Practitioner Case Study – June 2018

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Case Study

Patient Info:

  • Kim, 57yo, female
  • Previous Dx
    • Euthyroid Hashimoto’s
  • Rx
    • Lisinopril 5 mg/day-HBP
    • Tirosint 63 mcg/day-Hashimoto’s
    • Buspar 15 mg/day-Anxiety
  • Chief complaints
    • Constipation (3BM/wk), Hard/Compact, 10-IN
    • Bloating, 5-IN
    • Fatigue, 7
    • Insomnia, 5
  • Other signs and symptoms
    • Allostatic load, mod – fatigue, fasting, sleep, cravings,
    • Female, mild/mod – vag dryness, low libido, hot flash

Visit 1 (Day 1) – History and Exam:

Initial Impression

  • Kim presents as a 57yo female with a paleo low FODMAP-like diet, with a good lifestyle and demeanor but who is overly involved and worried about her health.  Fearful of foods, frustrated and the same applied to her TPO abs.
  • She has been Dx euthyroid Hashimoto’s and sleep apnea. Is using CPAP, and is on Lisinopril 5 mg/day-HBP, Tirosint 63 mcg/day-Hashimoto’s, Buspar 15mg/day-Anxiety.
  • Previous testing has found
    • Diagnostic Solutions: C. diff.  SIBO: H2 17, CH4 13 Bloods: TPO hover in thousands
  • Onset:
    • CCs started after 4x Abx for a sinus infection
  • Her symptoms have improved from AIP, LF (autoimmune paleo, low FODMAP) and especially from gluten-free.  Tirosint also helpful. Miralax was much more helpful than Mg/C but came off due to CBC findings. Thyroid Abs non-responsive to diet nor selenium, vitamin D.
  • Kim has not treated GI dysbiosis (formerly found) other than with diet, probiotics, and fermented foods.  She may do well from further treatment; namely Habx. She may also simply require a different method of constipation support; Miralax.  Her MD upped the dose of Tirosint to help lower her historically high TPO abs, however, this might be causing fatigue.
  • Diets are creating fear and resentment, appears to be following them too strictly.  Has been on Buspar for a long time, however, she might not need this any longer with improving diet.  May also have histamine intolerance, but careful with more dietary restrictions. Or, abdominal-pelvic adhesion and/or dyssynergic constipation are also possible.
  • Since she has not done much for GI has much potential, especially if she simply needs Habx, broader diet, and low dose Miralax.  Prognosis good to excellent.

Previous Diets

  • Low FODMAP – helps constipation, bloating but feels too restrictive.  AIP – very helpful, especially joints but depressed because she missed food.   GF – improved joint pain.

Previous Treatments

  • Tirosint – helps fatigue.  Miralax (osm. lax) – helps constipation. Sleep apnea (CPAP) – helpful.  Mg w vit. C – helps but not as much as Miralax. Buspar (anxiety) – helpful.  Se and vit. D – did not improve thyroid Abs.

Visit 2 (A Few Days Later) – Testing and Initial Recommendations

Testing

  • Tests ordered
    • Aero Lactulose SIBO breath test
    • BioHealth 401H stool test
    • LabCorp #2 – see markers at next visit
      • basics, additions
      • fT3 dialysis/LCMS
    • LabCorp #1 blood, stool, breath -– see markers at next visit
      • full GI
  • Rationale
    • Given her digestive symptoms, a GI eval is warranted (SIBO, BioHealth, and LabCorp)
    • Because I am suspicious that she either does not need thyroid Rx or is overdosed, I am ordering the more sensitive dialysis/LCMS testing for free T3

