How to (Successfully) Treat Thyroid Disorders

A Better Approach to Hypothyroid Treatment

Do you struggle with a thyroid disorder? Are you a clinician treating patients with hypothyroidism and struggling to get optimal results? In today’s podcast, we showcase some of the most essential clinical pearls when it comes to treating thyroid disorders taken from a recent issue of the Future of Functional Medicine Clinical Newsletter.

In This Episode

Episode Intro … 00:00:45
Case Study Introduction & Lab Results … 00:03:52
Clinic Visit & Recommendations … 00:11:26
Follow-Up Clinic Visits: Labs & Testing … 00:15:35
GI Pathogens … 00:16:46
Evidence Based Models vs. Lab Work Data … 00:20:47
Parasitic Treatment & Use of Alinia … 00:23:41
Antimicrobial Therapy … 00:32:50
Clinical Rules … 00:36:12
Thyroid & Medication Algorithms … 00:38:20
FFMR Plus … 00:46:13
Hypothyroidism & Gut Imbalances: Final Thoughts … 00:48:34
Episode Wrap Up … 00:54:16

How to (Successfully) Treat Thyroid Disorders - Podcast324 FMF Apollo

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Hey everyone. Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio. Today, we’ll discuss a case study which exemplifies how we can improve thyroid and overall health after using gut-based therapies. We’ll also go through a very important set of updates to our thyroid treatment algorithm. We’ve added some very important facets to that algorithm outside of medication use and I’m very happy to have them here. We also cover one additional study on the incidence of thyroid disease. This is very important because we sometimes portray hypothyroidism as an extremely high likelihood, and we should amend that. We should be able to give patients a risk association that is representative of the data. We want to strike that balance of educating them and prompting them to action, but also not scaring them and putting undue fear into their minds.

Let’s jump in here and go through all these bits and bites. Just a reminder that all of this information is taken from our Future of Functional Medicine Review (FFMR), which I previously referred to as a newsletter. Now I think it’s more representative to call it a newsletter and database because of examples we have in there now – the thyroid algorithm, a review on gastrointestinal markers for fungus, a review of the evidence on Blastocystis hominis, and whether or not it is a pathogen or how problematic it can be. Which ones should you use? Which ones should you not use? How and what are we using in the clinic? We’ll be adding more in the way of practice guidelines and clinical recommendations.

Not only will the FFMR be a monthly newsletter that has case studies and updates on research, but we’ll also be progressively trying to kind of call things down — What is the recommendation for assessing fungus in the GI? What is our position paper on T4/T3 combination therapy? It will be progressively moving towards practice recommendations and guidelines in tandem with the ongoing stream of information. If you would like to give that newsletter and database a review, we periodically run a promotion where you can obtain 30 days of all access (including all of the back issues) for $1.00. You can go through the thyroid algorithm and everything else.

➕ Full Podcast Transcript

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, make sure to subscribe in your podcast player. For weekly updates, visit 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 with your doctor. Now, let’s head to the show.

DrMichaelRuscio:

Hey everyone. Welcome back to another episode of Dr. Ruscio Radio. This is Dr. Ruscio. Today, we’ll discuss a case study which exemplifies how we can improve thyroid and overall health after using gut-based therapies. We’ll also go through a very important set of updates to our thyroid treatment algorithm. We’ve added some very important facets to that algorithm outside of medication use and I’m very happy to have them here. We also cover one additional study on the incidence of thyroid disease. This is very important because we sometimes portray hypothyroidism as an extremely high likelihood, and we should amend that. We should be able to give patients a risk association that is representative of the data. We want to strike that balance of educating them and prompting them to action, but also not scaring them and putting undue fear into their minds.

DrMR:

Let’s jump in here and go through all these bits and bites. Just a reminder that all of this information is taken from our Future of Functional Medicine Review (FFMR), which I previously referred to as a newsletter. Now I think it’s more representative to call it a newsletter and database because of examples we have in there now – the thyroid algorithm, a review on gastrointestinal markers for fungus, a review of the evidence on Blastocystis hominis, and whether or not it is a pathogen or how problematic it can be. Which ones should you use? Which ones should you not use? How and what are we using in the clinic? We’ll be adding more in the way of practice guidelines and clinical recommendations.

