Eric Balcavage - SHEICON - Final

METHYLATION /
HYPOTHYROIDISM
CASE PRESENTATION
Eric Balcavage DC, CNS, CFMP, BCIM
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Doctor of Chiropractic
Certified Nutrition Specialist
Certified Functional Medicine Practitioner
Board Certified in Integrative Medicine
Instructor with American Functional Neurology
Institute
OBJECTIVES
• Describe complaints and patient
demographics
• Associate history with patient
complaints
• Examine treatment options
• Identify best course of action
• Interpret results
PATIENT INITIAL PRESENTATION AND
PRIMARY COMPLAINTS
• 47 year old female
• Works full time as a
nurse
SECONDARY HEALTH
CHALLENGES
• Sleeping challenges (getting
to & staying asleep)
• Irritability
• Numbness in hands & feet
• Allergies
• Constipation
• Heartburn & reflux
• Reduced sense of smell &
taste
• Dry eyes yet eyes are
always tearing
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Reduced libido
Anxiety
Difficulty reading
Dropping things, clumsy,
bumping into things
Reduced ability to do
math
Difficulty expressing
thoughts
Difficulty using the
correct words
Reduced short term
ADL % LIMITATIONS
• Gardening 100%
• Vacuuming 100%
• Dusting/cleaning 80%
• Laundry 80%
• Reading 60%
• Bathing/grooming 60%
• Bending to brush teeth 60%
• Grocery shopping 70%
• Cooking 50%
• Sleeping 60%
• Work 60%
CURRENT DIAGNOSES
• Hypothyroidism
• Benign Multinodular
Goiter
• Endometriosis
• Adenomyosis
• Hidradenitis Suppurativa
• Ovarian Cysts
• Stress Incontinence
• Allergies
• Reflux
• Anxiety
• Insomnia
• Constipation
• Migraines
Clinical Considerations:
• Omeprazole:
• Hypochlorhydria, B def, Fe def, Poor
Medications
digestion, GSH def, methylation, ATP
def, Mitochondrial health, Dysbiosis
• Omeprazole 20mg QD
• Loratadine 10mg QD • 2 Blood Pressure Medications:
• Need to check homocysteine, Mg
• Synthroid 50mcg QD
depletion, Methylation, SNPs
• Propanolol 80 mg QD
• Thyroid medication, goiters:
• Xanax .5mg PRN
• AI/Hashimoto’s, Tyrosine steal
• Weekly allergy shots
• Allergy shots:
• Gut dysfunction, Histamine
• Multivitamin
intolerance, DAO, SNPs, Methylation
• Xanax:
• Dysbiosis, stress response, IDO
upregulation, SNPs, Methylation,
Tyrosine steal
Initial Evaluation
Self-assessment forms
indicated problems:
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Stomach
Intestines
Gall bladder
Liver
• MAF: 225
Colon
• BFAF: 144
Blood sugar
• BHNAF: 146
Adrenal
Thyroid
Female hormone
Brain endurance
Neurotransmitters
Presenting Metabolic
Panel: 4/21/2014
• Limited Panel
• Dysglycemia
• Iron need
• Malabsorption
• Mineral imbalances
• B12 need
• Subclinical infection
• HCl need
INITIAL EVALUATION
Physical Findings:
• Reduced circulation/temperature
BLE (75 degrees Bilat)
• Altered sensory perception UE &
LE to light tough, vibration and
sharp stimuli
• Palpable abdominal tenderness
• Cervical spine dysfunction
• Left cerebellum weakness
• Right hemisphere weakness
• “Zinc Challenge” – no taste
Additional Initial
Metabolic Panel Tests:
Interpretation:
• Dysglycemia
• Iron need
• Inflammation
• Multiple thyroid
problems
• Low fT3: Adrenals
• Potential
challenges with B2
• Methylation
RATING OF STARTING
COMPLAINTS
Potential reduced
function based on
current known
micronutrient
deficiencies:
• Low fT4
• MTHFR
• MTRR
• DMGDH
• GSR
• PDH
• Low Fe
• MPO
• CAT
• CDO
• Low Zn
• BHMT
• ADA
• SOD
WHERE TO START
WHERE TO START
Methylated Life Principles:
1. Dietary Fitness
6. Metabolic Fitness
2. Sleep Fitness
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Address GI tract
3. Physical Fitness
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Inflammation
4. Emotional Fitness
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Support nutritional
deficiencies
5. Respiratory Fitness
PHASE I: 60 DAY GUT REHAB PROTOCOL SUPPLEMENTS:
AI diet – reduce inflammatory foods and sensitivities
Zinc Challenge: no taste = Zinc def, zinc lozenges
GABA challenge (+): Leaky BBB, PRP Spray
Interphase: 2 weeks @ 2 - 2x/day, biofilm buster
Glutenflam: 2 per meal – DPPIV, anti-inflammatory
Vit D: 8000 IU/day sublingual – immune, gut barrier,
hormone, NT
• Tumero Active: 2 weeks (dosing) – anti-inflammatory
• Resvero Active: 2 weeks (dosing) – anti-inflammatory
• HCL Prozyme: Dosing - Support HCl – why low?
