Practitioner Case Study – June 2019

Dr. Ruscio Comments:

This is another guest case study from one of our readers, Dr. Joe Mather. It provides a powerful example of how difficult, if not impossible, it is to get thyroid medication form and dosage correct, if there is an active issue in the GI. You can see Joe’s clinical precision evolve over the course of this case study. Joe, thank you so much for sharing.

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Patient Info:

KB presented as a 49 y/o female, who works as an attorney and has been dealing with hypothyroidism, elevated blood pressure, mixed hyperlipidemia, and hormone issues. She has also made recent attempts to lose 10 pounds via processed protein shakes and bars. She is overall happy and doing well. My initial impression was of an active, intelligent woman with above average health habits.

Chief Complaints

• Hot flashes
• Fatigue
• Episodic periods of elevated BP, palpitations
• Knee pain

Rx

• Armour thyroid 90 QD
• Vitamin D 3000 QD
• Minastrin QD (for hot flashes)
• Imitrex PRN
• Clonazepam 0.5 1-2 po QHS prn
• Effexor 37.5 QD
• Meloxicam (for knee pain)

Initial Wellness Labs

• Glucose metabolism = 89/5.6/3.7
• hyperbetalipoproteinemia LDLp=1508, ApoB 112, Lp(a)37, hsCRP 1.1, O3i=4.6
• Vit D = 63
• TSH = 2.4
• 4F = 0.8
• 3F = 2.5
• TPO = 350
• TG = 6

At this time KB was looking and feeling pretty good. I clarified that her long-standing hypothyroidism was due to Hashimoto’s and focused attention on lifestyle factors that would help lower lipids and autoimmunity.

Initial workup started to evaluate thyroid contribution to health and long-term risk factors.

Recommendations:

Diet:

• Paleo diet with a reduction in processed foods

Supplemental:

• Increase Vitamin D to 5000 IU QD*
• Added fish oil, 2 caps a day
• Add Probiotic

Lifestyle:

• Discussed stress management

I began with a more focused workup with regard to Hashimoto’s. As you’ll see, this focus on prevention shifted toward trying to help calm very labile Hashimoto’s Disease.

*It is no longer my practice to push vitamin D levels to 80 for those with autoimmune disease.

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Visit 2 – Lab Review

• Coronary Calcium Score  = 0
• Low normal iron studies: ferritin = 40, % sat= 24.
• Female hormones menopausal:
  • FSH = 48
  • LH = 35
  • E2 = 30
  • P = <0.5.
• EBV EA <9 (negative)

Initial thought was to have her focus on the initial program and return in 6 months.

Dr. R’s notes:

• I am now looking at ferritin much more closely, in this case, it could be contributing to her fatigue.
• Her female hormones, of course, also flag.
• Both of these may improve from Minastrin but should be monitored. Knowing how long she had been on Minastrin and how this has impacted her subjectives could give clues its effectiveness. 
• My other notes will appear below in red.

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Visit 3 (4 months later)

Patient placed phone call to the office stating: “I have been experiencing a feeling of heartbeat/pulse in my head.” BP erratic with average SBP 140-150, headaches and palpitations. Flare coincided with a period of personal stress and travel.

• BP in office = 168/96.
• EKG in office revealed NSR, new first-degree AV block.
• Labs reveal TPO increased to 556, TSH = 2.84, T4 = 1.0, T3 = 4.9 (high)

Recommendations:

Diet:

• Start AIP diet

Supplementals:

• Trial switch to Synthroid 100mcg QD from Armour (had been on Armour for a long time, did not know her response to Synthroid)
• Magnesium glycinate 300mg a day
• Selenium 200mcg
• CoQ10 200mg a day
• L-carnitine 2g QD

Switching to Synthroid was a good idea, she may have improved T4-T3 conversion due to improved health via prior therapies (paleo, probiotics, etc.) hence causing the high T3.  

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Visit 4 (1 month later)

No improvement in symptoms, feeling increasingly fatigued. Thyroid labs and symptoms worsened.

Labs: TSH 13, T4F=1.3, T3F=2.0, TPO=647

Recommendations:

Diet:

• AIP: Added eggs and wine back to as KB was missing these foods

Medication:

• Changed back to 90mg Nature Throid

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Visit 5 (1 month later)

Added wine and eggs, still off grains and dairy. Very compliant with dietary restrictions, but has not seen dramatic improvements.

