Novel Approaches to Managing Pain and Inflammation

Novel Approaches to Managing Pain and Inflammation Functional Medicine Forum Fall/Winter 2003-4 David B. Wood, BS, ND B.S. Microbiology, Univ. of Washington, 1977 N.D., Bastyr University, 1983 Cofounder/President: Trinity Family Health Clinic, PS Cofounder/Vice President/CMO: Bio-Genesis Nutraceuticals, Inc 3/31/2008 Recommending a Strategy for Today and Tomorrow In this presentation I will present natural nutritional alternatives for your patients with pain and inflammation Ideas 3/31/2008 Vision Statement The direction in health care today is definitely back to a more natural approach  Patients are demanding it and published studies are proving that natural therapies work  3/31/2008 Vision Statement  Patients are more educated today about the side effects of drugs and the possible nutritional alternatives. It is becoming increasingly necessary for physicians to know how to integrate diet, nutrition, and nutraceuticals into a patients treatment plan. Science support this integration and patients are asking for it. 3/31/2008 Goal and Objective Know the key mediators of inflammation  Describe the key nutrients and botanicals effective in the treatment of pain and inflammation  Be able to effectively utilize specific nutrients and botanicals in various inflammatory conditions  3/31/2008 A Partial List of Inflammatory Mediators  Super oxide radical  Hydrogen peroxide  Lipid peroxide  5 - Lipoxygenase  Leukotriene B(4)  Cyclooxygenase  Inflammatory cytokines – Tumor Necrosis Factor          alpha (TNF alpha) – Interleukins (IL -6 and IL 1(B)) 3/31/2008 Classical complement pathway Alternate complement pathway Tromboxane Prostaglandin E2 (PGE2) NF Kappa B Arachidonic acid Platelet Activating Factor (PAF) Substance P C-Reactive Protein A Partial List of Conditions Related to Chronic Inflammation  Cancer  Heart Attack - coronary atherosclerosis  Alzheimer’s disease - damage to brain cells  Congestive Heart failure - Heart muscle wasting  Stroke - trombo-embolic events  Arthritis - damage to joint cartilage/synovial fluid  Aortic Valve Stenosis - heart valve damage  Kidney failure - damage to circulation and nephrons  Lupus (SLE) - induce autoimmune attack  Asthma - close airways 3/31/2008 A Partial List of Conditions Related to Chronic Inflammation         Psoriasis - induce dermatitis Pancreatitis - induce pancreatic cell injury Allergy - induce autoimmune reactions Fibrosis - attack traumatized tissue Surgical complications - prevent healing Anemia - attack erythropoietin production Fibromyalgia - elevated in fibromyalgia patients Metabolic Syndrome X – insulin/cortisol/glucose imbalance  Faloon W. Chronic Inflammation: The Epidemic Disease of Aging. Life Extension Foundation. Jan 2002. P13-21. 3/31/2008 Available Nutritional Options  Lifestyle  Natural Modification: – Diet (hypoallergenic, balanced CHO/PRO/FAT) Therapeutics: – Balanced Functional Foods – Omega 3 fatty acids – Antioxidants, Vitamin, Mineral and Enzyme Cofactors 3/31/2008 Available Nutritional Options Overview Licorice root –  Botanicals: – Turmeric (Curcumin) – Boswellia serrata – Ginger – Feverfew – White Willow Bark – Nettles (Urtica – – – – dioica) Ginkgo biloba Capsaisin – topical Commiphora mukul Rosemary 3/31/2008 Available Nutritional Options Overview  DL Phenylalanine  Bioflavonoids  Proteolytic Enzymes: – Bromelain – Papain – Trypsin  Homeopathics: – Arnica – Bryonia – Rhus toxicondendron – α Chymotrypsin 3/31/2008 Available Nutritional Options  Connective Tissue Repair Factors: – Glucosamine Sulfate (GS) – Chondroitin Sulfate (CS) – Methylsulfonylmethane (MSM)  Immune Modulators – Cetyl Myristoleate 3/31/2008 Lifestyle Modification - Diet  Food sensitivities are associated with increased joint pain and edema in patients suffering from episodic joint pain, chronic arthralgias, and inflammatory arthritis.   J R Soc Med 83(5):312-4, 1990 Ann Allergy 51:260-3, 1983  Double-blind study - 30 patients (arthritis & rheumatism) – 22/30 (73.3%) aggravation from provoking foods compared to 2/30 (6.6%) of placebo group.  