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PHASE I: 60 DAY GUT REHAB PROTOCOL SUPPLEMENTS:
• GI Revive: 2 servings/day for 60 days
• Glutamine based gut support with antimicrobials
• Thyroid Support: Thyroxyl & Thyro CNV 2 – 3x/day and dosing down
• Need to support low fT4 to support B2 to FAD
• fT3 to support cellular function
• pH support: Optimal Electrolyte
• Support mineral needs
• Probiotic support (multiple forms)
• Second 30 days
• Adrenastim
• Support low adrenals
• Nitric Balance (dosing)
• Support circulation, reduced iNOS, improve nNOS and eNOS
RATING OF
COMPLAINTS
ON 8/7/2014
- JUST OVER
60 DAYS INTO
CARE
PHASE 2: 30 DAY LIVER/DETOX
PROTOCOL
Supplements:
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Hepatosynergy: Methylation, Bile support, B vitamins
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Clearvite: Multivitamin
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Probiotics: Klaire
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Thyroid Support: Thyro CNV & Thyroxal
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Vitamin D
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Adrenastim
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HCl as needed
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pH support as needed
90 Day Reassessment
• MAF:
• Old total 225
• New total 40
• 82% improvement
• BFAF:
• Old total 144
• New total 29
• 80% improvement
• BFNAF:
• Old total 146
• New total 39
• 73% improvement
Patient comments:
• “Headache improved but still present”
• “Energy is returning”
• “Zest for life is returning”
• “Still dizzy with postural changes”
4 Month Metabolic Panel:
Interpretation:
- What are you thinking at this point?
4 Month Metabolic Panel:
4 Month Metabolic Panel:
Interpretation:
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Malabsorption
Mineral imbalances
Iron need
B12 need
Low trigs:
Methylation, SNPs
Inflammation
suppressed
Anterior Pituitary
Thyroid Underconversion, but
overall free thyroid
hormones
improving
Over-conversion to
rT3
High fibrinogen
Low but improving
vitamin D
CLINICAL
CONSIDERATIONS
• Why did she improve so much?
• Why does she still have
headaches?
• What else can we look at to
continue improvement?
NEXT STEPS
• Support protocol
• Perform the following tests:
- Genetic Variant
- HDRI Methylation Panel
- ONE Test
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Return in new year after
completion of tests
PHASE 2: DIGGING DEEPER
Variant Report
Homozygous SNPs:
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CYP2D6 S486T
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ACE DEL16
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BHMT 8
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CBS A360A
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MAO A R297R
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MTHFR A1298C
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MTRR A66G
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NDUFS7
PHASE 2: DIGGING DEEPER
Variant Report
Heterozygous SNPs
• CYP1
• DHFR
• NAT2
• SOD 2 & 3 • FOLR2
• GAD1
• ACAT
• AHCY
• NOS 2 & 3
• BHMT2
• PEMT
• COMT
• VDR BSM
• DAO
• VDR Taq
Clinical
Considerations:
• Homozygous SNPs
• Heterozygous SNPs
• Iron Deficiency
• Low fT4
OCTOBER 2014 LAB
PANEL:
Clinical considerations:
• Iron levels improved
• Fibrinogen ?
PHASE 2: ONE TEST
ONE TEST
HDRI METHYLATION PANEL
PHASE 2: SUPPLEMENTAL
SUPPORT STARTED 01/15/2015
• Week 1:
• DFH Complete Multi: 2 pills 3x/day with meals
• L-5-MTHF: 1 lozenge every other day
• Strengtia: 1 pill per day
• Digestzymes: 2 pills per meal
• Omega CO3: 1 tbsp. per day
• Week 2:
• Alpha Lipoic Acid: 1 pill per day (100mg)
• Molybdenum: 1 pill every other day (500mcg)
• Glycine: 1 per day (500mg)
* New supplement added every three days
1/22/15 METABOLIC PANEL
• Patient passes out while
performing morning void.
