Dr. Michael Ruscio’s Monthly – Future of Functional Medicine Review Clinical Newsletter
Practical Solutions for Practitioners
In Today’s Issue
Case study
Research
- Dr. Ruscio’s Review of Zonulin Testing for Leaky Gut
- Re-challenging FODMAPs: The low FODMAP diet phase two
- Rapid-Fire Research – ultra-concise summaries of noteworthy studies.
- Autologous stem-cell transplantation in treatment-refractory Crohn’s disease: An analysis of pooled data from the ASTIC trial
- Selective expression of histamine receptors H1R, H2R, and H4R, but not H3R, in the human intestinal tract.
- Using Hashimoto thyroiditis as the gold standard to determine the upper limit value of thyroid stimulating hormone in a Chinese cohort.
- Blocking nocturnal blue light for insomnia: A randomized controlled trial
Practitioner Question of the Month
Practice Tip
Case Study
Questionable Diagnosis of Hypothyroid by “Famous Thyroid Doctor” Results in Harming Patient Only to Later See Great Results by… Starting With The Gut.
Patient Info:
- Brittany, 33yo female
- Previous Dx
- Hypothyroidism, Epstein–Barr virus, Irregular heartbeat
- Rx
- NA
- Chief Complaints
- Gas, 6-IN
- Bloating, 5-IN
- Fatigue, 4-OC
- Constipation/diarrhea, 8-IN
- Other Symptoms
- Allostatic, mod – fatigue, insomnia
- Female, mod – digestion, cramps
- I am now making a rough tally of how high a patient’s allostatic load and female hormone symptoms appear (mild, mod, severe).
Visit 1 (Day 1) – History and Exam:
Initial Impression
- Intro: Brittany presents as a 33yo female, on a very healthy diet, with a good lifestyle, demeanor, and outlook on her health.
- Dx/Rx: Likely incorrectly Dx with hypothyroid and EBV
- Testing: NA
- Onset/History: Healthy child. IBS 2002-4 until went Paleo. 2015 got very sick with what she thinks was mono, fatigue lasted 1.5 years post.
- Family: AFib, thyroid conditions, anemia
- Tx: See below. Fairly naïve but has responded to what she has done. Other than thyroid Rx, all of which had caused reactions, even after multiple formula and dose changes
- Notes/DDX: Should be a simple case where GI is the main driver, classic IBS/dysbiosis.
- Other: Might also require antiviral/immune support, but not likely.
- Prognosis: Good to excellent.
Previous Diets
- Mg Citrate – helps constipation. Armour – felt worse, levels NR. Thyroid meds (any kind) – negative reactions. Probio – some help, some flare. Habx – up/down. EBV treatment – up/down. Vitamins B, C, and D – very helpful.
Previous Treatments
- Lower Carb, FODMAP and Paleo-like -helps. Low lectin – NR. Low histamine – slight help. AIP – NR. Female hormones best on low carb.
Visit 2 (a few days later) – Testing and Initial Recommendations
Testing
- Please send me the labs from before you went on thyroid medication. The labs that diagnosed you as hypothyroid.
- Optional – Aero Lactulose SIBO breath test
- Optional – BioHealth 401H stool test
- PCO testing at LabCorp
- CBC w diff, CMP, lipid panel, iron panel, Hemoglobin A1c, vitamin D
- TSH, free T4
- TPO and TG antibodies
- Rationale
- Prior labs- I now (unfortunately) ask all patients to send me the labs that diagnosed them as hypothyroid if they were diagnosed by any type of integrative or functional provider. You’ll be shocked by what follows in this case.
- GI testing as optional – because she was treatment naïve, she had performed some treatment but it was mostly haphazard, so chances are high by starting with my GI algorithm she won’t need to test.
- PCO testing – I’d like to see her current thyroid hormone and antibody status, and basic blood work
Recommendations
- Diet
- Please continue with your previous Keto, Paleo, low FODMAP
- See handouts at www.drruscio.com/patients
- Lifestyle
- NA
- Treatment
- Sequence: testing, diet & supplement program, follow up.
- NRT: B Complex, C+Biofizz, vitamin D/K
- GI: Lacto-Biff, S. boulardii, Soil-Based, Mg Citrate
- FU: 4 weeks
- Rationale
- Brittany seemed to respond well to therapies she had done in the past but just needed some structure and monitoring. So, we start simple.
Visit 3 – Lab Interpretation and Treatment Evaluation
Subjective Assessment:
- B Complex, C+Biofizz, Vitamin D/K – helping.
- Lacto-Biff, S. boulardii, Soil-Based, Mg Citrate – helping.
- Improved:
- Bloating, gas (much less). Food Intolerances. Constipation. Insomnia.
- Same:
- Worse:
- Diarrhea (vitamin C).
Lab interpretation:
- Labs from time of ‘hypothyroid’ diagnosis (file below)
- WNL – not hypothyroid
- LabCorp PCO file: Labcorp 11.21.18
- Lipid Panel Cholesterol 220-H, LDL 132-H
- Iron Panel Ferritin 151-H
- Vit D 2-H
- Dx:
- NOT hypothyroid. High ferritin due to inflammation
- NOT hypothyroid. High ferritin due to inflammation
Impression:
- Today Brittany has improved in almost all CCs. Labs are UR AND prior labs with well-known thyroid doctor showed she was NOT hypothyroid… likely why she felt terrible on Rx. Will continue current plan then fu.
