin, ESR Changes 2 qualitative Thyroid Ultra Sound Findings Clinical assessment

19. VASCULARITY: HYPO, HYPER, NORMAL SIZE:- REGULAR, ENLARGED ECHOGENICITY:- HETEROGENEOUS +/- CERVICAL LYMPH NODES ENLARGEMENT pathology in Ultrasound

20. hijama normalized the enlarged thyroid gland After hijama. Epi diameter (1.16mm) Before hijama Epi diameter (1.66mm)

21. Effect of Hijama on hyper vascular H.thyroid gland After Hijama Normal vascularity Before H. Hyper vascular thyroid

22. Hijama normalized hypo-vascular thyroid gland After hijama Normal vascularety Before Hijama Hypo- vascularety

23. hijama induces normal homogynousity in heterogynous thyroid gland After hijama More homogenized Before hijama Heterogynous

24. ultra sound changes with hijama Brings tissues back towards normal physiological status. Normalization of :- Size (thyroid and lymph node). Vascularity Homogeneous.

25. clinically All patients noted improvement in Menstruation regularity and amount Sleep pattern Energy level Constipation improvement Hair loss Psychological mode.

26. Results

27. Analytical plan Quantitative analysis: 1- (independent t-test); comparison of serum markers between hijama and control group, in both baseline and outcome 2- (paired t-test); Within-group comparison of serum markers between baseline and outcome in both hijama and control group separately: 3- Qualitative analysis: Ultrasound changes Clinical observation

28. Serum markers in Hijama group paired analysis (n=9) Before hijama After hijama P-value meanSDmeanSD prolactin284.21172.24181.4998.110.049 TPO99.76173.5236.1044.340.263 TG418.61358.73101.94121.000.013 ESR112.80197.6473.60131.640.256 TSH3.392.082.813.230.668

29. Serum markers in Hijama group: (paired analysis; n=9)

30. Compared TPO levels between the 2 groups independent T-test Hijama group n=8 Hijma group N=8 Control group n=9 Control group N=9 Control group N=9 P- value TPOmeanSDrangemeanSDrangeP- value Base line 99.76173.573.31- 515.00 29.81338.237.14- 1000 0.156 outcom e 36.1044.350.39- 119.40 397.76396.237.42- 1000 0.026* Stat. sign.

31. Evolution of TPO in the two groups T test Mann- whetney t test Significant reduction in TPO in the hijama group compared to control group

32. Results summary Independent t-test, non parametric Mann whitney U test:- No statistically significant difference between hijama and control group in base line TPO level. Statistically significant reduction in TPO level in the Hijama group compared to the control group.

33. Results Summary Quantitative data Statistically Significant improvement in:  TG (p=0.013)  Prolactin (p=0.049)  TPO reduction ( Mann whitney U) Limitations = small sample size. Qualitative data Improved radiologically and clinically

34. analysis conclusions Although not conclusive, preliminary data from this pilot study are presumptive of the efficacy of Hijama in reducing some biological markers including TPO, prolactin, TSH and TG, in patients afflicted with Hashimoto thyroiditis. However, a larger sample size is warranted to provide more powerful results and draw more solid conclusions.

35. 2 PATIENTS CONTINUED ON HIJAMA FOR 11 SESSIONS Plolonged hijama course

36. Clinical Observations Patient 1 Hijam a

37. Clinical Observations Patient 2 Hijam a

38. Clinical interpretation of data

39. 1-the Significant reduction in TPO antibody level, indicating Reduction in auto- immune process of the disease. 2- Significant reduction in TSH level on same dose of treatment, Indicating decrease in auto immune destruction of thyroid gland. 3- Ultrasound evidence of reduced inflammatory thyroiditis

40. conclusion The immune modulatory effect of hijama is promesing in preventing the development of other auto- immune conditions in the same patient. For the first time in English literature There is a good hope that hijama could cure auto immune thyroiditis and the patient might not need the life long medication.(thyroxin, or beta-blockers in gravis).

41. Future recommendations Bigger sample size Longer study duration Promising for auto immune thyroid disease Include gravis disease (high antibody and high T4 on B- blockers)

42. References Ahmed SM et al; immune modulatory effect of blood letting cuppng therapy in patients with rhumatoid arthritis; Egypt J immunol. 2005;12(2):39-51 Mohammed Sharif S. et al;evaluation of wet cupping treatment in patients with chronic articaria; The open conference journal, 2013,3,1-5 Chistiakov DA et al; immunogenesis of hashimoto thyroiditis; J auto immune diseaseMar;11;2(1)pubMed

43. THANK YOU وصلى الله غلى نبينا محمد وعلى اله و صحبه وسلم تسليما كثيرا