Two Challenges for Clinicians and How to Tackle Them
Unnecessary thyroid medication can be dangerous for a patient, even generating symptoms. Unfortunately, with overdiagnosis of hypothyroidism on the rise, more and more patients are being prescribed medications they don’t need. Hear a case study from a functional medicine clinician who was able to determine—through an evidence-based approach—that a chronically ill patient was not hypothyroid, getting her off unnecessary medication and feeling better. He also found that dysbiosis in her gut was the source of many of her issues. Also in this episode, learn systematic methods to get to the root of your patients’ histamine intolerance.
Dr. Michael Ruscio, DC: Hi everyone. Welcome back to Dr. Ruscio Radio. This is Dr. Ruscio. Today, let’s talk about histamine intolerance and about how the misdiagnosis of hypothyroidism is hurting patients. This is occurring both in conventional medicine and in alternative medicine. So, a lot to dig into today and really excited to expand on these. Now, I want to point out, again, that all of this information is essentially showcased from our Future of Functional Medicine Review Clinical Newsletter. If you’re new to our audience, this is a paid access, monthly publication that I write specifically for healthcare providers, including case studies and research study reviews, all with the objective of giving you exactly what you need to have an effective functional medicine practice.
[Continue reading below]
Dr. R’s Fast Facts Summary
Thyroid Case Study: May 2019 Issue of Future of Functional Medicine Review
- Excessive, unnecessary, lab testing from multiple providers is a common issue
- Patient was diagnosed with Hypothyroidism and started on medication also diagnosed with rheumatoid Arthritis
- Anxiety and panic worsened
- Treating the gut and stopping thyroid medication, led to much improvement
- Able to taper off anxiety meds successfully
Histamine Intolerance: June 2019 Issue of Future of Functional Medicine Review
- Intestinal dysbiosis drives histamine production
- Probiotics have an antihistamine effect
- They are powerful at fighting dysbiosis
- The hierarchy for addressing histamine intolerance is included in this issue of the Future of Functional Medicine Review
September Special for Clinicians: $1 for Full Month of Newsletter Access
- Get risk-free access to proven, evidence-based clinical insights
- Learn more & sign up at drruscio.com/review
To make it as easy for you as possible to decide if this is something you feel could help you, if you sign up any time during the month of September, you will receive your full first month of access for only $1. And you can access every issue of the review going back almost three years. If you go to drruscio.com/review, you can read a little bit more and you can, again, sign up for that first month of all access for $1.
Analysis: Incorrect Hypothyroid Diagnosis
Okay, let’s talk about another case study from one of our readers. In this case, it was from Dr. Robert Abbott. Again, what is so impactful in my mind about these case studies—not from me, but from people who are reading the newsletter—is it really proves the concept that the case studies, the research studies, and the other information that I share in the newsletter is fulfilling its promise: giving you actionable information that will improve the outcomes in your clinic.
If I’m being candid for a moment, one of the things that irritated me about my training in functional medicine in my early years, before I essentially went right to the research literature for most of what I get now, was the overwhelming amount of superfluous and needless information. There was so much fluff. There are definitely certain functional medicine educational bodies doing this today.
It is what it is, but it’s not helpful for the clinician who is looking to improve their patient outcomes. What I’ve tried to do with the Future of Functional Medicine Review Clinical Newsletter is to get to the point with what information you need to enhance your patient outcomes. And I’ve tried to help you understand how—in a visit-by-visit fashion—to think through and troubleshoot problems that your patients are suffering with, if you’re having a hard time figuring out the causative factors in the ball of yarn of symptoms that you’re unraveling.
From the May issue of the Future of Functional Medicine Review, we have a case study entitled “Fantastic Guest Case Study. A Patient Suffering from Incorrect Hypothyroid Diagnosis and Treatment. Thankfully, One of our Docs Identified This and Achieved Marked Improvements by Focusing on the GI.” There’s a lot here I want to share with you. I’m going to do my best to try to give you some details and not bury the lede here. But in short, this patient was incorrectly diagnosed with hypothyroidism, and medication actually made her worse. The whole time, GI or digestive dysbiosis was overlooked.