- My rant:
- I try to give every provider the benefit of the doubt. Hopefully, this patient misunderstood her diagnosis, which hopefully was ‘you’re not hypothyroid but your levels are not optimal and might benefit from support’. However, the fact that 1) this patient thought she was true hypothyroid and moreover, 2) was subjected to what I believe was roughly 7 months on different Rxs and felt worse the entire time – make me suspect this was terribly executed functional medicine care.
- What is appalling about this is that a well-known thyroid doctor who has literally written books on the issue and speaks at conferences, etc… Again, hopefully, this was just an isolated incidence, but…. I have seen this erroneous thyroid Dx enough times to think it’s Some of these thyroid gurus might be where all the misdiagnosis is coming from (they are teaching this to other clinicians).
- Finally, if you’re going to perform a trial of thyroid Rx in a case like this, you should look to symptomatic improvement to ensure this was the right choice. Pair this with a recent meta-analysis showing no benefit when treating subclinical hypothyroid with thyroid hormone (SCH is worse than Brittany’s normal labs) and you can help but ask yourself ‘what the heck is going on here?’. This display both ignorance to the literature and a poor ability to leave your dogma at the door and know when someone might not fit into your thyroid-centric model.
Recommendations:
- New
- Discontinue the vitamin D for 6 months, then retest and only use a maintenance dose of 2-6,000 IU/day
- Continue current plan
- FU: 6-8 weeks
Dr. Ruscio’s Comments
Brittany is not done with her care, but I wanted to point out that in only 2 months she has seen better results than she has seen in years. She is also no longer burdened with the thinking she is hypothyroid. You’ve likely heard me say that overdiagnosis/incorrect diagnosis of hypothyroid is a problem and that often times it’s a problem in the gut leading to the symptoms attributed to the thyroid. These cases are why. Don’t make this mistake. I expect her loose stools to improve with a reduction in her vitamin C and that her fatigue will follow the trend of all her other symptoms and improve with time.
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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How much vitamin D was her “Famous Thyroid Doctor” giving her? her level was 173! yikes.
Not sure, but likely too much. Zeleatry tends to permeate multiple areas; diagnosis, treatment, etc…
Just saw a patient who was seen by an ND. She had her on 96 capsules of supplements a day, and was inadvertently giving her 37,000 IU of vitamin D daily … for the good part of a year.
Well I guess the good news is there is a growing market for competent FM!
Just saw a patient who was seen by an ND. She had her on 96 capsules of supplements a day, and was inadvertently giving her 37,000 IU of vitamin D daily … for the good part of a year.
Well I guess the good news is there is a growing market for competent FM!
Well I guess the good news is there is a growing market for competent FM!
Dr Ruscio – I find a number of problems with your analysis. Many times what the patient tells us happened, is not always the conversation that took place with their Physician. I have had countless patients tell me that their Doctor said what sounded like outlandish advice. I was initially outraged that the Physician said something that sounded stupid or irresponsible. When I called this Physician, the story was actually quite different than the patient’s rendition. Many times, the response was quite reasonable.
I just finished an Integrative/Functional Medicine Fellowship with the American Academy of Anti Aging Medicine(A4M). We are routinely taught that lab values fall into two categories – “lab normals” and “optimal levels.” While the Thyroid levels on this lab report are technically within normal limits, they are not optimal. In the fellowship, we are taught the values that were hand written on this lab report – T4 1.1-1.2 and T3 around mid-value (in this case around 3.4) and a TSH <2 are optimal levels. . I have been taught this by multiple instructors – not just one.
Rather than being appalled, did you reach out to this Doctor to discuss the case?
I completely agree with you that a patient who does worse on a medication should be taken off of it. I disagree with you that a patient who is symptomatic with hypothyroid symptoms with suboptimal labs should not be tried on some sort of Thyroid support. This might include adaptogens, minerals, mitochondrial support, all the way up to Thyroid Hormone.
There are plenty of bad professionals out there. I am with you on the need to always do the right thing for our patients. I am a huge proponent and advocate of evidence based medicine. I have come to see that much in Integrative/Functional Medicine is based on anecdotal evidence from fellow practitioners who have seen good(or bad) results with certain therapies. In this case, many of my colleagues have seen positive results titrating thyroid hormone to achieve optimal levels, not dissimilar to the patient noted above. I find it difficult to believe that if a patient said that they felt terrible, and told their doctor this, that they would be continued on the same course of action.
Hi Eric,
All fair points.
1. I do agree that often times it’s not as bad as we are told. However, in this case the labs (which did not show hypothyroid) had written on them ‘call for Rx’ which was very premature.
2. Yes, the teaching of these values is the problem. It is subjecting far to many patients to thyroid hormone Rx. Hence this patients months of poor reactions. Considering a trial on thyroid Rx is absolutely an option, BUT this provider totally overlooked the gut and jumped right to an Rx. This is the problem. It’s the sequence in the hierarchy.