J Int Acad Prev Med July, 1982, pp. 5-16 3/31/2008 Lifestyle Modification - Diet  Balanced CHO/PRO/FAT diets    Blood sugar balance Insulin/Glucagon balance good eicosanoid - anti-inflammatory balance  Balanced Functional Foods: – Rx: BioInflammatory Functional Food    Blood sugar balance Cortisol/Insulin/Glucagon balance Promote production of anti-inflammatory prostaglandins/eicosanoids 3/31/2008 Lifestyle Modification - Diet  Eat More foods with a low glycemic index and high in monounsaturated fats Salmon & other fish Oatmeal & whole grains Olives & olive oil Nuts/Seeds and their oils Fresh fruits & vegetables Avocado  Eat Less or Avoid foods       with a high glycemic index, high in saturated fats and high in arachidonic acid (AA)  Fatty cuts of meat  Organ meats - high in AA  Egg yolks - high in AA  Pasta, juices, sugar, white rice, white bread - high glycemic index 3/31/2008 Lifestyle Modification - Diet  Additional diet references: – Werbach M. Nutritional Influences on Illness.2nd Ed.Tarzana, CA: Third Line Press; 1993. – Pinals RS. Arthritis associated with gluten-sensitive enteropathy. J Rheumatol. 1986;13(1):201-204. – Kelly VE, Ferretti A, Izui S, et al. A fish oil diet rich in eicosapentaenoic acid reduces cyclooxygenase metabolism, and suppresses lupus in MRL-lpr mice. J Immunol 1985 Mar;134(3):1914-9. – Brock TG, McNish RW, Peters-Golden M. Arachidonic acid is preferentially metabolized by cyclooxygenase-2 to prostacyclin and prostaglandin E2. J Biol Chem 1999 Apr 23;274(17):11660-6. 3/31/2008 Natural Therapeutics Omega 3 Fatty Acids   Rx: (BioG or FIT) EPA/DHA 1-2 BID TID with meals Fish oils (EPA/DHA) are associated with an antiinflammatory effect by inhibiting the 5lipoxygenase pathway, thus reducing the release of the superoxide radical and leukotrienes. – N Engl J Med 312:1217-23, 1985  Docosahexaenoic acid (DHA) of fish oil suppresses TNF alpha, IL-6, IL-1(B), and LTB(4). – Faloon W. Chronic Inflammation: The Epidemic Disease of Aging. Life Extension Foundation. Jan 2002. P13-21. 3/31/2008 Natural Therapeutics Vitamins, Minerals, Antioxidants Rx: (BioG) Vitamin E 400 high gamma fraction 1-2 QD with meal  Vitamin and Mineral antioxidants have been shown to reduce inflammation.  – Vitamin E (mixed tocopherols) inhibit lipid peroxidation. – Vitamin E may be as effective in ankylosing spondylitis as NSAIDS.  Nutr Dietary Consult June, 1988 3/31/2008 Natural Therapeutics Vitamins, Minerals, Antioxidants Rx: (TR) Boron 2-3 BID with food  Boron was effective in approx. 90% of arthritis  pts., including juvenile arthritis and adult RA pts. Pts. Took 6-9 mg elemental boron daily to achieve symptom relief then went to 3 mg per day for maintenance.  Int Clin Nutr Rev 11(2):68-70, 1991 3/31/2008 Natural Therapeutics Vitamins, Minerals, Antioxidants Rx: (BioG) OxyATP 1 BID with food  Selenium with Vitamin E has been shown to  enhance glutathione peroxidase levels and thereby reduce arthritic pain. – Proc N Z Workshop on Trace Elements in N Z Dunedin, U. of Otago, 1981:92  Zinc was shown to significantly reduce arthritic symptoms in psoriatic arthritis patients in a double-blind crossover study – Br J Dermatol 103:411-15, 1980 3/31/2008 Natural Therapeutics Vitamins, Minerals, Antioxidants  Copper bracelets found to be effective treatment for arthritis/rheumatism patients in Single-blind Crossover Study: 240 “arthritis/rheumatism suffers” were randomized into 3 groups. Gp I wore copper bracelet for 1 mo. Followed by a “placebo” bracelet for 1 mo. Gp II wore bracelets in reverse order, while Gp. III wore no bracelets. Copper bracelets were perceived to be more effective (p<0.01). – Agents Actions 6:454,1976 – Werbach, M. Nutritional Influences on Illness 2nd Ed. Tarzana, CA. Third Line Press,1993 3/31/2008 Natural Therapeutics Vitamins, Minerals, Antioxidants  Copper, Zinc and Manganese have been shown to significantly reduce inflammation by enhancing superoxide dismutase (SOD) production, thus reducing the level of the superoxide radical 3/31/2008 Natural Therapeutics Botanicals/Turmeric Rx: (BioG) ArthrogenX 2-3 BID – TID  Rx: (BioG) PainX 2-3 BID - TID  Turmeric (Curcumin) has been shown to have  antioxidant free radical scavenging properties. Specifically, curcuminoids have been shown to scavenge superoxide anions, hydrogen peroxide and inhibit lipid peroxidation. Studies have also demonstrated inhibition of lipoxygenase, cyclooxygenase, cytokines (TNF alpha and IL -1 beta. – Ramirez-Bosca’ A, et al. Antioxidant curcuma extracts decrease the blood lipid peroxide levels of human subjects. Age 3/31/2008 (18):167-9, 1995. Natural Therapeutics Botanicals/Curcumin  Curcumin showed significant subjective improvement for Rheumatoid Arthritis patients in a randomized, double-blind, crossover study. Dosage was 400 mg TID. Improvements in morning stiffness, walking time and joint swelling were noted.  