Questioning Incorrect Hypothyroid Diagnosis

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Intro:

Welcome to Dr. Ruscio radio providing practical and science-based solutions to feeling your best. To stay up to date on the latest topics as well as all of our prior episodes, please make sure to subscribe in your podcast player. For weekly updates, DrRuscio.com. The following discussion is for educational purposes only and is not intended to diagnose or treat any disease. Please do not apply any of this information without first speaking to your doctor. Now let’s head to the show. .

DrMichaelRuscio:

Hi everyone. Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio, and today we will go over a grab bag of different concepts, borrowed from various editions of our Future of Functional Medicine review, which thankfully seem to all fit together. We will showcase an American College of Gastroenterology monograph on the management of irritable bowel syndrome and constipation. This actually provides the most up to date “number needed to treat” comparison, looking at Rifaximin and probiotics. We’ll also touch on this paper we’ve discussed in the past from Dr. Satish Rao, a gastroenterologist who has been on the podcast, who I find to be an all around astute researcher and who’s work I generally appreciate. However, this one paper that claims that probiotics cause brain fog, really needs to be kind of reappraised. So we’ll talk about that again. We’ve discussed it on a previous listener question episode. We also go into a case study where an incorrect thyroid diagnosis was found, and we essentially proved this with a laboratory examination. The patient felt better coming off thyroid medication, even better with paleo low FODMAP and finally got the rest of the way there with a short course of herbal antimicrobials.

DrMR:

Before we begin, as a reminder, these are all showcased from various issues of our Future of Functional Medicine Review. If you sign up during the month of September, your first month of all access is only $1. If you go to drruscio.com/review, you can learn more and you can sign up. In short, this monthly paid access publication shares one case study and three to five research study reviews each month to arm you with not only the published evidence to become a better clinician, but also the case studies that tie together how to apply what one will learn in the published literature. Regarding those paper reviews, I attempt to give you everything salient about a given article broken down to the shortest, most concise bullet points so that you can, in three to five minutes capture, what would maybe take you 45 minutes to discern on your own.

Management of IBS and Chronic Idiopathic Constipation

DrMR:

Yep. So today then let’s jump in and let’s start with this monograph from the American College of Gastroenterology on the management of IBS and chronic idiopathic constipation. Now this was published in 2014, so it’s not necessarily super up to date, but it’s the most up to date paper that I’ve seen a side by side NNT (number needed to treat) for probiotics versus Rifaximin. Now the NNT is just one metric that evaluates the effectiveness of a given therapy. It’s how many patients need to be treated with a given intervention until one will see a notable response. So in this case, the NNT for probiotics is 7, for Rifaximin is 9. So even more evidence, and I think it speaks for itself. I often feel like I’m swimming against the tide where so many have misrepresented the information regarding probiotics and IBS and SIBO. I’m continually trying showcase the effectiveness of probiotics in this regard. So probiotics had a more favorable NNT then did Rifaximin. Now also full disclosure, we should be careful with comparing one treatment to another with the number needed to treat analysis. So I do want to acknowledge that. However, I also think it’s valuable to point out what we’re seeing here, even though the evidence hasn’t been in the studies, hasn’t been set up for a head to head comparison. We have discussed other studies that have done that and they found a similar thing, so I don’t feel this is in any way, twisting the facts, but I do want to disclose that number needed to treat from one therapy to another isn’t always an Apple to Apple comparison. Studies may differ in length of time and design and patient population. So just kind of your obligatory caution there. In looking at this table, it is very interesting to see that in the 23 trials in probiotics with 2,500 patients, there was an NNT seven. And in the five trials of 1800 patients for Rifaximin, there was an NNT of nine. Both of these had a quality of evidence that was considered low or moderate. Probiotics was low. Antibiotics were moderate. Again, this typically is a derivative of the size of the studies that comprise the recommendation. So again, in this case, we see the continued trend that the trial size for probiotics is smaller. In this case, 23 trials with 2,500 patients for the Rifaximin, five trials for for 1800 patients.

