Practitioner Case Study – May 2017
Dr. Michael Ruscio’s Monthly – Future of Functional Medicine Review Clinical Newsletter
Practical Solutions for Practitioners
In Today’s Issue
Case study
Research
- Carbohydrate malabsorption and histamine intolerance
- Mast cells, histamine, and IBS
- H. Pylori and autoimmunity
- Medical cannabis (marijuana) and autoimmune disease
Practitioner Question of the Month
Practice Tip
Case Study
*Note: this is a long case study but it does teach us a few valuable lessons.
Patient Info:
- Zenaida, 42yo female
- Dx: Graves’ hyperthyroidism
- Rx: Methimazole, 5mg/day
- Chief complaints
- Graves’ management
- Waking early
- All the below are better when Graves’ is managed
- Increased heart rate
- Appetite loss
- Anxiety
- Diarrhea
Visit 1 (4/8/16) – History and Exam
Zenaida presents as a generally healthy 42 y/o female with good diet and lifestyle. She recently was Dx with Graves’ (potentially with postpartum onset) and has responded well to Methimazole and AIP diet.
She would like to try and get off Rx and use a natural and cause-focused plan instead. We will treat with natural Graves’ protocol and investigate GI trigger while keeping her on Rx.
Then, once she has been stable for a few months, we will have Endo try Methimazole curtail.
She has responded well to initial treatment, so she had a very good prognosis. No confounding ddx.
Initial impression:
- Zenaida has much potential because she has not yet utilized many of the therapies that are documented to aid with thyroid autoimmunity: vitamin D, Mg, CoQ10, selenium, gut health.
- She had responded very well to Methimazole, which is a good prognostic indicator as to the severity of her case. It also suggests she will respond well to similar natural thyroid suppressing therapies.
- This two pronged approach of treating the hyperthyroidism and treating the AI should work well.
Visit 2 (4/15/16) – Testing and Initial Recommendations
Testing:
- Tests ordered
- Aerodiagnostics Glucose SIBO breath test
- Doctors Data Para 3x stool test
- Diagnostechs GI-15 stool/saliva test
- LabCorp Panel
- CBC w Diff & platelet count
- Metabolic Panel, Comprehensive
- Thyrotropin Receptor Antibody
- Thyroid-Stimulating Immunoglobulin (TSI)
- Thyroid Autoantibodies (TPO and TGA)
- T-4, Free (Thyroxine, Free)
- Thyroid-Stimulating Hormone (TSH)
- T-3, Free (Triiodothyronine, Free)
- Rationale:
- The incidence of SIBO has been shown to be increased in those with Hashimoto’s, irrespective of hypothyroidism. Because of this, I wanted to assess if SIBO may be present and if treatment could yield any therapeutic potential.
- Stool testing mainly to assess for any GI infection/dysbiosis for which treatment may benefit: AIT, namely H. Pylori or blasto.
- Thyroid panel of course to assess thyroid status.
Recommendations:
- Diet
- Continue on previous autoimmune paleo diet
- Have a snack when waking and see if this helps with your sleep
- Supplements
- General support: Vit. D
- Adrenal Support: herbal adaptogens
- Thyroid
- AI; Selenium, CoQ, Mg
- Hyperthyroid: Carnitine
- GI: lacto/bifido blend, S. boulardii, probiotic phage formula, fiber supplement
For more on treatment rationale, see my article here at https://drruscio.com/natural-management-graves-disease/.
Visit 3 (6/17/16) – Lab Interpretation and Treatment Evaluation
Lab interpretation:
- Aerodiagnostics Glucose SIBO breath test
- Normal
- Doctors Data Para 3x stool test
- 3x Yeast, 3x RBC
- Diagnostechs GI-15 stool/saliva test
- Raoultella ornithinolytica, K. pneumoniae
- LabCorp Panel
- See below
- Summary
- Potential bacterial pathogen and dysbiosis. Elevated liver enzymes. Euthyroid Graves’.
Subjective Assessment:
- Having a snack when waking did not help sleep.
- She reported adding rice into diet seems to have helped.
- Improved:
- Energy, skin dryness
- Same:
- Sleep; can only sleep for 6-6.5
- Worse:
- Occasional spurts of anxiety and fatigue
- Improved:
Impression:
- Zenaida’s labs are nearly euthryoid (technically subclinical hyperthyroid) but with thyroid AI that appears unmanaged. Today’s GI findings are mild, and will likely be addressed simply by using probiotics. We will retest Graves’ Abs in a few months and then decide on ideal time to curtail Methimazole. I anticipate she will do well.
- She also reported she feels a bit overwhelmed by the number of supplements and would like to curtail to minimal program ASAP. We agreed to do this after Ab retesting.
- I expect her glucose, liver enzymes, and GI findings may return to normal if we did nothing, but the probiotics she is on may also be adequate treatment for all of these.
Recommendations:
- Take steps toward exercising regularly
- Discontinue
- Have a snack when waking and see if this helps with your sleep
- Continue previous
- Diet
- Continue on previous autoimmune paleo diet
- Supplements
- General support: Vit. D
- Adrenal Support: herbal adaptogens
- Thyroid
- AI; Selenium, CoQ, Mg
- Hyperthyroid: Carnitine
- GI: lacto/bifido blend, S. boulardii, probiotic phage formula, fiber supplement
- Diet
- Repeat stool test for Raoultella ornithinolytica and yeast in 1 month
- Follow up: roughly 2 months, based on retesting time
Visit 4 (7/29/16)
Subjective Assessment:
- Still waking up early, but thinks exercising is helping.
- Hair now thinning/falling.
- Her endo now recommended the 5mg of Methimazole every other day.
Testing
- Retesting Diagnostech panel – now normal.