DrMR:

Not only will the FFMR be a monthly newsletter that has case studies and updates on research, but we’ll also be progressively trying to kind of call things down — What is the recommendation for assessing fungus in the GI? What is our position paper on T4/T3 combination therapy? It will be progressively moving towards practice recommendations and guidelines in tandem with the ongoing stream of information. If you would like to give that newsletter and database a review, we periodically run a promotion where you can obtain 30 days of all access (including all of the back issues) for $1.00. You can go through the thyroid algorithm and everything else.

Case Study Introduction & Lab Results

DrMR:

The case study we’re going to be discussing comes from the May, 2021 issue of the Future of Functional Medicine Review. The title of this case study is ‘Thyroid and Overall Health Improved Through Gut-Based Therapies, Despite Nutritional Labs Not Improving.’ This case study was led by the research director at the clinic, Dr. Robert Abbott. I’m very happy to announce that he and I are working very closely behind the scenes on pioneering data tracking and research publication. Now, this patient’s name was Rebecca. She was a 43 year old female who was well educated and well aware of functional medicine. Remember that, because it becomes more relevant in a moment. Her previous diagnosis was Euthyroid Hashimoto’s. This meant her thyroid hormone labs – TSH, T4, T3 – were normal, but she did have Hashimoto’s or positive TPO antibodies as the main way of signifying that. She was not on any prescriptions. Her chief complaints at her first visit were female hormone symptoms, PMS, mood fluctuations (especially around menstruation), fatigue, bloating, belching, diarrhea, and lower abdominal pain. We concluded that she presents with a constellation of gut and female hormone symptoms with normal thyroid hormone output.

DrMR:

Her previous testing had indicated a TSH of 3.3, which is normal. However, some in the functional medicine community would say that if it’s above 2.5, it’s abnormal. In the case study, we highlight this as orange, as opposed to things that are conventionally agreed upon being flagged. High or low and we’ll highlight in red. These things try to make reading through the case studies as comprehensible as possible. Her free T4 was 1.06. The range there is essentially from 0.8 to 1.98 so she was fairly squarely in the middle. Her ferritin was 19 and her iron saturation was 15. That ferritin is not technically low for a woman. It’s pretty close to the cutoff of 15. We’ve discussed some research from Soppi, who I believe is in Finland. He has theorized that below 100 is what should be considered normal for iron deficiency anemia. Other researchers have echoed and agreed with that same sentiment. I feel it’s too stringent of a cutoff. What I’ve observed when giving an individual iron with ferritin below 100 is a fairly low likelihood they will see dramatic improvement. I think 70 or 50 is a better cutoff to look at. It may not be this highly binary where this one level is where you’re going to have benefit or not from iron, but the lower you go, the higher the probability of benefit.

DrMR:

As clinicians we should be looking for ferritin below 100. Let’s say it’s at 60. If they’re sleeping well, they’re exercising, they’re eating a good diet, and they’re no longer having all these gut symptoms that could be causing their fatigue and they still have fatigue, that’s when I would consider using supplemental iron. Lab testing – in most cases, but not an absolute rule – is about 1/4 of the data. You need to make a decision. The context surrounding that 1/4 of lab testing data is really important.

DrMR:

Coming back to Rebecca’s case regarding onset, she had reported a period of severe stress about seven years ago. She noticed she had worsening fatigue, bloating, and gas. This is also when her PMS and female hormone symptoms became more prominent. She self-diagnosed herself with Euthyroid Hashimoto’s in 2019. I’m presuming here that she had done a direct-to-consumer lab to make that self-diagnosis. She followed the Autoimmune Paleo (AIP) protocol after the diagnosis and successfully lost some weight. Some of her symptoms improved, but the diet was not sustainable for her. Also important to keep in mind, she had no family history of autoimmunity or hypothyroidism. She had done some prior supplementation with vitamin C and PMS support supplements. There are a number of things that we’re considering in this case by building out the problems list. What factors are we putting on this problem list? Given her digestive symptoms, it could potentially be gut dysbiosis, SIBO, or a gut pathogen. There could also be a dietary mismatch – perhaps low FODMAP will be better for her than AIP. There may be some nutrient insufficiencies given the GI symptoms. Or there may be some issues with female hormones. The thyroid is already something on our radar screen regarding what seems to be Euthyroid Hashimoto’s. Prognostically, we expect this case to do really well.

