Gut-Thyroid and SIBO Case Studies

• Doctor’s Data
• Dr. Ruscio’s Additional Resources

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. It’s just me today flying solo, going through a few case studies. While it’s challenging to attempt to narrate a case study, because I’m trying to just pick and choose the tidbits that I think are the most instructional. I am excited to share them because so much of what we discuss from having a critical eye regarding research to being patient-centered, to being cost-effective, to being open-minded culminates in the outcome of a case study. Very excited to go through these with you. I just want to make sure to, again, mention that these case studies come from our monthly clinician’s newsletter, the Future of Functional Medicine Review. This is published monthly. It is paid access. It includes a case study and then usually three to five research study summaries. This allows you in just a few minutes to get all of the benefits and value from a research study that otherwise would probably take you 45 minutes to go through and kind of excise all of the valuable pearls. To make it easier for you to have a look at this newsletter and decide if it’s something that you feel would help you, for the month of September, if you sign up, your first month of “all access” will only be $1. That way you can go in, you can look at all the back issues, you can look at the most current issues, read around, and I’m sure that you’ll learn a lot from it. Hopefully, you will find it to be beneficial and then you will sign up and read this on a monthly basis. It will give you an ongoing exposure to the scientific cutting edge as we’re summarizing important research findings, but also case studies to continue to exemplify how we can help people with less time and less money. We can be quite savvy and smart with what we’re doing. It is not a dumbed-down model. Instead it is a very precise and effective model, but one that is not ensconced in hyperbolic, narrative around diet or reliant on wasteful or superfluous lab markers. So for the month of September, if you sign up your excess is just a $1 for the entire month.

Case Study 1: Unresolved IBS

DrMR:

So we’ll start off with a case study from the June 2020 issue. This is a case study by one of the doctors at Austin Functional Medicine. To kind of reiterate, I have recently moved from California to Austin and I’ve expanded the clinic and I’ve brought in a couple of doctors and these case studies are from those doctors. What this really substantiates is that, and maybe I shouldn’t say this, but what I do in the clinic isn’t really unique to me. It’s not really that special. That is actually a good thing. I say that in jest, but a good model, can really enable anyone to obtain pretty excellent patient outcomes. When I say excellent, I mean not only results, but also not making them afraid of food or spend a bunch of money that they don’t have to.

DrMR:

This case study is entitled: Hydrogen Sulfide, SIBO, and Improvement in Interstitial Cystitis by Treating the Basics. The case study opens with a 62 year old, menopausal female, who was treated unsuccessfully with conventional treatments for IBS. Her chief complaints included a number of things: constipation, bowel movement every other day, heartburn, being reliant on PPIs, bloating, diarrhea, abdominal pain, and chronic “sewer gas” in the gut with burps and flatulence. That’s part of where we see a presumption for hydrogen sulfide. Although it’s not definitive, it’s something that you may want to tuck away in the back of your brain when you hear things like that. Also had some urinary symptoms. The urge to urinate without any flow, bladder spasms and pain, dysuria. Also had some joint pain, some thumb, knee, and back pain, neurological migraines and brain fog. So a lot going on there. Again, she was conventionally treated for IBS without any help. I’m going to give you an overview on the initial recommendations for this patient. Paleo low FODMAP, the three categories of probiotics that we always talk about (lactobacillus/ bifidobacterium blend, a Saccharomyces boulardii and a soil-based probiotic). This is an important recommendation: more consistent usage of her CPAP machine. That is definitely one of the things that we ask in our paperwork at Austin Functional Medicine is about sleep diagnoses, sleep conditions, snoring, things like that. If someone has apnea and they’re not managing it, then that’s definitely something that could be a big needle mover. Additional recommendations included an enzyme acid combination, and an herbal laxative or Miralax depending on the patients preference.