3. I don’t see any need to call the doctor to talk this out since we are not co-managing. Happy to have a conversation, but if I called every doc who made a questionable decision I’d be on the phone a LOT. But, also understanding that sometimes what I am hearing from a patient is overblown, YES. I take all patient reports with a grain of salt.
I’ll close with this – people being told they are hypothyroid (when they are not) and being started on thyroid Rx (when they don’t need it) is becoming a pervasive issue. The solution is leaving the Rx (in these non-hypothyroid cases) to a end-phase consideration. I have codified this into the algorithm I introduced in a prior issues of the review. So again, it’s not that thyroid Rx is wrong, it’s just being used way to early and without due circumspection.
I don’t propose to have THE answer here, but I feel my suggestions are better than the standard recommendations of the field. And, this is also what the evidence supports.
Thanks for your comments, keep the feedback coming!
I wanted to suggest Dr Kharrazian’s 2011 thyroid book as a nice resource of common thyroid patterns and non drug interventions for these patterns. I often refer back to this before starting thyroid hormone to make sure I have tried therapies of least potential harm. I find that it is sometimes difficult to resist persuasion by the patient to start hormones when they are feeling terrible, desperate for relief and lab values are perhaps suboptimal. I’m not saying this is ideal, but this is often what plays out in the office.
I wanted to suggest Dr Kharrazian’s 2011 thyroid book as a nice resource of common thyroid patterns and non drug interventions for these patterns. I often refer back to this before starting thyroid hormone to make sure I have tried therapies of least potential harm. I find that it is sometimes difficult to resist persuasion by the patient to start hormones when they are feeling terrible, desperate for relief and lab values are perhaps suboptimal. I’m not saying this is ideal, but this is often what plays out in the office.
Well I guess the good news is there is a growing market for competent FM!
How much vitamin D was her “Famous Thyroid Doctor” giving her? her level was 173! yikes.
Not sure, but likely too much. Zeleatry tends to permeate multiple areas; diagnosis, treatment, etc…
Dr Ruscio – I find a number of problems with your analysis. Many times what the patient tells us happened, is not always the conversation that took place with their Physician. I have had countless patients tell me that their Doctor said what sounded like outlandish advice. I was initially outraged that the Physician said something that sounded stupid or irresponsible. When I called this Physician, the story was actually quite different than the patient’s rendition. Many times, the response was quite reasonable.
I just finished an Integrative/Functional Medicine Fellowship with the American Academy of Anti Aging Medicine(A4M). We are routinely taught that lab values fall into two categories – “lab normals” and “optimal levels.” While the Thyroid levels on this lab report are technically within normal limits, they are not optimal. In the fellowship, we are taught the values that were hand written on this lab report – T4 1.1-1.2 and T3 around mid-value (in this case around 3.4) and a TSH <2 are optimal levels. . I have been taught this by multiple instructors – not just one.
Rather than being appalled, did you reach out to this Doctor to discuss the case?
I completely agree with you that a patient who does worse on a medication should be taken off of it. I disagree with you that a patient who is symptomatic with hypothyroid symptoms with suboptimal labs should not be tried on some sort of Thyroid support. This might include adaptogens, minerals, mitochondrial support, all the way up to Thyroid Hormone.
There are plenty of bad professionals out there. I am with you on the need to always do the right thing for our patients. I am a huge proponent and advocate of evidence based medicine. I have come to see that much in Integrative/Functional Medicine is based on anecdotal evidence from fellow practitioners who have seen good(or bad) results with certain therapies. In this case, many of my colleagues have seen positive results titrating thyroid hormone to achieve optimal levels, not dissimilar to the patient noted above. I find it difficult to believe that if a patient said that they felt terrible, and told their doctor this, that they would be continued on the same course of action.
Hi Eric,
All fair points.
1. I do agree that often times it’s not as bad as we are told. However, in this case the labs (which did not show hypothyroid) had written on them ‘call for Rx’ which was very premature.
2. Yes, the teaching of these values is the problem. It is subjecting far to many patients to thyroid hormone Rx. Hence this patients months of poor reactions. Considering a trial on thyroid Rx is absolutely an option, BUT this provider totally overlooked the gut and jumped right to an Rx. This is the problem. It’s the sequence in the hierarchy.
3. I don’t see any need to call the doctor to talk this out since we are not co-managing. Happy to have a conversation, but if I called every doc who made a questionable decision I’d be on the phone a LOT. But, also understanding that sometimes what I am hearing from a patient is overblown, YES. I take all patient reports with a grain of salt.
I’ll close with this – people being told they are hypothyroid (when they are not) and being started on thyroid Rx (when they don’t need it) is becoming a pervasive issue. The solution is leaving the Rx (in these non-hypothyroid cases) to a end-phase consideration. I have codified this into the algorithm I introduced in a prior issues of the review. So again, it’s not that thyroid Rx is wrong, it’s just being used way to early and without due circumspection.
I don’t propose to have THE answer here, but I feel my suggestions are better than the standard recommendations of the field. And, this is also what the evidence supports.
Thanks for your comments, keep the feedback coming!