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Clinic Visit & Recommendations

DrMR:

After her initial intake visit, we saw her back to lay out our recommendations. At the clinic, the initial visit is really deep data mining where we are intaking a vast amount of information. We then go to work on working the problem, working the algorithm, and establishing the DDX (differential diagnosis) or problems list. We prioritize that, establish the treatment hierarchy we’re going to follow, and then use all of that information to generate the initial recommendations that we cover at the next visit. So at this next visit, we did some blood work and a stool test. Rebecca was quite insistent on doing a stool test as she quite fervently suspected that she had a parasite.

DrMR:

This ties into the earlier comment of her being quite well-educated on functional medicine. Unfortunately, that education comes with both gifts and detriments. The gifts were that she was able to put herself on an autoimmune paleo-like diet, and it was doing a good job with some of these dietary facets of her health plan. The detriment was this expected parasite and the fervor with which she wanted to pursue that. We order some baseline lab testing, but since it can take a few weeks for those tests to come in and we want to keep people continually moving forward, we also lay out some recommendations while we’re waiting for the labs to come in. We went through our probiotic therapy — in this case, a soil-based probiotic and a Saccharomyces boulardii probiotic. We also recommended an enzyme, an HCL (hydrochloride) supplement, some adrenal support, and also a pivot to a paleo low FODMAP diet; increased walking and spending time outdoors was also suggested. What we’re suspecting here is that there could be something going on in the gut. We likely can determine what’s going on there with a combination of empiricism, lab testing, and the low FODMAP diet. Herbal adaptogens will likely help her GI even further and also help buffer some of the stress that she has been under.

DrMR:

Essentially, her treatment recommendations were time in nature, walking, paleo, low FODMAP, probiotics, enzymes, and HCL. If we were seeing this patient today, I would underscore here that we would probably be more light handed in the treatment recommendations. One of the challenging things about case studies is that by the time we publish them, we’ve already slightly updated our model. This case study was from a year and a half ago. It takes time to see a case study through to fruition, and to also write it up and publish it. There are pros and cons here. There is a lot embedded here, but since we’re always updating our model, there are always these nuanced tweaks. One of the nuanced tweaks is waiting a little bit longer for the administration of enzymes, HCL, or any kind of adrenal support. So much of the purportedly adrenally mediated symptoms are really gut-brain in our observation.

Follow-Up Clinic Visits: Labs & Testing

DrMR:

At her third visit, she reported some improvements in her diarrhea and energy; the bloating had been somewhat curtailed, but remained challenged with some upper GI discomfort. She also reported some discouraging testing on her well water that showed elevated coliform bacteria. Her labs had a number of findings. Her most recent lab showed her ferritin was at 20 – about the same range; her vitamin D was at 34, homocysteine at 12, and alkaline phosphatase at 32. So there was some noise there. In my mind, the biggest things are potentially the ferritin and the homocysteine. The GI map is really where I’d like to point our attention to. When you access the FFMR and you go to the May, 2021 case study, you can see the actual report and images from the lab.

GI Pathogens

DrMR:

There were no overt GI pathogens present – no H. pylori. There was some presence of candida species, and there was also some normal bacteria that were flagged as high. I typically do not pay much attention to the normal bacteria being flagged high or low because I just do not see evidence showing we really understand what that means. Perhaps there are some perturbations. Are they causal or associative? Therefore, do they tell us how to do anything differently? My read on that is they do not. There were some elevations of dysbiotic bacteria like staphylococcus aureus and streptococcus. From that, we can say there’s mild dysbiosis and potentially some candida overgrowth. However, these DNA based stool tests being able to officially diagnose candida would be a bit of a stretch.

DrMR:

There’s something there, but I’m just cautious in how much I take away from that. Thus far, none of these findings would be changing the way I treat an individual and modifying the gut algorithm at all. When we get to the parasites section, we see that there is some Blastocystis hominis that registers, but it’s not flagged high. This comes back to the podcast conversation we had with David Brady and Tony Hoffman. The folks at Diagnostic Solutions make the GI map. It is their contention that when something is flagged high, that would be severe enough of a finding for conventional antibiotic care; enough to make someone so ill and so symptomatic that they were presenting for acute care. Between that very acute presentation and corresponding level of colonization and normal, there could be this subclinical colonization. So that’s what is suggested here for the Blastocystis hominis.