DrMR:

Testing included a GI-MAP stool test and an Aerodiagnostics SIBO breath test. At the three week follow up there were improvements in the acid reflux, in the bowel regularity, in the interstitial cystitis and some of the urinary symptoms, and a loss of 12 pounds. All of this occurred just based upon some good old Paleo low FODMAP, three probiotics, using your CPAP, taking an enzyme and using herbal laxative. So far, really in a great shape. Now, when looking at the labs, the SIBO was negative. Again, this could further suggest hydrogen sulfide SIBO, although we should be careful because this is very presumptive. So we don’t want to get too swept up in this. It’s just something to consider. I wouldn’t recommend massively changing the way that you treat a patient based upon this or telling them that they have this thing that can’t be tested and is somewhat elusive because patients tend to glom onto these things. So we want to be very careful with how much of this thinking we share with them, knowing that patients have a tendency to revert to the worst possible interpretation of anything. That is probably good in terms of an instinct that we have to try and get ourselves well, but this tendency is something that the clinician has to understand so they don’t flippantly mention things that people then go look up on the internet and get much more carried away than the clinician would. The GI MAP found some dysbiotic growth and was otherwise unremarkable. So there were some staphylococcus aureus, some streptococcus species found and some Enterococcus Faecalis. Let me pause for just a second and ask my fellow clinicians, what is your takeaway here regarding testing? And I’ll give you a moment to think.

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Recommendations Case Study 1

DrMR:

I’m going to go over my recommendations first, then come back to my takeaway. So the recommendation at this point in time: Gradually expand your diet away from the low FODMAP, and we will undergo some herbal antimicrobial therapy. At the next followup, her symptoms continued to improve and she was now at about 90% better. The bloating and abdominal pain were gone, heartburn 75% better, having daily bowel movements, brain fog and memory way better. The interstitial cystitis 80% better. There was an additional comment that this would likely be even better if she gave up caffeine. She was able to come off Prilosec and Omeprazole.

Is Testing Always Necessary?

DrMR:

So coming back to the question about testing, what I learn and have learned from case studies like this is that presumably I think fairly tenably to argue, we could have done everything that we did with this patient without any lab testing. Right? All we saw was some dysbiotic bacterial growth on a GI MAP, which in my opinion is not very informative. We can presume that some type of commensal disruption or dysbiosis is going to be present in a good subset of people with gastrointestinal symptoms. Maybe even in those without if it’s silent in the gut and only manifesting outside of the gut, extra intestinally. Do we need to have lab work to use herbal antimicrobials? No. Do we need to have lab work to use Rifaximin? Not according to the FDA. Not to say I love everything the FDA does, but they’re certainly not getting behind a position without due evidence to support it. So this is the case where we probably didn’t even need to use the testing. Is it wrong to do it? No. These things can be helpful. But the point I’m trying to make is if you have someone in front of you who is on a budget and they’ve already spent a few hundred dollars to see you, and they’re already spending the additional few hundred dollars on supplements, these lab tests add up. $200 here, $400 there, a retest, maybe, especially for someone who’s doing serial retesting, even though that seems somewhat archaic at this point for most things, not all. But I think for most of these GI markers, do you need to retest commensal dysbiosis? Probably not. I think it’s very hard to recommend that, especially knowing that the related price tag of maybe 3- to 4- to $500. So that’s $400 and then $400 again and then maybe even $400 a third time that you save. So these things add up quite quickly, right? So that could be 800 to $1,200 saved. Again, this is built upon the presumption that the patient has a dysbiotic commensal. So you have pathogens and you have commensals in these two different columns. Pathogens are a different ball game, because those are pathogenic, they are harmful. Commensals they tend to be generally good, although if they get in the right environment, they may be a little bit disruptive. They are kind of a gray area. So we don’t really need to do a strict accounting of what’s going on in the gut from that perspective. So the main point I want to just showcase here, again, this person did great with some simple, foundational supports, Paleo low FODMAP, enzymes, probiotics, using her C-PAP and then an escalation herbal antimicrobials. Labs along the way were interesting, but may not have been needed. These are things that we legitimately look at at the clinic to make sure we’re interrogating our model from all sides. To make sure that we always have a clinical model that is the most effective and is the most patient centered, meaning we’re not going to have anyone do a treatment longer than they need to, a diet more strictly than the need to, or to perform testing that they don’t need. This has a sizeable impact on the quality of care.

Case Study: Non-Responsive Hypothyroid

DrMR:

This is evidenced by the next case study that I’d like to share. This comes from August, 2020. This case study is entitled: Hypothyroid Case Did Not Respond to Levothyroxin, Did Not Require Combination Therapy, GI Support Resolved Symptoms. To define, “combination therapy” is referencing T4+T3 therapy like Armor, or Nature-Throid or WP Thyroid. So this is a crucially important case. I’m going to go into a little more detail because, handled incorrectly, this person, Monica, a 36 year old female could spend months or years wasting money and being subjected to medication changes that she doesn’t need. Her previous diagnosis was hypothyroid. She was on levothyroxin. Chief complaints: fatigue, bloating, weight gain, constipation, dry skin, and feeling cold. One of the things that I think is important and we have been doing for a while in the clinic is an “other symptoms category”. Because patients often decide what symptoms they think apply to the issue I am seeing them for. Initially she didn’t mention her PMS, her pelvic pain and her depression and brain fog that correlate with their cycles. But as part of our “other symptoms” category, these came up. That’s really important to note because, we’ll come to this little bit later, but it’s important to be in the lookout for other things that cause what one is assuming are being driven by thyroid. In this case, female hormones may have been the issue or one of the issues, so we want to pick all those things out.