Curcuminoids, p 117-121, PDR of Nutritional Medicine 1st Ed., Medical Economics, 2001 3/31/2008 Natural Therapeutics Botanicals/Curcumin  Curcuminoids have been shown to significantly inhibit promotion and progression stages of colon cancer.  Kawamori T, Lubert R, Steele VE, et al. Chemoprotective effect of curcumin, a naturally occuring anti-inflammatory agent, during the promotion/progression stages of colon cancer. Cancer Res. 1999; 59:597-601. 3/31/2008 Natural Therapeutics Botanicals/Boswellia  Boswellia serrata is the source of the spice Frankincense. It has been used in traditional Indian medicine for the treatment of chronic rheumatic inflammation.  Boswellic acids have been shown to inhibit 5lipoxygenase (the key enzyme in leukotriene synthesis).  Boswellia has also been shown to inhibit both the classical and alternate compliment pathways. 3/31/2008 Natural Therapeutics Botanicals/Boswellia  Boswellia displayed marked antiinflammatory activity in carrageenan-induced edema in rats and mice. It was equally effective in adrenalectomized rats. Boswellia inhibited elevations of serum transaminase enzymes and leukocyte counts  Singh GB, Atal CK. Pharmacology of an extract of salai guggal ex-Boswellia serrata, a new nonsteroidal anti-inflammatory agent. Agents Actions 18(3-4):407-12, 1986. 3/31/2008 Natural Therapeutics Botanicals/Boswellia  Boswellia has shown promising results with patients suffering from inflammatory bowel diseases such as: Ulcerative colitis. – Experimental double-blind 50 pts, 32-66 yrs old grad ll and lll. Reduction in symptoms of: abdominal pain, loose stools, mucous, blood, and necrotic material was 100% with the sulfasalazine grp and 91.7%, 88.9%, 80%, 86.5% and 79.2% in the boswellia grp, respectively. – Gupta I et al. Effects of Boswellia serrata gum resin in patients with ulcerative colitis. Eur J Med Res 20:3743, 1997 3/31/2008 Natural Therapeutics Botanicals/Ginger  Ginger (Zingiber officinalis) has had remarkable benefit for arthritic patients. Noted areas of improvement have been pain, inflammation/swelling, and morning stiffness.  Gingers mechanism of action appears to be its ability to quench 5-lipoxygenase, thromboxane, platelet aggregation and its dose dependent inhibition of prostaglandin (PGE2)  3/31/2008 Werbach M, Murray M. Botanical Influences on Illness 2nd Ed. Third Line Press Tarzana,CA 2000 Natural Therapeutics Botanicals/Ginger    Sharma JN, Srivastava KC, Gan EK. Suppressive effects of eugenol and ginger oil on arthritic rats. Pharmacology 49(5):314-8, 1994. Kiuchi F, Iwakami S, Shibuya M, et al. Inhibition of prostaglandin and leukotriene biosynthesis by gingerols and diarylheptanoids. Chem Pharm Bull (Tokyo) 40(2):387-91, 1992. Flynn DL, Rafferty MF, Boctor AM. Inhibition of human neutrophil 5-lipoxygenase activity by gingerdione, shogaol, capsaicin and related pungent compounds. Prostaglandins Leukot Med 24(2-3):195-8, 1986. 3/31/2008 Natural Therapeutics Botanicals/Feverfew  Feverfew (Tanacetum parthenium) reduces inflammation through its inhibition of the enzyme phospholipase A2. This mechanism effectively inhibits prostaglandins, thromboxanes and leukotriene formation at the initial stage of synthesis.  Feverfew is traditionally used in the treatment of vascular headaches such as Migraines, but due to its anti-inflammatory properties may have other uses in the treatment of inflammation. 3/31/2008 Natural Therapeutics Botanicals/Feverfew Rx: (BioG) MigraClear 1-2 BID  Feverfew  – Experimental Double-blind Crossover Migraine Study: 57 pts. Significant reduction in pain intensity as compared to placebo. Profound reduction in vomiting, nausea, sensitivity to noise, and light sensitivity  Palevitch D, Earon G, Carasso R. Feverfew (Tanacetum parthenium) as a prophylactic treatment for migraine: a double-blind placebo-controlled study. Phytother Research 11:508-11, 1997. 