Thyroid Labs: TSH = 5.07, 4F = 0.9, 3F = 3.1, TPO = 730

Recommendations:

Diet:

• Recommend reintroducing foods and monitor reactions because continued restriction was not showing improvement.
• Trial fasting

Supplemental:

• Increased Armour Thyroid dose: 1 tab QD, 1.5 tabs QOD. (Nature Thyroid was on temporary backorder, we had switched to AT in the meantime. )
• Started Inositol 600mg QD on empty stomach QD with aim to reduce TPO
• Patient overwhelmed by supplements – I had her to stop magnesium glycinate, selenium, CoQ10, L-carnitine

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Visit 6 (2 months later)

Email from KB: “Haven’t felt well since before January. I am wiped out. Have had to nap yesterday and today and still feel exhausted” During her office visit – ongoing fatigue, headaches, lightheadedness. New onset abdominal pain. KB continued to broaden her diet, did not notice any specific reactions, regained a few pounds. Average BP at home: 145/100

Had workup by OBGYN for the new onset abdominal pain including pelvic and abdominal ultrasound, bloodwork including CA125. Pelvic exam normal found to have a simple R ovarian cyst. He also switched HRT to Lopreeza.

Labs: TSH 4.58, 4F = 0.8, 3F = 3.7

Recommendations:

• Started Propranolol -10-20mg 1-2 PO BID PRN SBP>140
• Ordered Thyroid ultrasound and repeat labs
• Advised Doctor’s Data stool test (test completed June 8th)

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Visit 7 (2 weeks later)

Thyroid Ultrasound: “Small heterogeneous thyroid gland with vascularity and no nodule … chronic thyroiditis.”

Labs: TPO = 636, TG = 7, TSH = 8.28, 3F = 3.1, 4F = 0.7

Recommendations:

• Switched back from Armour to Nature Throid

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Visit 8 (1 month later)

KB had backed off on most supplements and meds as she was unsure if they were helping her or not (propranolol, Coq10, carnitine, magnesium, selenium, inositol). Continuing to have flares of “crazy BP.” Continues to take Effexor, Lopreeza, Nature Throid, and Vitamin D.

Doctors Data Stool Test: CSAP with O&Px3:

• Dysbiotic flora: Campylobacter 2+
• Imbalanced flora: alpha strep 1+, Citrobacter 2+. Klebsiella 1+
• Yeast: candida 1+, two samples with “few” growth
• No parasites

Recommendations:

Start gut program

Diet:

• Paleo diet – whole fruits, vegetables, meat. No grains or dairy.

Supplemental:

• Lacto / Bifido blend – 1 capsule twice a day
• Saccharomyces boulardii – 2 capsules daily
• Partially Hydrolyzed Guar Gum 7g – 1 scoop QD
• “Leaky gut cocktail” – 1 scoop QD

Do diet plus supplements for 2-4 weeks, then start Habx, taken with meals, for 4 weeks.

• Herbal blend – 2 caps BID
• Oil of Oregano – 1 TID

Recheck thyroid 1 month after this program. (These interventions were not done promptly as KB was traveling abroad.)

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Visit 9 (1 month later)

Email correspondence: “Since we stopped those supplements my TSH has gone up dramatically.” KB had not yet started the gut program previously recommended.

Labs: TSH = 15.7, 4F = 0.7, 3F = 2.7, TPO = 652, TG = 6

Recommendations:

• Restarted inositol CoQ10, Mag, Selenium
• At this point, KB was taking NT146 mg QD. I added Synthroid 50mg QD
• Asked her to start diet and supplements recommended in June

Note: Using two thyroid medications is not my common practice. At this stage, KB had been swinging up and down for seven months. In all honesty, I was struggling to try to help KB feel better.

Email From Patient (1 month later)

KB had traveled to Greece and as she was starting to feel better she did a lot of hiking and biking. Unfortunately, she then crashed. Reported fatigue, elevated BP, and shortness of breath. New loose stools, diarrhea, bloating. I got an email from the patient saying, “I’m flying home early as I feel terrible. BP better, but nauseous, light headed and weak.”