DrMR:

Recommendations Case Study 2

DrMR:

In the initial recommendations we ordered a fairly basic blood panel, but I did, in this panel run, and this comes back to something we’ve been chronicling in the Future of Functional Medicine Review clinical newsletter, a more sensitive measure of free T4 and free T3. This is known as the dialysis liquid chromatography with mass spectrometry. Essentially this is more accurate than the other more standard methodology (the immuno assay), because it filters out proteins that may confound the levels. Why this matters is if she has not been responding to Levothyroxine it’s possible that her T4 levels are not where they should be. That may be dictating her lack of response. Said even more plainly, you run this more sensitive methodolog if you’re thinking the TSH is normal, but something may be confounding the read on your T4. You may see an actual low T4 when you use this more sensitive methodology. If that was the case, that would be helpful to know.

DrMR:

There are holes you could poke in that theory, but it is at least attempting to be as responsible as possible with measuring thyroid hormone before just proclaiming, “You need a higher dose or you need a different medication”. We also did her thyroid antibodies and kind of tying to lessons learned from prior case studies, we left optional testing on the table. An Aerodiagnostics SIBO breath test and a Doctor’s Data stool test. We left them optional because we’re learning that we may not need these tests. They can be helpful, but if someone’s on a budget, knowing that that right there is about a $600 delta in price, I can’t seriously tell them, you must do this testing. The rationale there is basic GI workup, also checking for thyroid autoimmunity and we’re looking at the more sensitive measures of free T4 and free T3 so we can make a more tenable recommendation on her thyroid hormone medication, if that seems to be indicated. We’re having this individual start on a Paleo low FODMAP diet, and previously she was doing an OMAD or eating one meal per day. I made a note to continue doing that on most days, but try to eat two meals, two to three days per week, and to cut her coffee consumption in half. Other things I picked up during her intake were signs that her alostatic load may be too high, or she was a little bit burnt out, or she has “adrenal fatigue” which is, if I’m being really candid, a bogus diagnosis that we give people that haunts them forever and makes them afraid of food and drink and fun and caffeine. I think at this point it probably does more harm than it does good. Sorry, I’m being a little bit candid. But the last case study that we discussed from the prior podcast is a good example of how the otherwise healthy 62 year old male was made afraid of coffee and told to avoid it based upon bogus lab tests with no clinical indications that he had any kind of adrenal fatigue or stated more accurately, high alostatic load or burnout. We had her go on a multivitamin, a fish oil and vitamin D. Just good well-rounded nutritional support and we put her on all three probiotics plus a supplemental fiber.

DrMR:

Results

DrMR:

At the followup visit Paleo low-FODMAP was reported as being very helpful for bloating, fatigue and regularity. Wait a minute, I thought fatigue was only associated with thyroid. Of course, I’m saying that in jest, but it’s very much under appreciated that those with IBS or just digestive maladies also have that manifest as fatigue, or brain fog or mood lability. She found reducing coffee helpful as well. This was actually a case where reducing coffee consumption made sense. We didn’t say avoid coffee for six months ardently. We said reduce your, your coffee consumption based upon the good old fashioned method of reading the patient in front of you. Surprise, surprise, she found that recommendation helpful. Whereas the gentleman from the last case study, who was told to avoid coffee based upon a bogus lab, actually noticed no improvement at all. So this is part of the reason why I get a little bit passionate about these things. I do apologize for my passion. It’s hard just seeing time and time and time again, how patients are being given the wrong advice and it doesn’t have to be this hard. The probiotics and fiber she found helpful and she no longer needed Miralax. So that was great. We do know that fiber can help with regularity, although we have to be a little bit careful. So looking at her symptoms, improvements were noted in fatigue, bloating, constipation, her skin, her hormone symptoms and her clothes fit better. Her weight was the same and nothing was worse.