Recommendations

  • Diet
    • Please follow a loose paleo diet.  Only avoid foods you have noticed do not agree with you.  Experiment with nuts, beans/legumes, gluten-free grains and high FODMAP foods.
    • Please do not follow the results of your Cyrex test, as we will work to broaden your diet.
    • Please eat every 3-4 hours, most of the time.
  • Lifestyle
    • na
  • Treatment
    • Please be on the diet for 2 weeks before adding in the supplements, but continue diet until our follow up.  Then be on the supplements for 3 weeks before following up. Please make a note of the change you noticed from diet versus supplements.
    • First, perform a 4 day trial on peppermint.  Then start on the rest of your program.
    • Nutrient support:
      • vitamin D/K, fish oil blend
    • Adrenal:
      • Preg, DHEA
    • GI:
      • Lacto-Bif probiotic, Soil-based probiotic, S. boulardii (all 1x/day).
      • Fiber, Mag Citrate + Vitamin C and Miralax.
      • Work to find the minimum dose of Miralax.
  • FU: 6-7 weeks
  • Rationale
    • Kim was far too restrictive with her diet, so we advised her NOT to regard her food allergy testing and to work to broaden her diet.
    • We also used frequent meals to stabilize blood sugar
    • All 3 categories of probiotics were used, plus laxative and adrenal support

Visit 3 – Lab Interpretation and Treatment Evaluation

Subjective Assessment:

  • Peppermint – no change
  • Probiotics – helped bowels markedly
  • Fiber – might constipate
  • Eating more – feels good, makes her happy
  • Decreased Tirosint dose – felt fine
  • Overall “feels really good”

Lab Interpretation:

  • Aero Lactulose SIBO breath test
    • H2 15, CH4 2
  • BioHealth 401H stool test
    • Normal
  • LabCorp #1 blood, stool, breath
    • Normal
  • LabCorp #2 blood & urine *Fasting
    • UA -Abnormal, RT3 28.3-H
  • Dx
    • No diagnosis, high reverse T3 noted.
  • Summary
    • The high rT3 may be due to unneeded thyroid Rx but is not concerning at the moment.

Impression:

  • Today Kim has done great from eating more, taking less and enjoying her life.  Probios and Preg/DHEA very helpful for GI and energy. Fiber might constipate.  Peppermint – no change. Also able to decrease Tirosint. Today labs are generally UR.  Will continue with the current plan, sans peppermint, and then fu in 6 weeks to do program wean.

Recommendations:

  • Continue previous recommendations.
  • Starting
    • Stop peppermint now
    • Keep up the good work
  • FU: 6 weeks

Dr. Ruscio’s Comments

This case is a strong illustration of how important it is to identify patients who have gone overboard with health research and are inadvertently making themselves sick.  Kim could have very easily been pulled deeper into the ‘sickness’ mentality. In fact, our first visit was a bit tense because ‘she was expecting more after seeing an expert’.  She was a bit let down that I did not advise digging deep into further testing or provide more elaborate treatment recommendations. She was expecting this due to her functional medicine programming.

Kim noted that she was feeling better than she had in several years, after taking less medication and broadening her diet.  If I had said ‘she had SIBO’ due to her methane of 4, or a thyroid problem due to her high reverse T3, I would have been doing her a huge disservice.  She had the tendency to expect the worst and for her path to be challenging, however, Kim was much healthier than she realized. The ‘treatment’ she needed was a responsible narrative regarding her health, her labs and a treatment program that alleviated the unnecessary burden dietary restrictions plus provided a small degree of support.

Don’t miss these cases.  They will not respond to more treatment, because they do not require it.  You will save them much time, money and heartache if you can identify this out of the gate.

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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Discussion

I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!

16 thoughts on “Practitioner Case Study – June 2018

  1. Hi Dr. Ruscio,

    I’d be interested to hear you expand your thoughts on the use of pregnenolone / DHEA as support – either here or in the podcast.

    Reviewing these cases, and seeing the moderate female and allostatic load symptoms listed hereI assumed that you would have first added chaste tree extract / black cohost / dong quai or classic adrenal adaptogens for the allostatic load.

    What was it about her presentation that made you go the DHEA / pregenolone route? Do you find difficulty in getting women to stop these support or wean off?

