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“You can get past the dead end. You can break through the ceiling. I did and so have countless others.”

Clinical Pearl Wednesday #151

Coronavirus diagnostic and treatment concept. Laboratory table close up

Fatigue is such a frequent patient complaint and can really baffle providers as lab tests often come back in the “normal” range.  However, as more of us begin to explore a more functional or holistic perspective to health care, we begin to discover the benefits of using “optimal” lab values.  Optimal lab values come from a variety of organizations and vary a bit sometimes.  The key here, though, is to consider that “normal” lab values often leave patients symptomatic and dissatisfied with care. 

A few examples of optimal lab values include an A1c, a Free T3, and a Ferritin level. 

Mainstream medicine often diagnoses type 2 diabetes when the A1c level jumps higher than 6.5 or 7; however, various studies have indicated that patients often exhibit complications of diabetes, even at A1c levels as low as 5.6 – 6.0.  Optimal A1c then, is likely around 5.5 or less, to minimize development of cellular injury.  Various low carb experts provide a variety of educational resources to help patients learn the basic tenets of going low carb, but in the presence of certain glucose lowering medications, this journey may require professional guidance. 

Managing hypothyroidism is often a challenge but monitoring the Free T3 level will provide much better information about a patient’s thyroid health.  Free T3 is the active thyroid hormone the body uses for metabolism/function/energy.  Letting Free T3 run in the lower range of normal often results in major symptoms for patients, including depression, low body temperature, bradycardia, and fatigue that can be life-altering and severe.  Using liothyronine in decreasing doses over the morning can offer patients with a significant improvement in symptoms, allowing them to return to normal activities and function. Adjust liothyronine doses to target an optimal range in the upper quarter of the range. More on this discussed in the thyroid course just FYI.

Ferritin has long been overlooked as an important metabolic marker but checking iron and ferritin panels are becoming more and more important as the CBC is not impacted by low ferritin levels until the ferritin levels falls to the very bottom of the range, or even below range.  Symptoms of fatigue, headaches, and muscle aches can occur and are quite common when the ferritin levels fall below 60 ng/mL. At levels below 45 ng/mL, many patients report tachycardia, dyspnea, palpitations, weakness, headaches, migraines, brain fog, and a variety of other vague symptoms.  The CBC is not generally impacted until a ferritin level falls to 15 ng/mL or so.  Keep in mind that ferritin is the iron source of RBC production, so if ferritin level falls, the body begins to ration the iron, leaving RBCs with inadequate hemoglobin for oxygen transport.  This effect is the main contributor to the patient’s symptoms. Support and encourage patients to attain a ferritin level around 80 ng/mL or so and maintain it.  Checking these labs every 4-6 months will provide safe and effective monitoring. 

4 Responses

  1. I absolutely agree with everything you said! I am a clinical pathologist (laboratory physician), but I also have a wellness/aesthetics clinic where I practice hormone therapy, medical weight loss and aesthetics. There actually is no “normal” range when it comes to lab results. If you look at the top of the results page, it says “Reference Range.” It’s a reference to average results for a certain age range of males/females within a certain geographical area. I explain to my patients it’s like a dartboard, and their dart happened to land on X number. For hormone therapy, the center of the dartboard is when the patient FEELS wonderful, and has very few unwanted symptoms. Of course, for electrolytes, chemistry, CBC results, etc, the reference range doesn’t offer much leeway. But for hormones, it does. I go by how the patient feels. Basically, when they are establishing a reference range, they test a number of “healthy” people (often around 100 people) for certain tests. Outlying values are discarded and an average with standard deviations is determined. That gives us a range of values against which we can compare our patient’s results. Keep in mind that many of those people who were tested for the RR are on hormone therapy, thyroid replacement, etc, and many are not. For 25 years I’ve told practitioners to treat their patients, not the numbers. If your patient is symptomatic, he/she needs treatment. Getting baseline labs is an absolute must, and as you said, regular intervals of follow up labs that you can compare to their personal baseline. And never tell your patients they are in the “normal range” or out of the “normal range.” Its not a “normal” range. Go for optimal!!!

    Moyne Monts, MD
    Optimal Aesthetics
    Longview, Texas

  2. TPO antibodies is also very useful in diagnosing Hashi, the inflammation will be for some time before the TSH changes

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