Taken to hospital and labs
run.
• Primary recommends
switching to Armour.
• What Happened?
• May have supported too
heavily
• Current medications
• Low Thyroid
• Infection
• Adrenals
SUPPLEMENT CHANGES
02/18/2015:
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DFH Complete Multi: 2 pills 3x/day with meals
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L-5-MTHF: 1 lozenge every 3rd day w/ AdenoB12
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Strengtia: 1 pill per day
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Digestzymes: 1 pill per meal
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Omega CO3: 1 tbsp. per day •
Alpha Lipoic Acid: 1 pill per day
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Molybdenum: 1 pill every other day
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Glycine: 1 per day (just started) •
Histamine Block: take 1-2 per day with high histamine foods
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Patient opts for adding back Thyroxyl and Thyro-CNV
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Discussion regarding medications
03/06/2015: VISIT
• Patient feeling wiped out. • Increase the dose of thyroid support to 2 – 3x/day
• Added Iron support
• Reinforce need to address BP medications and
cholesterol medications because BP is too low
03/23/2015 VISIT
• 03/23/2015:
• Low Histamine diet and Histablock really helping congestion
and allergies – able to stop allergy shots and OTC
medications
• Taking adenoB12 and MTHF lozenges every 3rd day
• Added additional iron (DFH multi with Iron)
• Thyroid support: 2 – 2x/day
• Patient has added eggs back and choline rich foods
• Patient has phased out of molybdenum, glycine, ALA
• Continuing with: Probiotic, 4000 IU vitamin D, Omega FA, 1
digestive enzyme per meal
• Off of blood pressure and cholesterol medication and not
nearly as wiped out, feeling good but still have headache
4/29/15: HEAD AND NECK
ULTRASOUND & THYROID TESTING
• TSH: 1.5 (FL), fT4: 1.19
• Increased vascularity of left thyroid lobe,
remaining right thyroid tissue normal
CURRENT STATUS & SUPPORT
• Patient is doing well with improvement of all original
symptoms.
• Support and Buteyko breathing seems to have stabilized
headaches
• Patient is off all medication
• Patient is taking:
• DFH multi with iron
• Thyroxyl & Thyro CNV: 2 – 4 per day
• Omega 3 (anabolic labs) 1 per day
• DFH Digestzymes 1 per meal
• 4000 IU vitamin D
• Probiotic
REFERENCES:
1.Klimberg, V. Suzanne, M.D., et al. Prophylactic Glutamine protects the intestinal mucosa from radiation injury. Cancer 1990, July 1;66(1):62-68.
2.Hickson R, et al. Glutamine prevents downregulation of myosin heavy chain synthesis and muscle atrophy from glucocorticoids. Am J Physiol 1995 Apr;268(4 Pt 1):E730-E734.
3.Noyer CM, Simon D, Borczuk A, Brandt LJ, Lee MJ, Nehra V. A double-blind placebo-controlled pilot study of glutamine therapy for abnormal intestinal permeability in patients with AIDS. Am J Gastroenterol 1998;93(6):972-5.
4.Foitzik T, Stufler M, Hotz HJ, Klinnert J, Wagner J, Warshaw AL, Schulzke JD, Fromm M, Buhr HJ. Glutamine stabilizes intestinal permeability and reduces pancreatic infection in acute experimental pancreatitis. J Gastrointest Surg. 1997;1(1):40-47.
5.Herschler RJ. Dietary and pharmaceutical uses of methylsulfonylmethane and compositions comprising it. United States Patent 4,514,421:April 30, 1985.
6.Hutter JA et al., Anti-inflammatory C-glucosyl chromone from Aloe barbadensis. In: JNP 59(5):541-543, 1996.
7.Langmead L, et al. Antioxidant effects of herbal therapies used by patients with inflammatory bowel disease: an in vitro study. Aliment Pharmacol Ther., 2002 Feb;16(2):197-205.
8.Hough L, Jones JK, Hirst EL. Chemical constitution of slippery elm mucilage; isolation of 3-methyl d-galactose from hydrolysis products. Nature, 1950 Jan; 165(4184):34.
9.Lengsfeld C, Titgemeyer F, Faller G, Hensel A. Glycosylated compounds from okra inhibit adhesion of Helicobacter pylori to human gastric mucosa. J Agric Food Chem. 2004; Mar 24;52(6):1495-503.
10.Nichols TW, Faass N. Optimal Digestion, New Strategies for Achieving Digestive Health. Avon, New York, 1999.