Let’s get into some of the details. A direct quote from Robert’s write-up, “Previous Treatments and Therapies. Follows an AIP” or autoimmune paleo “dietary template – now in reintroductions.” So she does this personalized autoimmune paleo diet after her elimination reintroduction. “Worked with a health coach and NTC to address nutrition for autoimmune disease. Worked with various integrative healthcare providers,” and “Addressed clinically diagnosed SIBO in 2017 with prescription antimicrobials.”
Her current short-term and long-term health goals are to conceive off of anxiety medications, address digestive complaints, investigate and address hormonal concerns with a previous diagnosis of polycystic ovarian syndrome—this is where a woman has high levels of testosterone or other related male hormones—to lose weight, to optimize nutrition for conception, and to improve anxiety and eliminate panic attacks. She’s currently on a compounded T4/T3 and she’s been on this since 2014.
Getting Worse on Unneeded Medication
Let’s go into a quick summary of her history. Again, this comes right from Dr. Abbott’s write-up. “Since 2014, Susan has had significant laboratory testing, the majority of which has been excessive, wasteful and clinically unimportant.” I love how Rob is just getting right to the point on this! I’ll continue. “I am appalled at the course of laboratory testing that was pursued by multiple of her providers.”
Welcome to my life, where this is just something that drives me bonkers on an almost daily basis. Okay, continuing. I’m fast-forwarding now in his notes by giving you another excerpt. “Upon further discussion,” he’s referring to his patient, “she was diagnosed with hypothyroidism despite normal TSH and normal free T4, but was started on medication because ‘other markers pointed to her thyroid needing support.’”
Continuing with some of Rob’s notes here. “It is notable that she showed clear GI dysfunction in 2015, with improvement in a repeat stool sample in 2017 (the same year she pursued antimicrobial treatment for SIBO), however, testing and treatment was pursued in other domains rather than GI health.”
So essentially, there was some testing and treatment for her GI, and she improved both via labs and via her symptoms. But instead of continuing forward in an area of treatment, the gut, that seemed fruitful, the providers went to other domains other than gut.
Continuing from Rob here. “It is disheartening to see that she has been on thyroid medication that she likely did not need, was diagnosed with [rheumatoid arthritis], which she does not have, was tested for every chronic thing under the sun without clinical reason, placed on numerous supplements despite a persistence with” or of “overt GI dysfunction and symptoms pointing to imbalances in energy production and the GI tract.”
Hey everyone. I’d like to thank Aerodiagnostics, my favorite SIBO lab, for making this podcast possible.
Again, Aerodiagnostics is the SIBO lab I use in my clinic. They have impeccable organization, customer service, test quality, and support. Regarding support, if you’re not highly proficient in reading SIBO labs, Gary definitely offers the best clinical support I’ve ever come across. He goes over labs in detail and offers insight analysis and really goes above and beyond.
Aerodiagnostics offers cash pay and insurance billing options, and they do a terrific job of keeping costs low and billing easy. They are for accounts for clinicians and direct-to-consumer testing and Aerodiagnostics, again, is my go-to SIBO lab.
If you’re wondering about how hydrogen sulfide ties into traditional testing of hydrogen and methane, please check out our recent podcast with Gary from Aero. Essentially, we’ve developed a simple questionnaire that will allow you to hone in on hydrogen sulfide SIBO, without needing additional testing or cost. Aerodiagnostics, check them out.
So Rob is doing a really good job of pointing out many of the things that I’ve discussed in the podcast that are disheartening—that was a great word he used—which are, these patients are being exposed to so much over-treatment and over-testing and not getting better.
It gets worse here. I’m quoting again. “What is perhaps even more troubling is the worsening of anxiety and panic following the use of thyroid hormone replacement.” I’ve been saying for awhile now, on both the podcast and in our clinicians newsletter, that the promise of all of your symptoms coming from thyroid is a promise that rarely tends to be true. What’s even worse is, when giving a patient T3 who does not need T3, or when giving someone thyroid hormone of any type when they don’t need it,
many of these patients will get worse. Anxiety and panic are some of those symptoms. Unfortunately, this patient was kept on medication for quite a while because the provider or providers couldn’t conceive of the fact that she may not have been truly hypothyroid.