How to Handle Abnormal Results

DrMR:

Her TPO antibodies were 135. Now you probably know what I’m going to say here, which is the way that we handle this conversation could on the one hand subject someone to undue fear and fretting about their levels and tell them to go from gluten free to grain free and make sure there is no gluten in your toothpaste or your shampoo, and you’ll need to be on selenium for the rest of your life and yada yada yada. Or, we can have a more responsible, evidence-based narrative. For example, the best evidence to date suggests that TPO antibodies below 500 pose a minimal risk. It is also important to keep in mind that the one most carefully constructed study found that only 9 to 19% of patients with antibodies elevated, ever progressed to full blown hypothyroidism. Now, in this case, she was already diagnosed hypothyroid, but I would also share that with them just so they understand they have a recalibration of the importance or the gravity of TPO antibodies. What about her thyroid hormone levels? We talked about that. TSH was normal. Free T4 and Free T3 via the most sensitive methodology we’re normal. So it’s really hard to make a case for upping her dose or changing her medication. Her ferritin was 88, which,according to some work out of the Netherlands, a ferritin below 100 may be suboptimal, but I’m not going to jump on that. I’m going to wait and see, how does her fatigue look? Do we need to use iron supplementation for this ferritin that’s not optimal. Again, trying to stay in alignment with my own philosophy. Even though there’s some interesting evidence here that I vetted, regarding that Ferritin being below 100 could potentially be a problem, I’m not going to jump to, “Oh, you have this issue with ferritin and now we’ve got togo crazy with supplementation”. It’s something that we can think about and if I were to go back and do this case again today, I’d probably withhold the iron rather than recommending it. In this case, I gave kind of a soft recommendation that there is some preliminary evidence that has found that hypothyroid women who have Ferritin’s below 100 and are fatigued, may benefit from iron. In your case, your ferritin was 88, but your fatigue has improved, diminishing the likelihood that we need to use iron. Although if you wanted to, we could have you go on an iron supplement for a few months and reappraise. That’s a responsible way of handling that conversation.

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DrMR:

Continued Improvement

DrMR:

So we follow up a few months later to kind of assess how she’s doing. To clarify, no iron was given at that visit, but it’s coming. So at the next visit, when we follow up, she is seeing a regression if she deviates from the diet, mainly corn and gluten. Other foods seem to be okay, like cheese and other grains. Gluten might cause nerve pain. Still improved are her bloating, constipation, skin, weight, and her clothes fitting. But the following have regressed back to baseline, slight fatigue and female hormone symptoms, including PMS, cravings and headaches. Nothing has gotten worse. So the impression I have at this point in time, she continues to improve. However, fatigue and hormone symptoms are the least responsive. Gluten seems to cause neurological reactions. Today, we will start an iron. Because now we’ve made a better case for that and that’s why it’s just really important sometimes to wait and see and watch and wait. So we’ll start on the ferritin due to the fatigue and we’ll start on the female hormone supports given her symptoms. We will also bump her carbs up a little bit more because she has been noting as she’s been expanding her diet, she feels good on carbs. We will start the reintroduction of FODMAPs. So we’re doing pretty good, but just need some finishing touches. Side note for clinicians here, these finishing touches are much more apparent when you’re not overly treating the patient. Minimal treatment allows you to say, okay, these things that have improved have improved because of these couple therapies that we’ve been vectoring, but when things haven’t improved, it’s much easier to say, okay, now the things I’ve been withholding, but thinking about and building a case for, now they make sense. So this keeps you at that balance point of not over-treating anyone. So the recommendations today are to bring a bit more carbohydrate back into the diet. Gradually reintroduce FODMAPs, move more towards a regular Paleo like diet, be cautious with gluten. It may be best to strictly avoid this, given the pain reaction. So there you go. I’m not someone who scoffs at gluten free. There’s a time and a place. We just want to handle that conversation responsibly. So as not to make people afraid of gluten without any good reason. We started her on an iron supplement and we also started her on Estro Harmony and Progest Harmony our two herbal blends that help to balance female hormones. When following up a few months later, she suspects the iron supplement is helping her fatigue. The increased carbs, she feels is very satisfying and satiating. The female hormone supports, she feels has relieved her headaches, cravings, and PMS. The FODMAP reintroduction led to some bloating and some weight increase so she stayed a little bit more lower FODMAP. You know, to me, that is the best way to navigate the FODMAP re-intro. Let them discover where their boundary is through their own biofeedback. Looking at the symptoms, we see improved fatigue, bloating, constipation, her skin, PMS, cravings, headaches, brain fog, and depression. The same, her weight was a little bit up and down. She seems to be navigating that by personalizing her diet. Worse? Nothing. My clinical commentary here. Her symptoms, fatigue and constipation, namely could have easily been attributed to the thyroid. This provides a clear example of how we should start with basic thyroid hormone replacement and GI care, and then reevaluate.