3/31/2008 Natural Therapeutics Botanicals/Licorice  Licorice root (Glycyrrhiza glabra) inhibits prostaglandin synthesis similar to cortisol. Studies have shown that licorice extends the half-life of endogenous cortisol. Glycyrrhizin may be effective alone or as an adjunct to corticosteroid treatment.  Licorice inhibits: cortisol degradation, phopholipase A2, prostaglandin E2, generation of ROS by neutrophils. – Werbach MR, Murray M. Botanical Influences on Illness 2nd Ed. Third Line Press, Tarzana, CA 2000. 3/31/2008 Natural Therapeutics Botanicals/Nettles  Stinging Nettles (Urtica dioica) has been shown to potently inhibit NF-kappaB activation by preventing degradation of IkappaB-alpha, its natural inhibitor. NF-kappaB is elevated in several chronic inflammatory conditions and enhances the expression of proinflammatory gene products. – Riehmann K, Behnke B, Schulze-Osthoff K. Plant extracts from stinging nettle (Urtica dioica), an antirheumatic remedy, inhibit the proinflammatory transcription factor NF-kappaB. FEBS Lett 442(1):89-94, 1999. 3/31/2008 Natural Therapeutics Botanicals/Nettles  Nettles has also been shown to inhibit arachidonic acid, leukotriene B4, and cyclooxygenase. – Obertreis B et al. [Anti-inflammatory effects of Urtica dioica folia extract in comparison to caffeic malic acid.] Arzneim Forsch 46:52-6, 1996 – Werbach M, Murray M. Botanical Influences on Illness: A Sourcebook of Clinical Research. Third Line Press, Tarzana, CA. 2000 3/31/2008 Natural Therapeutics Botanicals/Nettles Rx: (BioG) BioAllergy Plus 2 TID  Nettles most recent use has been in the  treatment of allergic rhinitis or hayfever. Freeze-dried Urtica dioica has shown moderate favorable benefit for 58% of patients in the treatment group as compared to 37% of placebo group without sedation or stimulation. – Mittman, P. Randomized, double-blind study of freeze- dried Urtica dioica in the treatment of allergic rhinitis. Planta Medica 56:44-47, 1990. – Flynn R, Roest M. Your Guide To Standardized Herbal Products. One World Press, 1995. 3/31/2008 Natural Therapeutics Botanicals/Ginkgo Rx: (BioG) Ginkgo Plus 1-2 daily  Ginkgo biloba inhibits PAF (platelet  activating factor). PAF is instrumental in many inflammatory and allergic processes. This would include: neutrophil activation, increasing vascular permeability, smooth muscle contraction including bronchoconstriction and reduction of coronary blood flow. – Werbach M, Murray, M. Botanical Influences on Illness: A Sourcebook of Clinical Research. Third Line Press, Tarzana, CA. 2000 3/31/2008 Natural Therapeutics Botanicals/Ginkgo  Ginkgo biloba is thought to have its antiinflammatory effect through its ginkoflavoneglycosides (kaempferol, quercetin, isorhamnetin, prothocyanidins), terpenes (ginkgolides and bilobalides). Standardized extracts usually contain 24% ginkgoflavonglycosides and 6% terpenes. 3/31/2008 Natural Therapeutics Botanicals/Capsaicin  Capsaicin - Topical preparations ranging from 0.025 to 0.075 % capsaicin derived from Cayenne pepper (the fruit of Capsicum frutescens) have been effective (range 53100%) in the treatment of cluster headaches, neuralgia & neuropathy (including diabetic neuropathy), post-herpetic neuralgia, postamputation pain, postmastectomy pain, psoriasis,and Arthritis (osteo and rheumatoid). Dosage is up to 4x/day. Initial burning sensation fades over time and rarely necessitates cessation of therapy. 3/31/2008 Natural Therapeutics Botanicals/Capsaicin     Marks DR et al. A double-blind placebo-controlled trial of intranasal capsaicin for cluster headache. Cephalalgia13(2):114-16, 1993. Ellison N, Loprinzi CL, Kugler J, et al. Pase lll placebocontrolled trial of capsaicin cream in the management of surgical neuropathic pain in cancer patients. J Clin Oncol 15(8):2974-80, 1997. Epstein J, Marcoe, J. Topical application of capsaicin for treatment of oral neuropathic pain and trigeminal neuralgia. Oral Surg Oral Med Oral Pathol 77:135-40, 1994. Deal CL et al. Treatment of arthritis with topical capsaicin: a double-blind trial. Clin Ther 13(3):383-95, 1991. 