This actually points out, I think, something that is important to mention. Unless you’ve been exposed to the thinking that we should be double-checking thyroid diagnoses, you may assume that a patient presenting to your office who has hypothyroidism is hypothyroid. “Well, I was told I’m hypothyroid!” You may just take that as a matter of fact. Unfortunately, I think things have progressed far enough to the point where we want to be double-checking this diagnosis.
Now, we also should be very careful… How can I term this delicately? We also want to be careful not to un-diagnose someone with a condition unless they meet the criteria. So caution should be exerted in both directions. But fortunately, to diagnose someone with hypothyroidism is fairly clear-cut. So if you look at someone’s labs, as in this case study, and their TSH is normal and their free T4 is normal, that is not a hypothyroid case.
Now, there is some gray area. Technically, if the TSH is elevated and the T4 is normal, they are diagnosed as subclinical hypothyroid. That’s the technical diagnosis. Where there’s gray area is whether or not they need medication. But outside of that issue of subclinical hypothyroidism, as long as we are doing this carefully, it’s fairly straight-forward in terms of checking the diagnosis. And for some patients, as this case is substantiating, that is a huge step forward in terms of resolving the underlying cause. In this case, it’d be an estrogenic, physician-induced disease from unneeded thyroid medication.
Understanding the Gut-Thyroid Connection
Moving on in this case study, the outcome that we eventually land at is, treating her GI and stopping the unneeded thyroid medication led to a reduction of symptoms and ability to start tapering off Clonazepam. So she’s able to start tapering off her anxiety medication, see a resolution of her symptoms, and get off an unneeded medication.
Remember, all of the details are listed in the case study, in terms of her specific symptoms and how they improved over time. But the simple concept I want to articulate to you here is, the symptoms she had are a bit less important than understanding what’s driving those symptoms. So in this case, you could have had depression, joint pain—obviously she had some anxiety because she was on anxiety medication—fatigue, constipation or diarrhea. The specifics of the symptoms aren’t of paramount importance. What is important is realizing that this patient was experiencing some iatrogenic symptoms, meaning the symptoms were physician-induced, by putting her on a medication she didn’t need. So that wipes out some of the symptoms.
And then the ones that she was initially going to the doctor for appear to have a causative implication coming from the GI tract. In this case, again, it’s great to see that it’s not just me saying this, other clinicians are seeing this. They are finding these cases that have been misdiagnosed with hypothyroid and have been on medications for years and years and years before figuring out they didn’t need the medication. And in this case, were being harmed by their medication. And the issue that needed to be addressed was their gut.
Let me just share the final quote here from Rob. “Susan reports continued improvements in her health and is very happy overall with her progress.” That is the outcome Rob was able to achieve. And, I mean, look at this case study. Tons of testing had been done, and this patient got nowhere. Rob ordered some very simple testing, got her off an unneeded medication, and knew some fairly standard therapies for her gut. And now this “chronic case” was very happy with how she was feeling only a number of months later. This is the power of understanding the gut and gut-thyroid connection and then intervening appropriately.
I also want to be careful to say, it’s not to say that no patient needs thyroid medication or anything of that nature. But unfortunately, the main demon that clinicians are going to have to be grappling with out there, metaphorically of course, is this over-diagnosis and incorrect diagnosis of hypothyroidism. This is what Robert’s case study so beautifully outlines.
Histamine Intolerance & the Gut
Another factor that can occur in the gut—that can be hard for some clinicians to navigate—is histamine intolerance. I was very happy to be able to include a presentation for clinicians in the June 2019 issue of the Future of Functional Medicine Review entitled, “Gut Dysbiosis, Immune Activation and Histamine Intolerance – Untangling the Web.” What can be perplexing about histamine intolerance, outside of the fact that it can manifest with gastrointestinal symptoms, is the degree of neurological involvement that’s oftentimes involved as part of histamine intolerance. In this presentation, I share symptoms. More importantly, I share this causal web of interconnectivity between the gut and the immune system in the gut, histamine intolerance, and dysbiosis.