DrMR:

She did great on Paleo low FODMAP and on probiotics. Then we found normality of her Free T4 and Free T3 via the most sensitive thyroid hormone measure, the dialysis with liquid chromatography and mass spectrometry. Remember that her thyroid levels may have even improved slightly as her absorption of the medication was improved as her gut became healthier. Finally a slight push to balance her female hormones with herbal supports and we saved this patient from months or even years of pursuing thyroid fine tuning. You know, there is a time and a place for that, but just make sure to follow the thyroid algorithm. This is also listed for providers once you’re in the Future of Functional Medicine Review log in area, you can look at the navigation menu and click right through to the thyroid algorithm. So we want to be really careful to engage in the thyroid medication fine tuning at the right time in the right place and this is something that we’ve learned from the case studies that we’ve been publishing here in the FFMR. You can go through all sorts of exercises and trying to optimize T4 alone, upping the dose of T4, adding in T3, switching over to a T4/T3 combination, going to Tirosint which is the liquid gel tab and never get someone feeling better. There is a time and a place for that, but we have to start with their gut health in tandem with just basic thyroid replacement. In this case, not just vacuously fall into assuming that all of the symptoms were thyroid when they clearly had a skew toward female hormones. It’s just so important. This is why, I admittedly harp on not getting obsessed with the labs. It is good to looking to the labs, but don’t forget the person sitting right in front of you. It would have been so easy to say, constipation, skin issues and fatigue and brain fog. It’s gotta be your thyroid. If you were looking at this in a very narrow minded way. But if you’re looking at this more broadly, it becomes pretty evident to say, Hmm, there’s also PMS and these symptoms tend to wax and wane with her cycle and she has an exacerbation of her GI symptoms when she’s menstruating. Sounds like there may be some female hormones and symptoms here and that those are not thyroid. So hopefully this is helpful again, sorry if I’m being a little bit preachy here, but it’s just disheartening seeing people suffer. I see that so often, it’s really unfortunate when someone comes in and they’ve spent thousands. I mean, just last week, someone saw a self proclaimed gut guru, did their program for $10,000 and felt worse the entire time.

DrMR:

I mean, this person, their entire lifetime as a patient will probably not even spend half of that. Maybe not even a quarter of that and she’s already seeing improvements. So I don’t mean to be kind of bashing the field, I just wish I didn’t hear so many horror stories from patients walking in. I really appreciate you guys kind of humoring me and listening to these case studies because even though I may appear a bit critical and I suppose I am being quite a bit critical, the silver lining is for those of us who are doing good work in this field, there is a never ending line of patients who are in need of help. And for those providers who are newer, or are still trying to refine some of this, hopefully these case studies and my musings kind of help lead you down a better, more efficient and more efficacious path.

DrMR:

Final Thoughts

DrMR:

I want to close by saying I don’t ever impute to any provider, a negative motivation. Although I do think that we’ve drifted into a very dicey territory where lab and supplement companies are too influential in the educational model. So doctors and clinicians are maybe not fully appreciating how much of the education here is kind of fraught with errors. So hopefully this is helpful. And remember for the month of September, if you sign up for the Future of Functional Medicine Review, it only costs you $1 for your first month of access. You can read these case studies in full, you can access all of the research study summaries, making it take you only like three minutes to get all the information from a research paper, which otherwise may take 45 minutes to an hour. It is my hope that this will help to plug you into a way of thinking and rationalizing through these things that has the patient’s best interest in mind. And will result in your contribution to leading the field into a better direction because integrative and alternative medicine is amazing and I’m so happy to be in the field. But I have concerns that if we don’t clean up our act, at some point, there’s going to be some very heavy regulations mandated making this field much more like conventional medicine, which would be just incredibly sad. Part of how I think we avoid that is not wasting people’s money or doling out recommendations that are counterproductive to someone’s health and healing. So that is another episode. I hope it was helpful. Please let me know what you think and we will talk to you next time. Bye bye.

Outro:

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