3/31/2008 Natural TherapeuticsBotanicals/White Willow  Rx: (BIOG) PainX 2-3 TID  White Willow (Salix alba) – An extract of willow tree bark is as effective as a common prescriptive drug for the treatment of low back pain. The study compared the efficacy of white willow bark extract to rofecoxib (Vioxx) in 228 randomly assigned individuals with low back pain treated for a period of 4 weeks. In all measures of pain relief WWB was found to be as effective as rofecoxib.  3/31/2008 Rheumatology (2001;40:1388-93) Natural TherapeuticsBotanicals/White Willow WWB has been used therapeutically for 2000 years.  WWB is:  – – – – – 3/31/2008 Anti-inflammatory Antipyretic Analgesic Hemostatic Antithelmintic Natural TherapeuticsBotanicals/White Willow  Common historical uses include: – Temporary use in pain: HA, menstrual pain, – – – – – toothache, arthritis, gout, angina, sore muscles Antiseptic for UTIs Fevers, rheumatic conditions Inflammatory pain Connective tissue disorders Astringent for dysentary, diarrhea, intestinal worms and parasites. 3/31/2008 Natural TherapeuticsBotanicals/White Willow  Recognized in the United States Pharmacopoeia (USP) for 1820 – 1926. – Predominated until replaced by cheaper synthesized ASA (acetyl-salicylic acid) – Better tolerated than ASA – Significant differences between WWBE and ASA – Salicin converted in the liver to ASA, thus bypassing gastrointestinal toxicity problems. 3/31/2008 Natural TherapeuticsBotanicals/White Willow Salicin in WWB appears to suppress the production of prostaglandins. It also appears to inhibit cyclooxygenase –2 (Cox-2) and to a lesser degree cyclooxygenase – 1 (Cox-1) enzymes.  Individuals allergic to ASA should avoid WWB extracts.  3/31/2008 Natural Therapeutics – Botanicals/Commiphora mukul  Commiphora mukul („guggal‟) – has anti- inflammatory, antipyretic, antiseptic, antispasmodic and antiatherogenic properties.  Common traditional uses – – Neuralgia, rheumatism, muscle spasms, inflammation and many infections – Considered a strong anti-inflammatory  Modern day uses – – Reduction of elevated cholesterol and triglycerides via its guggulsterones E and Z. 3/31/2008 Natural Therapeutics – Botanicals/Commiphora mukul  Commiphora mukul – – Experimental arthritis (animal) study: albino rabbits induced by intra-articular injection (Rt hock joint) of killed mycobacterium adjuvant. Designed to produce replica of human rheumatoid arthritis. Phenylbutazone, ibuprofen and fraction “A” of gum-guggual were all shown to be effective in reducing thickness of joint swelling. Commiphora mukul compared favorably and was beneficial in the treatment of experimental arthritis.  Sharma JN, Sharma JN. Comparison of the antiinflammatory activity of Commiphora mukul (an indigenous drug) with those of phenylbutazone and ibuprofen in experimental arthritis by mycobacterial adjuvant. Arzneimittelforschung 1077 Jul;27(7): 1455-7 3/31/2008 Natural Therapeutics – Botanicals/Commiphora mukul  Commiphora mukul: – Experimental inflammatory (animal) study: Myrrhanol A, a new triterpene isolated from guggul (Balsamodendron or Commiphora mukul Hook) – gum resin, displays potent anti-inflammatory effect on exudative pouch fluid, angiogenesis, and granuloma weights in adjuvant airpouch granuloma of mice. Its effects were more marked than hydrocortisone.  Kimura I, Yoshikawa M, Kobayashi S, Sugihara Y, Suzuki M, Oominami H, Murakami T, Matsuda H, Doiphode VV. New triterpenes, myrrhanol A and myrrhanone A, from guggulgum resins, and their potent anti-inflammatory effect on adjuvant-induced air-pouch granuloma of mice. Bioorg Med Chem Lett. 2001 Apr 23;11(8):985-9. 3/31/2008 Natural Therapeutics – Botanicals/Commiphora mukul    Singh BB, Mishra L, Aquilina N, Kohlbeck F. Usefulness of guggul (Commiphora mukul) for osteoarthritis of the knee: An experimental case study. Altern Ther Health Med. 2001 Mar;7(2):120, 112-4. Duwiejua M, Zeitlin IJ, Waterman PG, Chapman J, Mhango GJ, Provan GJ. Anti-inflammatory activity of resins from some species of the plant family Burseraceae. Planta Med. 1993 Feb;59(1):12-6. Arora RB, Taneja V, Sharma RC, Gupta SK. Antiinflammatory studies on a crystalline steroid isolated from Commiphora. Indian J Med Res. 1972 Jun;60(6):929-31. 