DrMR:

So important to keep that in mind. We should also keep in mind that the finding here was that the adverse events for Rifaximin as compared to probiotics and placebo were all about the same. That is important for two reasons. So the adverse events for probiotics, Rifaximin, and placebo, all approach, essentially zero. Why that matters is because some people will avoid Rifaximin, even though they should use this antibiotic for their IBS or for their SIBO, because they’re operating under the assumption or stereotype that all antibiotics are bad for you. That doesn’t seem to be the case, especially with Rifaximin being a non-absorbable antibiotic. The effects are localized predominantly to the small intestine. However, in the other direction supports that for those who say, well, my patients can’t take probiotics because the reactions that they have reactions. Again, the evidence doesn’t seem to support that either. So if you’re, if you’re someone who wants to only believe in drugs or wants to only believe in probiotics, this poses quite the challenge to you because it’s hard to be reconciled, unless you just realize that they’re both viable in my opinion. However, I do think it’s justifiable to start with probiotics before an antibiotic. Also from the same paper, and we’ll put the data tables in the newsletter again, if we can fit them, supplemental fiber outperformed prescription constipation treatments, like Oresalore (Prucalopride and Linzess). This is also important to mention, because we should at least have a therapeutic trial if we are someone with constipated type IBS. We want to be a little bit careful because the fiber can lead to, in some people, worsening of the constipation or an exacerbation of bloating, but that’s not guaranteed to be the case.

DrMR:

So it is something to consider. In some cases we may want to wait until we’ve gotten someone out of the acute phase, or we’ve gotten someone past the point where they have a high degree of symptoms that may increase the probability that someone will not react to fiber. That’s more my clinical observation than anything there that I know of being published, although there may be a remnant from the inflammatory bowel disease literature, where those who are in remission are less prone to flare from fiber than those who are active. So it’s a parallel analogy, but it still kind of reinforces the thinking that fiber can be helpful. The more active someone’s condition is, the more cautious we may want to be with fiber. Now, if someone just has constipation and little to no other symptoms like gas or bloating or abdominal pain, that also increases the rationale and the likelihood that they’ll be able to tolerate that fiber without any problem.

DrMR:

Just one more data point here. Again, hopefully my attempt at reporting these things as neutrally and objectively as possible is helping you to see where I am coming from. I don’t like the term opinion because there’s what the evidence shows and there’s what the evidence doesn’t show. In this case, multiple data points showing a proximal effect of probiotics to Rifaximin. So with all these data points, it’s just hard to understand why probiotics are sometimes shied away from, for IBS or for SIBO.

When the Conclusion Doesn’t Match the Data

DrMR:

Then there is, unfortunately, this paper by Dr. Satish Rao. I really like most of his work, but this was one that I feel like was really off the mark. I think there was a hypothesis where I feel like they were trying to back in the data to fit the hypothesis. In this case, I don’t think the data actually support the hypothesis and I’m not the only one who’s come to this conclusion. I’ll show you some published retorts to the Satish Rao paper in a moment. The paper is entitled “Brain Fogginess, Gas and Bloating: A Link between SIBO, Probiotics and Metabolic Acidosis”.

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DrMR:

So this paper got a lot of media attention, but unfortunately, as we will go through, I think the conclusion was exciting, but not really what the data supported. Unfortunately, when a conclusion is alluring, people will run with that and they will not bridle themselves if the underlying facts don’t support the conclusion. So 30% of brain fog patients had SIBO, but what’s left out of the narrative here is that 90% of the brain fog patients had digestive symptoms. So actually what tracked more with brain fog was the GI symptoms, not the SIBO. But that’s not as attractive of a hypothesis. Rao also makes a false conflation stating that all those with brain fog were taking probiotics. This is true, but only one third of the patients taking probiotics had SIBO. So again, making the claim that probiotics cause SIBO and that causes brain fog, is not true in two thirds of the cases. Two thirds of the cases where they were taking probiotics had no SIBO, but had brain fog. So are you starting to see like why I take issue with this study? So 90% of the brain fog patients had GI symptoms. Likely what’s going on here is the gut brain connection, not necessarily the probiotics causing SIBO connection. Now my suspicion here is even further reinforced when we know that there is data showing that probiotics can clear this condition known as DL lactic acidosis. So when Rao says probiotics cause SIBO causes brain fog, there’s actually this intermediary step, that he has documented in some patients, which is interesting. That is small intestinal overgrowth can lead to high levels of D and L lactic acid and that can cause brain fog. However, here’s why I think that the data were kind of contorted to fit the hypothesis, we have data showing that probiotics can treat D-lactic acidosis. If you’re looking at the writeup of this, there are three studies that I’ll link to. So for all these reasons, this paper really felt like it was reaching to support a conclusion Rao already had in his head and not report on the data objectively. There was also a published rebuttal, I’ll link to this also, entitled “Brain Fogginess and D-Lactic Acidosis: Probiotics are Not the Cause”. This was a pretty pointed retort. Just to quote, and this this appeared in Pub Med also, “In their recent study Rao and colleagues incriminated probiotics in the induction of D-lactic acidosis, thereby causing such symptoms as brain fogginess, abdominal pain and bloating. This report has been picked up by dozens of media outlets from Newsweek to psychology today, and has the potential to portray probiotics, products that are safely consumed by millions around the world, in a negative light. Many benefit from probiotics and could be frightened on the basis of this report, into stopping them with potentially negative impacts on their health. For these reasons, the study deserves careful scrutiny. The problems with this paper are first signaled by the very title of the piece where the authors conflate two separate entities, probiotics, and small bacterial overgrowth, and in, so doing give the impression that they were equally culpable in the pathogenesis of their patient’s symptoms. No evidence is provided to support this”.