11.Lipski E. Digestive wellness. New Canaan, CT: Keats, 1996: 200-03.
12.Pizzorno JE, Murray MT. Textbook of Natural Medicine (2nd Ed.), Churchill Livingstone, New York, 1999.
13.
PDR for Herbal Medicines 1st Ed., Medical Economics Co., Montvale, New Jersey, 1998.
14.
Fetrow CW, Avila JR. Complimentary & Alternative Medicines: Professional's Handbook. Springhouse, Springhouse, PA, 1999.
15.
Werbach MR, Murray, MT. Botanical Influences on Illness: A sourcebook of clinical research. Third Line Press, Tarzana, California, 1994.
16.
Bascom A. Incorporating Herbal Medicine Into Clinical Practice. F.A. Davis Co., Philadelphia, 2002.
17.
Cheallier A. Encyclopedia of Herbal Medicine. Dorling Kindersley, London, 2000.
18.
PDR for Nutritional Supplements 1st Ed., Medical Economics Co., Montvale, New Jersey, 2001.
19.
Robbers JE, Speedie MK, Tyler VE. Pharmacognosy and Pharmacobiotechnology. Williams & Wilkins, Baltimore, 1996.
20.
Mahmood A, FitzGerald AJ. Zinc carnosine, a health food supplement that stabilizes small bowel integrity and stimulates gut repair processes. Gut. 2007
Feb;56(2):168-75. Epub 2006 Jun 15
21.
Odashima M. Zinc L-carnosine protects colonic mucosal injury through induction of heat shock protein 72 and suppression of NF-kappaB activation. Life Sci. 2006
Nov 10;79(24):2245-50. Epub 2006 Aug 2.
22.
Mikami K, Otaka M, Watanabe D. Zinc L-carnosine protects against mucosal injury in portal hypertensive gastropathy through induction of heat shock protein 72. J
Gastroenterol Hepatol. 2006 Nov;21(11):1669-74.
23.
Morgan R, Gao G, Pawling J, Dennis JW, Demetriou M, Li B. N-acetylglucosaminyltransferase V (Mgat5)-mediated N-glycosylation negatively regulates Th1 cytokine
production by T cells. J Immunol. 2004 Dec 15; 173(12):7200-8.
REFERENCES:
13.PDR for Herbal Medicines 1st Ed., Medical Economics Co., Montvale, New Jersey, 1998.
14.Fetrow CW, Avila JR. Complimentary & Alternative Medicines: Professional's Handbook. Springhouse, Springhouse, PA, 1999.
15.Werbach MR, Murray, MT. Botanical Influences on Illness: A sourcebook of clinical research. Third Line Press, Tarzana, California, 1994.
16.Bascom A. Incorporating Herbal Medicine Into Clinical Practice. F.A. Davis Co., Philadelphia, 2002.
17.Cheallier A. Encyclopedia of Herbal Medicine. Dorling Kindersley, London, 2000.
18.PDR for Nutritional Supplements 1st Ed., Medical Economics Co., Montvale, New Jersey, 2001.
19.Robbers JE, Speedie MK, Tyler VE. Pharmacognosy and Pharmacobiotechnology. Williams & Wilkins, Baltimore, 1996.
20. Mahmood A, FitzGerald AJ. Zinc carnosine, a health food supplement that stabilizes small bowel integrity and stimulates gut repair processes. Gut. 2007 Feb;
56(2):168-75. Epub 2006 Jun 15
21. Odashima M. Zinc L-carnosine protects colonic mucosal injury through induction of heat shock protein 72 and suppression of NF-kappaB activation. Life Sci.
2006 Nov 10;79(24):2245-50. Epub 2006 Aug 2.
22. Mikami K, Otaka M, Watanabe D. Zinc L-carnosine protects against mucosal injury in portal hypertensive gastropathy through induction of heat shock protein 72. J
Gastroenterol Hepatol. 2006 Nov;21(11):1669-74.
23.Morgan R, Gao G, Pawling J, Dennis JW, Demetriou M, Li B. N-acetylglucosaminyltransferase V (Mgat5)-mediated N-glycosylation negatively regulates Th1
cytokine production by T cells. J Immunol. 2004 Dec 15; 173(12):7200-8.
QUESTIONS &
ANSWERS
QUESTIONS & ANSWERS
1. Why didn’t I run more testing initially
2. What are the Methylated life fitness factors
3. Why did she improve so much in the first 60 days?
4. Why did the headaches linger the longest?
5. What would I go back and change from a
treatment perspective looking back?
6. Why did breathing exercises help morning
headaches?