3/31/2008 Natural Therapeutics Botanicals/Rosmarinus officinales  Rosmarinus officinales (Rosemary): contains rosmaricine, aromatic essential oils, diosmin, beneficial minerals (Ca, Mg, P, Na, K).  Reported uses have been: – Smooth muscle stimulant – Analgesic, antioxidant, antibacterial and antiviral – Soothe and calm irritated nerves) – Soothe irritated stomach – Balance electrolytes – Lower elevated blood pressure – Decrease capillary permeability/fragility (diosmin) Stronger than rutin 3/31/2008 Natural Therapeutics – Botanicals/Rosmarinus officinalis  Reported uses con‟t: – Europe/China – Headaches – Europe/China – Stomach pains/dyspepsia – Europe/America – Cholagogue – Antitumorigenesis (animal/mammary) – Germany – quickens and quiets circulation and relieves  symptoms of rheumatism and neuralgia – German Commission E approved for internal and external use. Avoid large doses: gastrointestinal irritation, kidney irritation. Has been used as an abortifactant in very large doses. Several gram doses should not be used during pregnancy. 3/31/2008 Natural Therapeutics – Botanicals/Rosmarinus officinalis     Blumenthal, M (Ed): The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. American Botanical Council. Austin, TX. 1998. Aruoma, OI, et al. An evaluation of the antioxidant and antiviral action of extracts of rosemary and Provencal herbs. Food Chem. Toxicol. 1996, 34(5): 449-456. Singletary KW, Nelshoppen JM. Inhibition of 7,12dimethylbenz(a) anthracene (DMBA)-induced mammary tumorigenesis and of in vivo formation of mammary DMBA-DNA aducts of rosemary extract. Cancer Lett. 1991, 60(2): 169. Fitzpatrick, FK. Plant substances active against mycobacterium tuberculosis. Antibiotics and Chemotherapy, 4(5), 528-536, 1954. 3/31/2008 Natural TherapeuticsNutritional Options/DLPA  DL-Phenylalanine (DLPA): may have analgesic properties thought to be through DPA‟s blockage of enkephalin degradation by the enzyme carboxypeptidase A. – DLPA should be avoided by those with PKU and those taking MAO inhibitors. 3/31/2008 Nutritional TherapeuticsNutritional Options/Bioflavonoids  Hesperetin/Hesperidin (glycoside form of Hesperetin): – phenolic antioxidant. – Anti-inflammatory via interference with – – – – 3/31/2008 metabolism of arachidonic acid (AA) and histamine release. Inhibits phospholipase A Inhibits lipoxygenase Inhibits cyclo-oxygenase Decreases microvasculature permeability Nutritional TherapeuticsNutritional Options/Bioflavonoids  Quercetin/Rutin (Quercetin-3- rutinoside): – Phenolic antioxidant – Anti-inflammatory via:     Inhibition of lipid peroxidation Inhibits degranulation of mast cells, basophils and neutrophils In vitro and animal studies show that quercetin inhibits tyrosine kinase, nitric oxide synthase and modulates activity of the inflammatory mediator NFkappa B. Inhibits formation of inflammatory prostaglandins and leukotrienes. 3/31/2008 Natural TherapeuticsProteolytic Enzymes   Bomelain: contains: 4+cysteine proteases  Acid phosphatase  Peroxidase  Amylase  Cellulase  Stem proteases: ananain and comosain Bromelain’s uses: • • Speeds healing time Pain reduction (post surgery and athletic injuries) 3/31/2008 Natural TherapeuticsProteolytic Enzymes   Bomelain: Open study, 59 patients with blunt injuries to M/S system. – Clear reduction in swelling, pain at rest and during movement and in tenderness reported. – Most common method of expressing Activity in GDU (gelatin digesting units) or MCU (milk clotting units) – 1 GDU approx. = to 1.5 MCU 3/31/2008 Natural TherapeuticsProteolytic Enzymes   Bromelain: Anti-inflammatory mechanism not well understood  Possible mechanisms: – Activation of plasmin production from plasminogen – Reduction of kinin via inhibition of conversion of kininogen to kinin. – Proteolytic degradation of circulating immune complexes (CIC) – Inhibition of signaling by extracellular regulated kinase (ERK)-2 and p21ras. 3/31/2008 Natural TherapeuticsProteolytic Enzymes  Bromelain: – Kumakura S, Yamashita M, Tsurufuji S. Effects of bromelain on kaolin-induced inflammation in rats. Eur J Pharmacol. 