DrMR:

So I’ll end the quote there, but you know, I’m not the only one who read this paper and said this seems like a reach. So on a prior listener questions episode, we address this. In this newsletter, I give you a little bit fuller of a writeup, but those are kind of the main takeaways. So remember, these are the sorts of things that we’re compiling in the Future of Functional Medicine Review clinical newsletter. So that clinicians are essentially getting the straight talk on these issues. The amount of patients I am seen in the clinic who experience improvements in their neurological symptoms from probiotics is fairly high. To stop all those patients from using probiotics would be a real travesty. I mean, as the rebuttal author has already stated. So I do feel these are important studies that we’re showcasing in the review that will help lead and guide patients down the most accurate path.

Incorrect Hypothyroid Diagnosis

DrMR:

This ties into the case study. Again, I always find the narration of these case studies to be challenging because I don’t want to bore you with every detail, but I do want to showcase some of the high points. This case study was entitled “Incorrect Hypothyroid Diagnosis, Gut Health was the Cause of Symptoms”. Unlike the other case studies that we’ve showcased throughout the month of September here, this was a patient that I saw directly. So where to start? The patient was a 43 year old female previous diagnosis hypothyroid, but I put in parentheses in my notes, by a functional medicine doctor. So clinical tip here, in our paperwork, if someone is hypothyroid, I now ask who made the diagnosis and I give a few options, conventional endocrinologist, family practice doctor, integrative medical doctor, functional doctor, naturopath. I’m not trying to incriminate any one of these groups, but there is definitely a trend in those who are outside of the conventional model, as they tend to have a fairly high suffrage rate of this false hypothyroid diagnosis. In 1985 she was diagnosed with hives, 2000 with idiopathic thrombocytopenia, and in 2015, Hashimoto’s hypothyroidism, adrenal fatigue, leaky gut. So, you know, we get out into functional medicine, we just see a bunch of diagnoses being kind of doled out there. So her prescription was NP thyroid and low dose naltrexone. Chief complaints, even though she was being treated for her “hypothyroid”, were fatigue, insomnia with warmth, can’t lose weight, brain fog, bloating, and anxiety. She also had a pulsing feeling in the abdomen. One of the things that I’m paying attention to, I can’t say I’ve seen enough of these cases to be able to decide if this is a viable trend or not, but fatigue and insomnia and anxiety, these are symptoms that are known to occur in those who have hyper thyroidism and could also happen in those who are being put on thyroid medication who don’t need it. So I’m paying more attention to this, it could be my bias importing itself, knowing that those are symptoms that occur in hypothyroidism. However, it is also possible that in some of these cases, the fatigue, insomnia and anxiety are being driven by being put on a thyroid hormone that that one does not need.