DrMR:

Based upon the lab results, our read on this is that we really don’t need to be pursuing this with harsh anti-microbial therapy. This is perhaps a contentious statement, but the signal that Blastocystis hominis in the research literature is a pathogen, is a mild signal at best. This means it has been shown to correlate with GI symptoms, but the signal is mild. The benefit after going through therapy is also mild. That’s using the more conventional cutoff criteria for saying someone has Blastocystis hominis. So this is a presumably milder case than what is seen in much of the research – a mild finding for a mild signal. That is why I wouldn’t be too quick to act on the Blastocystis hominis. I wouldn’t deviate from the evidence-based gut algorithm that we’re already using at baseline. There’s much more evidence in working through the process of basic dietary elimination –> low FODMAP –> probiotics –> elemental dieting or anti-microbial therapy –> immunoglobulins –> end phase empiric trials with HCL or enzymes.

Evidence Based Models vs. Lab Work Data

DrMR:

This is a much more evidence-based model than using lab work to personalize. There are numerous studies in IBS or functional gastrointestinal disorder cohorts that have used basic elimination diets, low FODMAP diets, probiotics, antimicrobials (or more literature for antibiotics), some evidence for immunoglobulins, or enzymes. We’re applying the therapeutics in order of what’s most common in our population and what has the best evidence to support those common findings. That’s more scientific than saying here’s the thing on a lab that may or may not be an issue; that we’re going to just throw away all the research that informs a gut treatment algorithm in light of this one finding. That’s not really the best way to approach this. Now, if the individual had a clear finding or pathogen, then that’s different. However, to rectify more of the subtle imbalances and dysbiosis on something like a GI map, I think the best strategy is our gut algorithm and not just directly treating the numbers.

DrMR:

So to continue on with her lab, there were some other elevations. Beta-glucuronidase, according to Ilana Gurevich’s review, is not a highly accurate marker. So that’s one I don’t look too closely at. Secretory immunoglobulin A (IgA) was the same finding from Ilana’s review. There was also an elevation of anti-gliadin antibodies. Per the evidence on the more well-studied version of this marker, the blood sample found either a 50% or 60% accuracy. The stool testing may not be as accurate. Knowing that we have maybe a 50/50 on the blood (and this is a touch less accurate on the stool), is still something to consider. I would still use that to advise the patient – to be careful with gluten and go through the same exercise of gluten elimination and reintroduction. What I wouldn’t do is go too far the other direction and say you can never have gluten. I would use this to say there’s some evidence here that you may have a problem with gluten. We’ll continue healing your gut. Then, per the gut-healing algorithm end phase and once your symptoms are where we want them to be, we’ll go through some expansion of your diet, figure out what your dietary boundaries are, and let your own symptomatic response be the ultimate guide for us.

Parasitic Treatment & Use of Alinia

DrMR:

So, Rebecca was making some progress with the simple therapies, but she was quite insistent that she had a parasite and needed strong antibiotic or anti-parasitic treatment for that parasite. This is where I see some of the remnants of the BioHealth testing – William Timmins, Daniel Kalish – and the earlier naturopathic medicine cohort that was a bit more gung-ho on infections. As an aside, this theory really helped me — this was the only camp of thought way back when I was in college and feeling terribly, that posed the idea that I may have had a parasite.

DrMR:

So, I’m not being dismissive of the premise entirely, but there’s a difference between a gold standard stool antigen recognition of a clearly agreed upon pathogen – as in my case with entamoeba histolytica – vs. a potential pathogen like Blastocystis hominis. Also, the Blastocystis hominis is a mild pathogen and it’s not even enough to be considered totally positive. So Alinia – or another type of antibiotic oriented parasitic – is a consideration. This early on, it’s probably going overboard. It’s like bringing a bazooka to what could be a knife fight. We confront that thinking, along with Rebecca’s indoctrination of feeling this is a super pathogenic parasite and that parasites are the cause of all problems. So some concessions were made here in her case to use Alinia, which appears to be a very well tolerated drug.

DrMR:

I used it myself for the amoeba way back when, so there’s not a lot of risk associated with this. However, as Rob and Rebecca were going through the consult, there was a potential of pushing this patient away if we didn’t meet her halfway with the Alinia as an option. It was probably a bit of an overkill. However, when considering the alternative of this person going out into the wilderness of functional medicine, it was the right call to entertain the patient preference of a more aggressive therapeutic. I just wanted to clarify some of the thinking that underlies that decision.