When you understand these different factors, you can untangle this web. And it’s actually not that hard. But we have to first understand the causative factors at play, because some of these are counterintuitive. Depending on how educated you are in the realm of gut therapies, a low FODMAP diet may or may not strike you as counterintuitive. If you’re new, maybe it does. If you’re more sophisticated in your understanding of the gut, you appreciate the fact that a low FODMAP diet, by starving bacterial overgrowth in the gut, can lead to reduced immune activation as measured by histamine and leaky gut in these patients, and also cause an improvement in gastrointestinal symptoms. What else I think is counterintuitive to some is the use of probiotics. This is another thing that I detail.
Actually, it’s kind of ironic. It seems that the more important therapies in gut health tend to be the most misunderstood, which is really unfortunate for the healthcare consumer. But I suppose from a market advantage perspective, it leads to a huge gap for clinicians who understand how to use these tools appropriately. There’s a huge gap in the marketplace.
Probiotics are another example of this. I share numerous studies in this presentation that outline how probiotics have an antihistamine effect. In fact, in allergic and histamine-mediated conditions like allergic rhinitis or rhinoconjunctivitis, or just seasonal allergies, probiotics—regular probiotics, not a special histamine-free probiotic, just your standard probiotics that fall into our three category system that we’ve talked about in the past—have shown the ability to improve these histamine-mediated conditions.
When we combine that with the understanding that intestinal dysbiosis drives histamine production, and understand that probiotics can be powerful at fighting intestinal dysbiosis, things like yeast or fungus, then we understand that yes, while a probiotic may contain some histamine, the net effect tends to be an antihistamine. I supply all the references in this presentation in a very easy-to-follow format that substantiates that. I wrap this all up with a bow at the end, with a stepwise interventional hierarchy for clinicians to follow, including the optimum time to utilize a low-histamine diet.
Ironically, in one with presumed histamine intolerance—we have to say presume, because while you can do testing to “diagnose” this, the diagnostic criteria are very hazy—the first diet to use (ironically, at least in my opinion) is not a low histamine diet. But I do lay out for you when the low histamine diet should be considered in this stepwise interventional hierarchy for gut dysbiosis, immune activation, and histamine intolerance.
A No-Fluff Resource for Clinicians
All of this is detailed in the Future of Functional Medicine Review Clinical Newsletter, which is why I am so excited about it. The feedback that we’re getting is really humbling and gratifying to see clinicians applying this and hitting home runs. So I really encourage you to take a moment, head over to drruscio.com/review. For $1, sign up for all access to every issue of the newsletter for nearly three years. Really give it a good look.
And I’m sure you will conclude that this is something that can help you, and start turning you in the direction of more precisely applied functional medicine, and help you not get pulled into some of these detours that can take away from clinical efficacy.
Because really, you want to get people healthy as quickly as you can. That is how you build a practice that has a waiting list. I think that’s what we all want. We all want to have the luxury of not worrying about our schedules being full.
For the lay people listening to this, it’s like your boss telling you, “Well, you may or may not have a paycheck next week.” It’s a very challenging position for clinicians to be in. And if you’re working for someone else, you want to be doing the best job you can working for them and not be plagued by, “Oh, it’s this patient again. I’m really not sure what to do.”
Again, I’ve constructed the Future of Functional Medicine Review Newsletter in such a way as to give you what you need to get patients healthy. And just none of the fluff and frivolous information that won’t advance the agenda of getting a patient healthy as quickly as possible.
Again, that’s our Future of Functional Medicine Review Clinical Newsletter. Today, a few—hopefully what you found to be—pearls regarding misdiagnosis of hypothyroidism and how to untangle this web of histamine intolerance. Again, if you head over to drruscio.com/review, first month, all access for $1. I hope you will check it out and I am confident that you will find it well worth it. All righty, guys, we will talk to you next time. Bye bye.
What do you think? I would like to hear your thoughts or experience with this.
Dr. Ruscio is your leading functional and integrative doctor specializing in gut related disorders such as SIBO, leaky gut, Celiac, IBS and in thyroid disorders such as hypothyroid and hyperthyroid. For more information on how to become a patient, please contact our office. Serving the San Francisco bay area and distance patients via phone and Skype.