DrMR:

My initial impression of Amy. She is a 43 year old female on a paleo like diet with a good demeanor, a healthy outlook and lifestyle. We’ve covered her diagnoses. Her previous testing showed TPO 250. So that’s actually a pretty good TPO antibody. We have discussed that 500 might be a viable cutoff point to know when there’s cause for concern and not. Here is another indication that she might be on a medication she does not need. In her previous testing from her last doctor, she had low TSH which probably tells you she’s taking too much thyroid hormone. Again, that kind of strengthens the fact that the insomnia, fatigue, and anxiety may be a derivative of being overdosed. Her ferritin was 34, which we know that can also correlate with fatigue. Okay. She had responded previously to paleo and paleo low FODMAP. She had seen a slight help previously from herbal antimicrobials and from Rifaxamin. She noted no improvement when starting on the third medication and no improvement when starting on probiotics.

DrMR:

So this is likely a gut dysbiosis case, potentially paired with histamine intolerance and also she might be reacting to presumably unneeded thyroid medication. I had some notes in my writeup that I want to share here. Are you seeing how all of this fits together to support an incorrect thyroid diagnosis? The functional medicine doctor made the diagnosis, which, unfortunately, raises suspicion. Also no family history of hypothyroid and no improvements from thyroid medication. So this puts me at a suspicion level of extremely high. We continue forward to her follow up visit a few days later, where we lay out all of the recommendations. I asked her to send the labs that diagnosed her as hypothyroid, and I gave her a optional SIBO breath test and an optional Doctor’s Data stool test. As we have discussed, I’m a bit more kind of light handed on some of these testing recommendations, knowing there are so much that we can do within the gut health algorithm that doesn’t change much, at least out of the gate, by the results of lab testing. The rationale here is let’s double check her hypothyroid diagnosis and give her an optional testing protocol for her GI health. Regarding the therapeutic recommendations, we had her go back onto the paleo low FODMAP, but we also asked her to perform a one week trial on the low histamine diet and to continue to generally restrict histamine if she found it helpful and not to worry about it if she didn’t. Some of those details are really important because sometimes you can tell someone to do a dietary trial and they say, “well, I just, I stayed on the additional restrictions even though I didn’t notice any benefit, it couldn’t hurt”. Actually it can hurt, right? Those things can hurt because they can actually lead people into a little bit of dietary neuroticism or under eating. We put her on an iron supplement, given the lower ferritin. It wasn’t flagged low, but was suboptimal. Vitamin D with K, a multivitamin, and fish oil. She had noted that probiotics had not helped her prior. Now I go a level further and I ask if they have used the three different probiotics in conjunction like I advocate for. If they have not, I started there. So like we’ve been discussing at the clinic, we’re continually refining the model based upon observation with patients to try to be as precise as we can, because that’s not something that we want to miss. We’ve gotten even more atuned with our intake process to clarify and be granular and ask have you used the 3-for-BALANCE, or a three category probiotic together? Because if someone says minimal or no response to that, there’s no need to revisit it.

DrMR:

But if someone’s only done a probiotic haphazardly, then we do want to start with the evaluation of the three different types in synergy. In her case, given her treatment history, we omitted the probiotics and went right onto the herbal antimicrobials. We did stagger the initiation. So another kind of clinical tip don’t start multiple lines of therapy at once. Don’t have her go paleo low FODMAP, low histamine, and on the herbal antimicrobials. Because when you follow up, you will most likely get a “yeah, I feel better”. But what we really want to know is “I really noticed an improvement on the low histamine and then I saw an equal amount of improvement from the microbials” or perhaps, “I noticed nothing on low histamine and I only improve what I went on the anti-microbials”. So the staggering here does help the clinician tease apart cause and effect so that we can be on a minimal intervention, not a maximum intervention. Follow up seven weeks later.

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Patient Stops Meds and Feels Fine

DrMR:

Even though I never advise anyone to take themselves off a medication in kind of a self dictated manner, she decided to stop using her thyroid medication and reported she felt fine doing so. The paleo low FODMAP is helping her GI. The low histamine did not help. And the antimicrobials you concluded might help. In terms of her symptoms improved were fatigue, insomnia, brain fog, anxiety, bloating, menstrual pain, and her weight gain. Nothing was the same. Constipation was a little bit worse, which you sometimes will see with low FODMAP. So overall we’ve kind of hit the nail on the head with this out of the gate. Looking at her Doctor’s Data test, she had three types of commensals that were overgrown, alpha hemolytic strep, gamma hemolytic strep, and Klebsiella pneumonia. To tell you the truth, I don’t tend to scoff at those too much. Otherwise her profile came back normal, including functional markers normal and all of the parasitology. The SIBO breath test she did not perform. When we looked at the labs that diagnosed hypothyroid, her TSH was 3.5, which is in the normal range and her free T4 was 1.0, also in the normal range. So this is just one more example of the fictitious hypothyroid diagnosis. It is not helping patients when we tell them that if your TSH isn’t below or at 2.5 you’re hypothyroid, that is aggregiously irresponsible.