DrMR:

So at that conversation with Rebecca, an approach was agreed upon to use anti-microbial therapy, a higher dose of probiotics, and then to fill a prescription for Alinia, but hang onto it for a little while. At the follow up, after being on those recommendations for about four weeks, she was doing really well with the overall protocol – meaning higher dose probiotics and herbal antimicrobials. It completely reinforced my posit. However, she then went on a two week beach vacation and expanded her diet to include wine, dairy, and grains. This seemed to exacerbate some of her symptoms. There’s an important note here in how we interpret this. Some would say that if she was having those symptoms, it’s the parasite and we need to go bullying in with the Alinia. That’s one theory.

DrMR:

That used to be a theory that I operated underneath. However, if you consider this, there is an ongoing musculoskeletal parallel I like to draw. If we can appreciate that healing a sprained ankle takes time, then we could appreciate that if someone was doing an ankle rehab plan, they may have went for a run. In this case, the patient went to the beach and had wine, alcohol, dairy, gluten, and everything else. The athlete saw a regression in their ankle pain and this person saw some regression in their gut symptoms. We wouldn’t say that rehab plan wasn’t working because the athlete was actually doing really well. We just went too aggressive with expanding their activity. As soon as we flare the injury, it’s the same thing with Rebecca — too aggressive in terms of having fun, being up a little bit late, having the wine, and eating the bad food for an extended period. As evidenced by the fact that she went on vacation for two weeks, this probably wasn’t just one night. So, her gut was on the right path. The derailing from that doesn’t mean that the intervention was wrong. It’s just that the expansion was too soon. That’s the way I interpret this.

DrMR:

It also appeared that the HCL was giving her some heartburn. This is part of the clinical observation that we have seen that leads us to delay the use of enzymes and acid until later phase. I don’t want to say this is common, but it is common enough to rethink how early in the hierarchy we use this. She also remarked that she had been more strict with her diet since the flare, but still noticed some cravings were plaguing her. She also hadn’t yet seen any changes in her PMS and had not yet started the Alinia. Two steps forward, one step back. This happens and that’s okay. The larger observation of improvement to me is an excellent prognostic indicator.

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DrMR:

The impression here is that we are on the right track and we’re going to move forward with the recommendations. Level 2 – mainly due to the fact that Rebecca was showing a strong patient preference for it – will be to start on the Alinia, repeat some of the testing after the course of Alinia, and then follow up. At the follow up visit a number of weeks later, she reported global improvements in her digestion and her female hormone symptoms. She mostly attributed this to the herbal antimicrobials and to the Alinia. Most likely without the Alinia, we probably would have gotten here with a bit more time in the herbal antimicrobials. However, again, I’m not overtly opposed to the Alinia – it was just probably overkill at that point in time.

Antimicrobial Therapy

DrMR:

Her lab work was similar in many regards. Although, I do want to point out that her TPO halved from 81 to 37, which is still acceptable and nothing that I would be worried about. You will see that in some cases of antimicrobial therapy. In fact, I recently did a video review and there’s this very cool graphic in this video of one of Dr. Mather’s patients that we were seeing through the clinic. Her TPO antibodies went from between 650-750 down to about 350 after a course of herbal antimicrobials. We’ve referenced in the past that using antibiotics for H.pylori caused a significant reduction in TPO antibodies. Not all the data there agree, and that’s important to mention, but there is a signal of benefit and it’s a secondary benefit of antimicrobial therapy.

DrMR:

I wouldn’t recommend antimicrobial therapy with the express goal of lowering TPO antibodies, but in a person for whom it seems to be the right place and time, it’s definitely a consideration. Otherwise, there was still some of the background noise on the lab work — vitamin D was 34, ferritin was 20, and TSH was still normal at 3.3. The TPO antibodies did improve and the homocysteine was also the same at about 12. Now, the GI map looks similar, but now there’s no candida and now there’s no Blastocystis hominis. However, there are elevations of another dysbiotic bacteria – pseudomonas. She went from having normal bacterial flora – a few high to now having a few low. You see so much shifting around with a normal flora and dysbiotic flora. I’m still having a hard time saying that we use these findings to change the GI algorithm. By going through the GI algorithm, that seems to be the best way to get someone to resolution.