1988; 150:295-301. – Masson M. [Bromelain in blunt injuries of the locomotor system. A study of observed applications in general practice]. [Article in German]. Fortschr Med. 1995; 113:303-306. – Mynott RL, ladhams A, Scarmato P, Engwerda CR. Bromelain from pineapple stems, proteolytically blocks activation of extracellular regulated kinase-2 in T cells. J Immunol. 1999; 163:2568-2575. – PDR for Nutritional Supplements, 1st Ed. Medical Economics/Thomson Healthcare. 2001. 3/31/2008 Natural Therapeutics Homeopathics  Arnica Montana: – Inflammation from injuries, falls, blows, bruises and contusions. Strains, sprains. Muscular tonic. Sore, lame, bruised feeling. Neuralgias, rheumatism (fibromyalgia?).  Bryonia: – Aching in every muscle. Stitching, tearing pain, worse by motion, better rest. Rheumatic pains and swellings. Joints red, swollen, hot. 3/31/2008 Natural Therapeutics Homeopathics  Rhus Toxicondendron: – Inflammation/pain of skin, mucous membranes, joints, tendons, ligaments, fascia, sheaths - aponeurosis and muscles. Rheumatic pain. Tearing asunder pains. Ailments from strains, overlifting. Rheumatism in cold season. Motion limbers up. Worse cold, rest. 3/31/2008 Natural Therapeutics Homeopathics  Consideration of other common homeopathics: – Aconite, Belladonna, Bellis perennis, Calendula, Chamomilla, Echinacea, Hamamelis, Hypericum  For acute perscribing or if perscribing in concert with botanicals, enzymes, antioxidants, etc: – Rx: stick with low potencies which can be repeated often and carry less concern for neutralizing effect or „proving‟ the remedy 3/31/2008 Natural Therapeutics Connective Tissue Factors  Rx:  (BioG) ArthrogenX 2 - 3 BID - TID with meals  Glucosamine sulfate  Chondroitin sulfate  Methylsulfonylmethane (MSM)  Rx: (BioGP PainX  2-3 BID – TID between meals 3/31/2008 Natural Therapeutics Glucosamine sulfate  Glucosamine sulfate(GS) is one of several naturally occurring amino sugars that are essential for rebuilding and healthy maintenance of connective tissue, including tendons, ligaments, cartilage and bone matrix.  Increased age is associated with glycation of cartilage that reduces the production of proteoglycans involved as joint lubricants. GS is an essential component of proteoglycans and may be required to re-establish proteoglycan levels. 3/31/2008 Natural Therapeutics Glucosamine sulfate     Meta-analysis of thirteen double-blind placebocontrolled clinical trials revealed that GS was superior to placebo in all thirteen studies, as measured by global pain scores or the Lequesne index. Patients receiving GS have a gradual and progressive reduction in joint pain and tenderness, as well as improved range of motion and walking speed. GS is also reported to be equally or more effective than ibuprofen, and is better tolerated than ibuprofen. GS needs to be stabilized with either NaCl or KCl for maximum effectiveness. 3/31/2008 Natural Therapeutics Glucosamine sulfate  De Camara C, et al. Glucosamine sulfate for osteoarthritis. Ann Pharmacother 32(5):580-7, 1998.  Qiu, G et al. Efficacy and safety of glucosamine sulfate versus ibuprofen in patients with knee osteoarthritis. Arzneimittelforschung 48(5):469-74, 1998.  Deal C, et al. Nutraceuticals as therapeutic agents in osteoarthritis. The role of glucosamine sulfate, chondroitin sulfate, and collagen hydrolysate. Rheum Dis Clin North Am 25(2):379-95, 1999.  Drovanti A, et al. Therapeutic activity of oral glucosamine sulfate in osteoarthrosis: A placebocontrolled double-blind investigation. Clin Ther 3, 3/31/2008 260-272, 1980. Natural Therapeutics Chondroitin sulfate    Chondroitin sulfate (CS) is a glycosaminoglycan that is a major component of cartilage, is rich in sulfur, and related to GS. CS helps to hold water and nutrients in joint tissue, and enhances the circulation of nutrient molecules in cartilage. Meta-analysis performed on seven randomized, double-blind clinical trials using CS showed it to be significantly superior to placebo with respect to the Lequesne index and other pain scores. 