DrMR:

In my mind tantamount to malpractice. It’s frustrating because I see at least one case of this a week, if not almost one case of this a day. We’ve discussed some of the papers that have been published that support my contention, probably the best paper was from a University of Athens study that found 60% of the patients they assessed were actually not hypothyroid. We are not helping patients by proclaiming all of their symptoms are being caused by thyroid and then manipulating the ranges to make everyone fit into the new diagnostic criteria for hypothyroid. That can lead people away from what’s actually causing their problem. In this case, it’s not a surprise that the individual felt no different when stopping her thyroid hormone medication and who knows, maybe that is part of the reason why her fatigue, insomnia, and anxiety got better. It can also be due to the improvements in our gut health. So I don’t want to over attribute to the thyroid medication cessation, what may have been caused from the gut, but it’s also possible that discontinuing the unneeded thyroid medication, which was suppressing her TSH to an abnormally low level was actually not working in her favor. So at this point, my impression is that the paleo low FODMAP and herbal antimicrobials have led to pretty much all chief complaints improving today. She was not responsive to low histamine prior labs show. She was not hypothyroid and currently has mild bacterial dysbiosis. We will continue our current plan and add a little bit of magnesium. And my clinical note here is this is madness due to the thyroid. So those are our chains. We follow up about a month later and she noted that the second month of herbal antimicrobials was helpfu and she maintained all of her improvements even after stopping them. Clinical tip, I usually follow up three to four weeks after someone ends anti-microbials cause I want to see what their trajectory is after stopping antimicrobial therapy. If I follow up three days later and they say they’re improved, that’s all fine and good, but I really want to know, do you maintain the improvements from the antimicrobials weeks afterwards? Are you improving more or are you regressing? Now myself and all the doctors at the clinic are changing our followup intervals to assure that we follow up at the most opportune time. She also underwent a FODMAP re-introduction. This is one of the other recommendations. Again, I don’t go through every detail here, but in accord with my philosophy I always want to get someone on the minimal amount of supplements and the broadest possible diet.

DrMR:

The FODMAP reintro went okay, but she can also tell that too much aggravates her symptoms. She’s finding where her boundaries are. The magnesium citrate was slightly helpful. So for this visit, everything was improved, including the weight gain. Fatigue, insomnia, brain fog, anxiety, bloating, menstrual pain, weight gain, and constipation were all improved. Nothing is the same. Nothing is worse. Overall Amy is happy with where she is. All chief complaints improved and we will maintain this plan and retest her thyroid and ferritin and then follow up. We did a ferritin retest, a retest of TSH, TPO and Free T4. Made a couple of little remarks, small tweaks, then we moved forward to her next visit a number of weeks later. She has maintained all of her improvements. Her ferritin has come up five points, so not a lot, but it’s moving in the right direction, so we will coast on that for awhile. Now this is important. Her TSH was 5.2, her Free T4 and her Free T3 were normal. So this is where evidence is really important. There are some who may really freak out with the TSH being slightly elevated, but in a younger woman like this, that is not considered to be abnormal. Now, if she was very young, if she was in her teens, then that may have been a problem, but at age 43, a mild elevation like that is really not considered abnormal. The majority of those cases will spontaneously remit. The data on what happens when we give patients with a mildly elevated TSH and normal Free T4 thyroid hormone clearly indicates there is no benefit unless they are very young, unless they are infertile and trying to get pregnant, or if their TSH is above 10.