DrMR:

I look at these lab findings with the normal and dysbiotic bacteria to likely correlate with that, but I use the patient’s symptoms first. Now it’s different for overt pathogens, but remember there were no overt pathogens found. The blasto (short for Blastocystis hominis) was a gray area and the blasto did go from some detected to none. Again, remember that likely could have been done with more minimalistic therapies. Either way. I’m happy to see that she is feeling better. There are still a few things here to tie up. We may potentially get her on some iron, but overall we’ve seen some pretty nice improvements in all of her gut symptoms and female hormone symptoms. This is definitely a clinical win showing that we can see improvements in a number of markers – including thyroid antibodies and most importantly her symptoms.

Clinical Rules

DrMR:

There are a few clinical rules here. We’ve been trying to write these clinical rules into the case studies. Clinical Rule 1: Begin the sequential GI therapeutic hierarchy for individuals with thyroid dysfunction before the use of thyroid hormone replacement. The one caveat is if someone’s overtly hypothyroid, then you’d want to treat the hypothyroidism. In this case, she was not. Some in functional medicine would have said that TSH above 2.5 “is hypothyroid” and to start there because it’s the thyroid driving the symptoms. As we’ve demonstrated with this case study, that’s not the case. The GI symptoms were the cause of some of the other non gut and more neurologically based symptoms – the fatigue, bloating, belching, mood, and menstruation.

DrMR:

This case illustrates the importance of treating the individual and not treating the labs in isolation. Clinical Rule 2: Address the gut before robust nutritional repletion. Another argument could have been made that because her vitamin D was 34, her ferritin was 20, and her homocysteine was 12, we have to go hard with high dose B vitamins, iron and vitamin D. We demonstrated here that we saw improvements in all of her symptoms without doing that. Now we can still do that, but we don’t want to do too much at once. Then, as a clinician, you’re not really sure if the symptoms are coming from the vitamin D, the iron and, the B-complex or from the gut treatments. Prioritize and execute – hence hierarchy, hence algorithm. Clinical Rule 3: Do not treat the labs – treat the patient.

Thyroid & Medication Algorithms

DrMR:

So that is the case study from May, 2021. At the same time, we went through a number of updates to our thyroid algorithm, and I’m actually very happy about this. We really built out the thyroid algorithm. There are a number of things here I’d like to point to. We created a small intro section called ‘Intention of the Thyroid Treatment Algorithm.’ There are five main intentions. The first objective is to correctly identify patients to distinguish if they hypothyroid – Are they sub-clinical hypothyroid or are they auto-immune hypothyroid? The second objective is to better predict the need for thyroid hormone replacement medication. Even though I spend a lot of time criticizing the overuse, it’s not all or none. It’s about knowing the right time to use these various interventions. The third objective is to better predict the ability for patients to discontinue replacement medication. Remember the meta analysis that we discussed recently that found 34% of patients were able to come off their thyroid hormone medication. This is is not left wing, alternative medicine just criticizing conventional medication saying you don’t need that stuff or these diseases are BS. That is not the case at all. We just want to make sure that if someone has been incorrectly diagnosed or been given thyroid medication based upon the subclinical hypothyroidism, that it’s double checked. If they do not need the medication, the appropriate deprescription exercise is gone through. The fourth objective is to correctly apply an evidence informed therapeutic hierarchy, prioritizing lifestyle and gut-based treatments before medication if indicated. The fifth objective is to improve overall hypothyroid patient outcomes. There’s also a section for screening and clinical history.

DrMR:

Before you go into the algorithm of test, there are a number of guideposts we put out for screening. I’m not going to go through all of these, but one we’ve discussed on the podcast before is to qualify a prior diagnosis. As appeared in the meta-analysis and the journal Thyroid, they point out something that I’ve been saying for a few years now — doctors have not become accustomed to checking the diagnosis. In the doctor’s defense, I don’t think they were really aware of the level of misdiagnosis that was present. Do the important due diligence of making sure that you qualify someone as hypothyroid. Don’t just allow them to go from doctor to doctor carrying forward this diagnosis without anyone ever questioning it. There are indicators that we spell out here that may flag for you a risk of misdiagnosis and what type of provider made the diagnosis.This is where those in conventional medicine and in the standard box are probably doing it right most of the time. Conversely, if it’s an integrative doctor or someone in the natural health camp, the likelihood of an incorrect diagnosis is actually much higher. For example, was there a conventional lab range elevated TSH paired with a low free T4?

