Practitioner Question of the Month – June 2017

Hi Dr. Ruscio,

Thanks for all the great information you put out. I HAPPILY subscribed after following your podcast for 2 years. I especially appreciate your dedication to evidence based treatments as well as your concern for lowering the cost of functional medicine for patients.

In the last two case studies you’ve mentioned several labs that you routinely use. I’m a MD just starting my functional medicine practice and would find it extremely helpful if you could elaborate on your thought process into which labs you select for your patients in the case reports.

Looking into some labs that you’ve mentioned in your case studies, it looks like the 401H from BHL is roughly compatible to the GI-1 panel from diagnostechs. Do you find one more sensitive in certain cases? Are the costs to the patient roughly the same? Do you routinely find enough parasites to justify the diagnostechs GI-2 panel – or do you find the regular O&P sufficient? Do you find these tests to be superior to Genova’s CDSA?

Thanks,
Joe Mather

Thanks Joe and glad to have you on board.

Happy to elaborate, Joe. When ordering non-SIBO testing, I look at this essentially in the window of if a patient has insurance or if they don’t have insurance.

If they have insurance, I’ll order a profile through Quest or a profile through LabCorp. It takes a bit of time to dig out all the codes to be able to order a profile that’s comparable to other tests like the 401H or the Doctor’s Data profile. However, it can be done, and I have found good results with those.

Listing all those codes and going into that is beyond what I can do here. It is something I plan on covering in a clinical training course that I plan on releasing at some point in the next couple years.

And there is one nuance wherein Quest does offer the anti-vinculin and anti-CDTB antibodies, which is essentially the IBS Check test that used to be available through Commonwealth Labs. Quest has made their own version of it, known as IBSDetex.

So if you know how to use this information, then I will add the IBSDetex test to the Quest panel in patients with IBS or suspected SIBO or diagnosed SIBO.

Now, I’m going back and forth in my mind about running two stool tests in tandem or two non-SIBO gut profiles in tandem. For more severe cases, I typically run two. I’ve been doing that a little less lately, to be honest with you, because I’m not sure it’s fully necessary. In cases that are a little less severe, I will typically just run one non-SIBO profile.

And so if it’s one profile, it might just be a LabCorp panel. If it’s two, it would be LabCorp and then one of the other labs I’ll mention now, which are the non-insurance labs.

Labs I like there are the 401H by BioHealth, also the Doctor’s Data profile. There are two that I use—the comprehensive parasitology 3X or the comprehensive stool with parasitology 3X.

The difference is the comprehensive stool with parasitology 3X has additional markers that are helpful for differential diagnosis of inflammatory bowel disease, namely lactoferrin and calprotectin.

I find the other markers in that panel, the functional markers, to be close to useless, just my opinion on that. But they don’t really tell you anything. And I’ll save you the details as to why, but it’s really just the lactoferrin and calprotectin that I’m after when I order that expanded panel from Doctor’s Data.

I also will sometimes use the Diagnos-Techs select panel of 15 markers. And what’s different there is that looks at salivary antibodies for things like candida, H. pylori, toxoplasmosis, amoebiasis.

And so instead of just stool analysis for these things, as you see in the 401H and the Doctor’s Data profile, you’ll get an antibody, again for H. pylori, amoebas, and worms. Actually, I don’t believe—maybe candida also. I believe candida has a culture and antibody profile. So you get a slightly different window there.

And then experimentally, I’m looking at the GI Map test, which also can bill to insurance. It’s an updated version of some PCR technology, which I’ve really had some reservations about. And there have been some major limitations within the past. So I’m open to it, but I’m proceeding cautiously with that.

So I find all these profiles to be somewhat equivalent. I can’t say I’ve found one to be more sensitive than the other. And I have been paying attention for that.

I do sometimes think the functional labs may over-report lactoferrin and calprotectin because their ranges are more narrow. But that’s, I guess, an issue of interpretation.

So I find them all to be generally the same in terms of effectiveness, with the exception of the GI Map, which I’m currently still trying to make my mind up on.

The costs are the same for all the non-insurance tests to patients generally speaking, although if you do the expanded version of the Doctor’s Data profile, it’s a couple hundred dollars more. I think at least it’s $150 more.

And I do find them preferable over Genova’s CDSA. I haven’t classically been a big fan of Genova. I’m certainly open to it if the right data was presented to me, but I have not been a big fan of much of Genova’s GI and stool testing historically.

Healthcare and medicine are changing. And one of the main changes that is occurring is the broader adoption of telemedicine, or video consults. This is being used fairly regularly in much of the alternative and functional medicine community, but it’s also starting to gain broader adoption in conventional medicine circles.

And the reasons for this are quite simple. It saves time, and it saves money. So as long as there’s not an overt need for someone to be seen in the office physically, we’re seeing the utilization of technology to allow patients to check in via phone or video consults.

Now, this is great. But it also poses a concern, which is compliance with HIPAA. There is a service, the VSee Service, that is a HIPAA-compliant platform that allows you to perform video or phone consults.

It also offers other services, but in my mind, the most attractive component of this is knowing that your video consults or tele-video consults are HIPAA-compliant.

The other thing that’s noteworthy about this is it has a low bandwidth, much lower than that of Skype.

So it should greatly reduce what I’m sure anyone who uses Skype becomes frustrated with, which is dropped calls, call interruptions, patchy audio, and patchy video, which can be quite annoying because it can interrupt the flow of the visit and also detract from the time efficiency of the visit, which can be a big deal.

So this platform allows us a less-interruption-prone, HIPAA-compliant experience for virtual video consults.

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