Don’t Believe the Thyroid Hype

DrMR:

It’s very important to mention that there may be a little bit of natural flux in some of these endocrine systems and it’s not a requirement to pave over someone’s hormones for the rest of their life with a thyroid medication. It’s really sad how that is the message that’s being portrayed out there. People are saying “Oh my gosh, you have fatigue, you have anxiety, you have constipation, all this is from your thyroid”. I know that it’s not according to the Lab Corp ranges, but the functional ranges are more narrow. That 3.5 that you had, even though it’s normal, it isn’t functionally normal and even though your Free T4 was normal, you’re hypothyroid and you need to be on medication. That’s just so irresponsible. I’m sorry, I’m not trying to take a dig here, but when you go and research some of these concepts, like who benefits from the thyroid medication in the subclinical hypothyroid camp, you have your answer. So you really have to be ignoring a fairly substantial body of science to get behind that. For any clinicians who are doing that, I’m sorry if I’m coming at that kind of aggressively. I do not think it’s any clinician’s fault. I think we have been taught an incorrect model regarding thyroid and we really need to reappraise it and pull it back. I would be open, I wouldn’t be very endorsing, but I would be open to reserving a trial on thyroid hormone medication for these individuals that have these subtle perturbations end phase, but not initial phase. So my impression: she is still feeling great. She stopped her thyroid hormone in may and retested about six weeks later. Her labs show mild subclinical hypothyroidism, TSH of 5.2 and normal Free T4 and Free T3. So we will continue with dietary expansion and supplement curtail, and that’s really it. We will monitor her and if she does drift into true hypothyroid, which she almost for certain won’t because that six to eight window was what was used in the study in Athens and that seemed to be more than adequate. But if she does drift into true hypothyroid we can address that. We know that what her TPO antibodies being 250, she is at minimal risk. Remember we discussed the Tehran prospective follow up study where 9-19% of patients converted to hypothyroid. Being at 250, knowing that’s minimal risk, she may have a 9-10% risk. With everything else that she’s doing to improve her gut health, to using the vitamin D he is really putting herself ostensibly in the minimal risk category possible.

Episode Wrap-Up

DrMR:

Another case here where just subjectively looking at thyroid and making sure that that is handled appropriately, not dogmatically, may have alleviated the cause of her anxiety and her fatigue and her insomnia when paired with the appropriate therapeutics for her gut. It wasn’t very difficult to get this person off of medication that they didn’t need, devoid of thinking they have a disease when they don’t and remedy all of their symptoms. This is another reason why I’m just so passionate about what we’re doing at the clinic and these case studies that we’re sharing with you via the Future of Functional Medicine Review clinical newsletter. Remember that September is a promotional month for $1 you obtain all access. If you go to drruscio.com/Review, you can sign up. Otherwise I’m hoping that this is providing people a bit of an antidote to what I think is a really kind of runaway narrative regarding thyroid. I welcome questions and commentary on this. As you know, I do want to become involved in this discussion to try to steer things in the most constructive direction possible. This is an area that we will likely start publishing case studies in peer reviewed journals. We need to go through some of the hoop jumping to convert these into a peer reviewed case study submission format so that we can have even broader acceptance of these. In any case, many examples here of how things in SIBO and IBS can be handled better by having a more nuanced understanding of probiotics. Also how we don’t want to be too quick to assume there is a thyroid problem when the best objective data suggests that there is not. By using these things correctly, but not dogmatically, because in this case, prior response to probiotics was not there.

DrMR:

So we didn’t just use a probiotics because I spent so much time talking about probiotics. We still want to maintain a degree of objectivity. So in this case, given the history of non-responsiveness of probiotics, even though maybe we could have gotten the benefit from using the three in conjunction, we decided to omit that go and go to herbal antimicrobials while also rectifying some of the errors in the interpretation of thyroid. What do you know, just a few months later, and this person is on the right path. So again, hopefully this is helping. Remember about the promotion at drruscio.com/review and the new clinic with our expanded clinical team of doctors. We are now more able to help you with the difficult task of getting competent advice in the field. There are many very, very talented people out there, and I should probably do a better job of acknowledging that it’s just really sad, put yourself in my shoes where I see maybe one of these cases a day. I don’t know how it got this out of hand, but I’m trying to really sound the alarm bell here from my platform. Any case hope this has been helpful. And if it has, don’t forget about leaving us a review on iTunes, if you have not yet. Otherwise I will talk to you guys next time.

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