DrMR:

Another obvious thing to look for – did the person clearly notice benefit from starting the medication? Does the individual present with symptoms that could be iatrogenic due to unnecessary medication – namely fatigue, insomnia, and racing heart? There’s some more information here that gives clinicians a checklist to go through. I’m not going to read through every one of these points, but I do want to point your attention to the part two we’ve added also – the non-medication treatment. This is really important because obviously there’s a lot here that can be done from a non-thyroid hormone medication perspective. We wanted to give people a hierarchy to work through here, including GI workup or GI considerations like H.pylori, SIBO, dysbiosis, dietary changes, iron insufficiency, and others.

DrMR:

We then get to the medication algorithm. It ties in with the preceding sections, but when you get to the medications, starting with T4 is actually the better place to start. The combination of T4 plus T3 is an option. It’s frustrating to feel like I’m combatting a lot of the field in saying this, but starting with the combination therapy is not the best way to go. There is a signal in the evidence that patients have a higher index of negative side effects from the combination therapy. The promise is that if you take the combination therapy, all your symptoms will go away. That is a promise that is not really substantiated. There is some evidence that finds some individuals do feel better on combination therapy, but that’s an overwhelming minority of patients.

DrMR:

So what do we do? We don’t throw the baby out with the bath water. We don’t go to either extreme. In the spirit of an algorithm or a hierarchy, we start with a therapeutic intervention that is going to be the most helpful for the most people. It is also the most minimally invasive or laden with side-effects. That would be front loading with getting someone generally healthy, including their gut. You’re not trying to medicate symptoms that are not thyroid in nature, but just look like thyroid – like fatigue, constipation, and depression – which can totally be driven by the GI. We get that noise out of the way. Now we have a cleaner slate and we trial T4 only. For most, that will work. If not, there is then the option of escalating to the combination of either a desiccated hormone or a T4 plus T3.

DrMR:

We also added a section about the two or three general options for deprescribing or tapering someone off of thyroid medication that had been used in the research studies. They were also summarized in the meta analysis we discussed earlier. So, a lot there.

FFMR Plus

DrMR:

The last study actually comes from the Future of Functional Medicine Review Plus. This is a weekly brief of all the latest research, which is also available as an audio read. For me – and I think I speak for all the clinicians at the office when I say this – this has been a game changer. Now, once per week, I either do a 15 minute read that gives me the same amount of value that used to take me five to seven hours – or I listen to it when I’m on the go. It is immensely helpful.

DrMR:

One of the things that was immensely helpful from a recent addition was the clinical outcomes after discontinuation of thyroid hormone replacement – a meta analysis. This is the meta analysis that we’ve been referencing. This is where I found the meta analysis. The meta analysis came from the review that we do and published in the FFMR Plus. Those are the PubMed alerts I’ve been crafting and honing for years that I get sent anytime a new study is published on a whole array of matters in healthcare – Hashimoto’s, hypothyroid, hyperthyroid, SIBO, dysbiosis, candida, IBS, IBD. I read through that looking for studies that are important and impactful. What do you know? This study was hugely impactful and it was flagged. It came up in our FFMR plus. That’s why I’m so passionate about this tool. The short takeaways are about 1/3 of patients may be able to effectively discontinue thyroid medication and remain perfectly normal. A lot of this comes from individuals who are subclinical hypothyroid being given medication – or just frankly, misdiagnosed as hypothyroid to begin with and no one has questioned it.

Hypothyroidism & Gut Imbalances: Final Thoughts

DrMR:

That’s a whole lot about thyroid via a case study, via our thyroid algorithm, and via a recent meta analysis. I hope it’s becoming clear that as everything here at the operation grows, we are really trying to put science first to inform the most accurate clinical model possible. This is best for the individuals that we work with and best for the clinicians for whom we offer these training resources. You saw the case study that exemplified a lot of the gut first facet of the thyroid algorithm, which we’ve crafted to give clinicians a system to follow. This allows them to parse through all the various interventions in thyroid in the most efficient way. Finally, we concluded with a meta analysis that was really pivotal support for what we’ve been saying for a while – there is a subset of patients who are being told they are hypothyroid who are not.

DrMR:

Our continuation of that has been that they do have symptoms oftentimes coming from the gut. The prevalence of functional gastrointestinal disorder – gut symptoms as a broad category – is about 40% of the population. I’ve cited on the podcast in the past that 4.6% of the US population is hypothyroid. Actually when you dig into that number more deeply – and this is why I always double, triple, quadruple check – you realize that hypothyroidism has two components: subclinical, which is 4% of the population and then true hypothyroid, which is 0.6%. When you filter out subclinical hypothyroidism, it’s actually even more rare than my previous quoting of the literature has suggested. If we’re looking at prevalence data, 0.6% of the population is hypothyroid. Let’s compare that to a specific condition in the gut – IBS – which is about 15%.