She had not yet started Habx – I had her start them at this time.

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Visit 10 – Phone Consult (2 weeks later)

Following a phone consult with KB I made the following note:

“She is feeling good overall; however, oil of oregano was causing diarrhea and nausea. She stopped this and is feeling much better, I’ve asked her to increase the other antimicrobial she was taking to 4 capsules daily and follow up with me in 1 month.”

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Visit 11 (3 months later)

“Everything has been fine.” Because KB was feeling so well, she just didn’t follow up with me. At this point, she had been on Habx (herbal blend without oregano) x 2.5 months

Dr. R’s note: A key turning point here 

Review of symptoms:

• Energy: “Improved 30%”
• Bowels: no constipation, diarrhea, bloating
• Acid reflux has gone away (without telling me she had been taking omeprazole OTC)
• BP 138/74
• Meds – Synthroid 50 QD, NT 97.5 QD
• Supplements: Habx, GI Select, PHGG, Saccharomyces boulardii 500mg QD, Selenium 200, -Mag 300, CoQ10 200, Inositol 750 QD, Probiotic BID, Vit D 2000,

Recommendation:

• Stop antimicrobial – wait 1 week, then:
• Stop gut-healing nutrients  – wait 1 week, then:
• Consider stopping fiber – reassess with labs
• Labs

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Visit 12 (1 month later)

Victory! Improvement in KB’s labs that mirrored how she was feeling.

Great job Dr. Mather!!

Changes in labs:

• TPO 735  to  305
• TSH 6.9  to 0.46
• F3 1.9 to 3.7

Recommendations:

• Decrease Synthroid to 25 mcg QD
• She weaned off of antimicrobial and will wean off of gut healing nutrients after this bottle is finished.

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Visit 13 (2 months later)

	July 2018	August 2018 *	December 2018	February 2019
TSH	15.7	6.94	0.46	0.04
TPO	652	735	305	208
F3	2.7	1.9	3.7	3.5

*Started Habx

Also of note: Triglycerides improved from 314 in November 2018 to 147 in February 2019.

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Visit 14 (1 month later)

Back to exercising intensely 5x a week. Energy and brain fog – “much improved!”

“Hair coming back!” (This had been a chronic issue that never came up initially. Perhaps most importantly in New Orleans, she tolerated king cake and wine without symptoms or issues. Despite my recommendations to broaden her diet she was fearful of broadening her diet.)

Recommendations:

• Switched to Synthroid 137mcg QD
• Stop inositol, stop magnesium
• She was feeling so good that she felt she no longer needed her long-standing antidepressant. As such, I had her wean Effexor ½ tablet x 1 month, then stop or go to ½ QOD. Getting off antidepressants is now a fairly common occurrence with my gut patients.

Takeaways:

• I originally started caring for KB in the early stages of my understanding of functional medicine. As such, I started her on a strict elimination diet, which was neither helpful or needed. Looking back, I think that the diet contributed to her fatigue. I seldom use an elimination diet in my clinic these days.
• Pay attention to what is not working so that you can learn what not to do. It is now my habit to keep a detailed list of symptoms and interventions that have been trialed on every patient.
• This case is evidence against chasing thyroid labs. I spent way too much time trialing various thyroid medication combinations in an attempt to get her symptoms and fatigue under control. This meant extra stress on KB having to get frequent labs and more stress worrying about the results. I now find this is rarely needed, and perhaps make one or two small changes in dose.

YES

• KB ultimately did better on Synthroid than a natural product.

YES

• From the time of her first Hashimoto’s flare in January to the turning point in August when we started Habx, KB was really suffering and I hadn’t been of much help. Looking back, I could have saved months of frustration and thyroid swings had I started with KB’s gut health.
• Metabolic improvements were seen when her gut health improved. She was also able to wean off antidepressants which she had been on for many years.
• KB was a lesson for me in perseverance. There is always a reason why someone is sick, we practitioners need to be diligent until we find the root cause of their illness.

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Dr. Mather – thank you so much for sharing this case study illustrating the importance of the gut in recalcitrant thyroid cases. 

When we look at this case in juxtaposition to my thyroid algorithm, we can see how well it works in practice  https://drruscio.com/practitioner-2019-mar-research/#r4

Well done!