- See below
- Her endo did retesting of blood work
- Normalized; liver enzymes, glucose , fT4
- Vit D: 78
- Report too large to include; image below
Impression:
- Overall, thyroid is doing great and she is still coasting and in Graves’ remission. She has even been able to reduce her Rx.
- Many previous lab findings are clear, but vitamin D is now high. Thyroid levels look excellent, even slightly hypo. Will retest thyroid AB soon. Starting program curtail now. Will soon perform thyroid AB retesting, if levels improve. Starting multi and Omegas for hair today.
Recommendations:
- Discontinue vitamin D during the summer
- Continue previous
- Diet
- Continue on previous autoimmune paleo diet
- Supplements
- Adrenal Support: herbal adaptogens
- Thyroid
- AI; Selenium, CoQ, Mg.
- Hyperthyroid: Carnitine
- GI: lacto/bifido blend, S. boulardii, probiotic phage formula, fiber supplement
- Starting
- General support: omega 3,6,9 blend, multivitamin
- Take your entire program (1x) only in the morning
- Follow up: 2-3 months
- Diet
Visit 5 (10/21/16)
Subjective Assessment:
- Hair loss is now improving/slowing
- Is still waking early
Testing, labs with endo
- TSH, T4, T3 – normal
- CMP, CBC, ferritin – normal
Impression:
- Today is maintaining euthyroid status, even after decreased Rx dose. Is still having thinning hair and insomnia, but they are improving. Derm did not have any recos for hair.
- We will try modified fast and an elemental diet for sleep now. Will also trying increasing carb intake and see if this helps with sleep.
- Will also start curtailing her program further
- Will follow up in 4 months, but have her perform Graves’ retesting before this appointment. I have also added a test for androgens to evaluate if hair loss may be from high androgens. Unlikely but worth ruling out.
Recommendations:
- Continue previous
- Diet
- Continue on previous autoimmune paleo diet
- Supplements
- Adrenal Support: herbal adaptogens
- Thyroid
- AI; Selenium, CoQ, Mg
- Hyperthyroid: Carnitine
- GI: lacto/bifido blend, S. boulardii, probiotic phage formula, fiber supplement
- Starting
- Take your program every other day, and only 1x in the morning when you do
- Perform retesting before our next visit
- Have a small serving of starch or fruit at each meal. Have a small meal before bed.
- Experiment with a 2-4 day fasting using the Modified Fast or an elemental/semi-elemental diet.
- Retesting
- Dihydrotestosterone (DHT), HPLC/MS
- Thyroid AB retesting
- Follow up: 1-3 months
- Diet
Visit 6 (2/22/17)
Subjective Assessment:
- Increasing carbs – no effect
- Modified fast (using bone broth) – hungry/angry
- Hair – still falling but having lots of regrowth
- Sleep – same
Testing, with her Endo
- TSH, T4, fT3, CBC, CMP – wnl
- TRAB – H 2.05,
- But low end of positive range. Down from 6.04 previously
- TPO not tested
Testing I requested
- Not performed, so we are missing
- TPO, androgens
Impression:
- Labs show normal thyroid fx, and much improved thyroid Abs, CBC, and CMP compared to baseline.
- Overall, Zenaida continues to do great. She has no symptoms of Graves’. Her sleep and hair are not great, but hair is improving.
- Today will start continue program curtail. Also, she will speak with Endo about Methimazole curtail, and after a few months off Rx we will retest thyroid and curtail her program more at follow up if stable.
Recommendations:
- Continue previous
- Diet
- Continue on previous autoimmune paleo diet
- Supplements
- Thyroid
- AI; Selenium, CoQ, Mg
- Hyperthyroid: Carnitine
- GI: lacto/bifido blend, S. boulardii, fiber supplement
- Thyroid
- Starting
- Discontinue: Adrenal support, probiotic phage formula
- Speak with your endocrinologist about coming off Methimazole
- Follow up: 2-4 months to continue program curtail
- Diet
Dr. Ruscio’s Comments
Admittedly, this was a mild case of Graves’, which makes its co-management much easier. She responded very well to both conventional and natural therapies. She was able to reduce both her Rx and natural treatment program and maintain improvements. It’s important to take away from this case that the more quickly/easily someone responds indicates they should be able to curtail off their treatment program sooner rather than later. Time taken to achieve remission and time between relapses are both prognostic indicators for the severity of autoimmune conditions, generally speaking.
It’s also important to notice that her GI lab findings, glucose, and liver enzymes cleared simply with her initial treatment program, most likely from the probiotics. Don’t forget about how helpful a basic intervention like this can be.
Her thyroid autoimmunity responded very nicely also, with a marked reduction in her TRAB – likely from the autoimmune support of vitamin D, selenium, CoQ10, and Mg. The low iodine and low allergen nature of the AIP diet may have helped with her thyroid autoimmunity as well. Her thyroid function also responded very well, likely from a combo of the Methimazole, Carnitine, and treatment of her gut with probiotics.
Her hair was slow to respond, but after a few months it did start to improve. Her sleep we still have not been able to make much impact on. Time may be the main factor here, meaning this may improve all by itself with time. We will also continue with some small experiments to see if we can improve this. This all being said, she has been thrilled with her results overall.
It is also important to mention that while she was following an AIP diet, I reminded her that she did not have to be strict and only needed to be compliant about 80% of the time. This was noticeably relieving to her, as she had initially come to my office very scared of autoimmunity. Another example how managing this conversation is very important.
She may relapse at some point in the future, but we have already identified a plan that has worked well for her, so if she does we will revisit this plan.
I’d like to hear your thoughts or questions regarding any of the above information. Please leave comments or questions below – it might become our next practitioner question of the month.
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