DrMR:

If you want to play devil’s advocate, it’s unfair for me to compare a niche diagnosis of hypothyroid to a broad diagnosis of functional gastrointestinal disorders, which would be 0.6 to 40. So let’s do a specific diagnosis to a specific diagnosis: Frank hypothyroid 0.6 vs IBS about 15. It is an order of magnitude difference between the two – actually more than an order of magnitude. Again, it’s not to say that there is never anything to intervene in regarding thyroid, but if we’re looking at the probabilities of these things, it should be really clear that the problems in the gut are far more common than hypothyroidism. If we know that these problems in the gut can cause some of the same symptoms that are attributed to thyroid – fatigue, depression, potentially dry skin, and definitely constipation – then before we use a theoretical diagnostic criteria for hypothyroid, we should get someone to a point where they are devoid of gut symptoms and then re-evaluate. That’s a charitable read because the evidence for the theoretical premise of some of the functional medicine thyroid camp is pretty paltry. There is a grain of truth that some people – perhaps 10% of those who do not feel well on T4 – will do better on combination therapy. That’s a far cry from saying everyone who has a TSH above 2.5 is hypothyroid.

Dr. Ruscio Resources:

Hi everyone. This is Dr. Ruscio. In case you need help, I wanted to quickly make you aware of what resources are available to you. If you go to drruscio.com/resources, you will see a few links you can click through for more. Firstly, there is the clinic, which I’m immensely proud of the fact that we deliver cost-effective, simple, but highly efficacious functional medicine. There’s also my book, Healthy Gut, Healthy You, which has been proven to allow those who have been unable to improve their health even after seeing numerous doctors to be able to help them finally feel better. There’s also our store where there’s a number of products like our Elemental Heal line, our probiotic line, and other gut supportive and health supportive supplements. Health coaching – we now offer health coaching. So if you’ve read the book, listened to a podcast like this one, or are reading about a product and you need some help with how to use it or to integrate it with diet, we now offer health coaching to help you along your way. Finally, if you’re a clinician, there is our clinician’s newsletter – The Future of Functional Medicine Review. I’m very proud to say that we’ve now had doctors who’ve read that newsletter find challenging cases in their practices, apply what we teach in the newsletter, and help patients who are otherwise considered challenging cases. Everything for these resources can be accessed through drruscio.com/resources. Alright – back to the show.

Episode Wrap-Up

DrMR:

At the risk of getting too into the weeds, if we’re zooming way out, what’s more common? Start there and then work your way down toward the things that are less common. Use the evidence base of what we have clinical or interventional trials for in these various facets. So what’s most common? Problems in the gut. What therapeutics in the gut have the best clinical trial and interventional evidence? Start with those, move your way toward the treatments that have less evidence, and then segue to the second consideration – which might be the thyroid – and do the same thing again. That’s the thinking that underlies how we’ve constructed the algorithms that we use both in GI and in thyroid. Remember that if you want to read more of the thyroid algorithm, the other supporting materials, and the case studies, please sign up for the Future of Functional Medicine Review. $1.00 and you’ll get 30 days of access as long as you sign up any time in October. I hope you will so that you can better understand some of these nuances. If you’re a patient, it might be a little bit intense of a read, but we’ll give you some criteria to navigate your healthcare. If you’re a clinician, it’s definitely on the mark for you so you can offer the best to your patients. Hopefully the FFMR can function as a tool to give us a better paradigm to steer towards; to help patients get well, not spin their wheels, not waste their money, and not get sucked into fear (as Rebecca did about a parasite.) It allows for a more balanced, practical, and accurate discussion of her health, of her labs, and of what’s going on in her system – which I termed as some dysbiosis and is less scary and less pathogenic. In any case, I hope this has been helpful. Please consider a month trial for $1 on the FFMR. Otherwise, thank you guys for listening and for hanging out with me. Again, I hope this was helpful. We will talk to you next time.

Outro:

Thank you for listening to Dr. Ruscio Radio today. Check us out on iTunes and leave a review. Visit drruscio.com to ask a question for an upcoming podcast, post comments for today’s show, and sign up to receive weekly updates.


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