    Joe Mather

    1. Hi Joe,
      Preg/DHEA are another form of adrenal support, I can’t say I feel them to be any better or worse than adaptogens. With adrenal support, you can get some spillover benefit for female hormones. Sometimes I start with Preg/DHEA, sometimes with adaptogens. If someone has a really impaired GI I might start with Preg/DHEA since they are sublingually dosed.
      Hope this helps.

      1. Thanks, It’s very helpful, especially to hear you don’t find them superior to adaptogens.

        Would it be correct to assume that you typically give Preg/DHEA as support for somewhere around 3-6 months while you address other root issues?

        1. So if GI (constipation, IBS, decreased motility) is more of an issue, you would choose hormones over adaptogens even without hormone testing?

          Both preg and DHEA?

  2. Hi Dr. Ruscio,

    I’d be interested to hear you expand your thoughts on the use of pregnenolone / DHEA as support – either here or in the podcast.

    Reviewing these cases, and seeing the moderate female and allostatic load symptoms listed hereI assumed that you would have first added chaste tree extract / black cohost / dong quai or classic adrenal adaptogens for the allostatic load.

    What was it about her presentation that made you go the DHEA / pregenolone route? Do you find difficulty in getting women to stop these support or wean off?

    Joe Mather

    1. Hi Joe,
      Preg/DHEA are another form of adrenal support, I can’t say I feel them to be any better or worse than adaptogens. With adrenal support, you can get some spillover benefit for female hormones. Sometimes I start with Preg/DHEA, sometimes with adaptogens. If someone has a really impaired GI I might start with Preg/DHEA since they are sublingually dosed.
      Hope this helps.

      1. Thanks, It’s very helpful, especially to hear you don’t find them superior to adaptogens.

        Would it be correct to assume that you typically give Preg/DHEA as support for somewhere around 3-6 months while you address other root issues?

        1. So if GI (constipation, IBS, decreased motility) is more of an issue, you would choose hormones over adaptogens even without hormone testing?

          Both preg and DHEA?

  3. Dr Ruscio – Given that her antibodies are still high and have not responded to AIP/GF diet, selenium or Vitamin D, what do you think the cause of her autoimmunity is?

    Given that she has shown high TPO as well as multiple allergens positive on Cyrex test(while not noted in the case summary, but intuited from the history), would you start her on an immune modulator like Moducare?

    Thanks,

    Eric Nager

    1. Hey Eric,
      I think you might be missing the important message illustrated by this case study. She is healthy, and does not need to do more, she needs to do less, worry less, enjoy her life and depart the functional medicine indoctrination that can occur inadvertently subsequent to this type of thinking. This clinical over-thinking was leading her to think she is ill. Did that not come across in the write up? This is a KEY point. *on the go, sorry if this is not super polished*

  4. Dr Ruscio, I have a similar patient, she has many gastrointestinal discomforts, she only makes use of the Tirosint 88mcg. Do you think I should start fodmaps with her?

  5. Dr Ruscio, I have a similar patient, she has many gastrointestinal discomforts, she only makes use of the Tirosint 88mcg. Do you think I should start fodmaps with her?

  6. Dr Ruscio – Given that her antibodies are still high and have not responded to AIP/GF diet, selenium or Vitamin D, what do you think the cause of her autoimmunity is?

    Given that she has shown high TPO as well as multiple allergens positive on Cyrex test(while not noted in the case summary, but intuited from the history), would you start her on an immune modulator like Moducare?

    Thanks,

    Eric Nager

    1. Hey Eric,
      I think you might be missing the important message illustrated by this case study. She is healthy, and does not need to do more, she needs to do less, worry less, enjoy her life and depart the functional medicine indoctrination that can occur inadvertently subsequent to this type of thinking. This clinical over-thinking was leading her to think she is ill. Did that not come across in the write up? This is a KEY point. *on the go, sorry if this is not super polished*

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