Practitioner Question of the Month
When to Treat the Thyroid Instead of the Gut
I am a GP and been looking to offer more integrative care to my patients. I have found your work extremely helpful, thank you. I have been treating a patient for SIBO and she has experienced a good response from Rifaximin. However, she remains what I suspect is subclinical hypothyroid with a TSH that hovers around 5.5 and free T4 that is normal but usually in the lower half of the range. I know you are not a fan of ‘functional ranges’ but I am wondering what you would do for someone in this case. Her main symptoms are fatigue and mood lability.
Thanks, and great question Hinder. Fortunately, there may be a fairly simple answer here. As we have discussed previously using the dialysis/LCMS testing method, T4s and/or T3s can often uncover cases that were previously thought to be borderline normal (euthyroid) as in fact being hypothyroid. This is, in part, because this testing method filters out binding proteins that can confound results. So, repeat the test using the dialysis/LCMS method, instead of the immunoassay, and you may see that now the fT4 is also flagged low. If so, you have qualified this patient to begin on thyroid replacement Rx.
The other factor to mind here is age. The older the patient is, the less likely they will be to respond to thyroid hormone Rx. TSH normally increases with age, so seeing a minor elevation, 5-9 roughly, in those over 65 is not unusual. Therapy can still be initiated here but you should be looking to correlate therapy with some positive response; energy, body composition, CRP, HbA1c, and cholesterol level improvement are all good examples.
Finally, remember that fatigue and mood fluctuations could have other causes. Chiefly consider: meal frequency (is she eating enough/frequently enough), histamine intolerance (is she over consuming histamine-rich foods), lifestyle (stress, sleep, exercise) and female hormones (does she also exhibit signs of female hormone imbalance; PMS, altered cycle length, hot flashing…).
Hope this helps!
Voxer – a free, simple tool that can greatly enhance communication
This is a quick one but impactful none the less. Voxer is a free app you can download on any smartphone. It is essentially like a texting but doing so with audio. Technically, you can text or talk but the audio component is what makes it the most novel. The picture you need to communicate with someone on your team about whatever. The communication is too wordy for an email, but you also don’t feel the need to set up a call. Or maybe, it’s just too difficult to set up a call. This is where Voxer is a game changer.
You can have a delayed conversation via Voxer. Send someone an audio message asking your question, or whatever, and they will instantly be able to listen and respond. Now, if they are tied up, they can respond when they have a moment. You can have a delayed back and forth discussion that allows the ease of communication verbal speech affords, but you can also utilize the convenience of not having to be on the phone with someone in real time. Voxer can be used 1-1 (with two people) or as a group conversation.
Voxer has enabled me to reduce the number of meetings I have to schedule with my team by roughly 40%. This is huge. Give the app a quick download and then experiment. I think you will like it.
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.