3/31/2008 Natural Therapeutics Chondroitin sulfate    Leeb B, et al. A meta-analysis of condroitin sulfate in the treatment of osteoarthritis. J Rheumatol 27(1):205-11, 2000. Deal C, et al. Nutraceuticals as therapeutic agents in osteoarthritis. The role of glucosamine, chondroitin sulfate, and collagen hydrolysate. Rheum Dis Clin North Am 25(2):379-95, 1999. Morrison M. Therapeutic applications of chondroitin-4sulfate, appraisal of biologic properties. Folia Angiol 25, 225-232, 1977. 3/31/2008 Natural Therapeutics Methylsulfonylmethane     Methylsulfonylmethane (MSM) is a source of organic sulfur found naturally in the human body. MSM is a stable metabolite of DMSO and is 34% elemental sulfur. MSM supports many functions, including maintenance of connective tissue. Collagen basement membrane, procollagen and collagen are partially dependent on dietary sulfur. MSM has been found to lessen destructive changes in joints. 3/31/2008 Natural Therapeutics Methylsulfonylmethane  Murav‟ev V, et al. Effect of dimethyl sulfoxide and dimethyl sulfone on a destructive process in the joints of mice with spontaneous arthritis. Patol Fiziol Eksp Ter (2):37-9, 1991. 3/31/2008 Natural Therapeutics Immune Modulators  Cetyl myristoleate (CM) is a naturally occurring ester of a myristoleic acid that is commercially obtained from palmitic acid.  An investigation into why mice do not get arthritis led to the discovery of CM as the responsible agent.  In a study of rats injected with an arthritisproducing material, the CM group was healthy and had virtually no signs of arthritis, whereas the control group was unhealthy and had severe swelling. 3/31/2008 Natural Therapeutics Cetyl myristoleate  Cetyl myristoleate is thought to have several mechanisms of action: – CM serves as a lubricant for the joints – CM functions as an immune modulator. – CM mediates the inflammatory process by promoting a balanced T Helper1 to T Helper2 cellular response.  Diehl H, et al. Cetyl myristoleate isolated from Swiss albino mice: an apparent protective agent against adjuvant arthritis in rats. J Pharm Sci 83(3):296-9, 1994. 3/31/2008 Boswellia, Ginger, Nettles, Turmeric, Feverfew Nettles Ginger Licoric e 3/31/2008 Summary - Natural Inhibitors of Inflammatory Mediators  Hypoallergenic, CHO/PRO/FAT balanced diets (nutrient dense)  All inflammatory mediators  Omega 3 fatty acids    5 - lipoxygenase, TNF alpha, IL-6, IL-1(B), Leukotriene B(4) Super oxide radical  Antioxidants, Vitamins, Minerals   3/31/2008  Vitamin E/Selenium - lipid peroxide Boron - ?enhancement of Testosterone, Estrogens, DHEA, and Vitamin D. Copper, Zinc, Managanese - Superoxide radical Summary - Natural Inhibitors of Inflammatory Mediators  Botanicals – Turmeric (Curcumin)  Super oxide radical  Hydrogen peroxide  Lipid peroxide  5 - lipoxygenase  Leukotrienes  Cyclooxygenase  Inflammatory cytokines (TNF alpha, IL - 1 beta) 3/31/2008 Summary - Natural Inhibitors of Inflammatory Mediators  Botanicals – Boswellia serrata  5 - lipoxygenase  Leukotrienes  Classical complement pathway  Alternate complement pathway 3/31/2008 Summary - Natural Inhibitors of Inflammatory Mediators  Botanicals – Ginger  5 - lipoxygenase  Leukotrienes  Thromboxane  PGE2  Platelet aggregation 3/31/2008 Summary - Natural Inhibitors of Inflammatory Mediators  Botanicals – Feverfew  Phospholipase A2 - inhibiting at initiation step of: – Prostaglandins – Thromboxanes – Leukotrienes 3/31/2008 Summary - Natural Inhibitors of Inflammatory Mediators  Botanicals – Licorice  Phospholipase A2 - inhibiting at the initiation step of: – Prostaglandins (PGE2)  ROS  Inhibits degradation of cortisol 3/31/2008 Summary - Natural Inhibitors of Inflammatory Mediators  Botanicals – Nettles  NF Kappa B  Arachidonic Acid  Leukotriene B4  Cyclooxygenase 3/31/2008 Summary - Natural Inhibitors of Inflammatory Mediators  Botanicals – Ginkgo biloba  PAF (Platelet Activating Factor) – Capsaicin (topical)  Substance P  Immune Modulators – Cetyl Myristoleate  Cytokines (TNF alpha, IL - 1beta - via regulation of T Helper 2 cell activity) 3/31/2008 Suggested Clinical Work-up and Protocol for a Patient with Pain and Inflammation  R/O Hypersensitivity (Food/Environmental) – Elimination/Challenge Diet – Allergy testing   IgE - Environmental (Immediate) IgG - Food (Delayed)  Balanced Whole Food Hypoallergenic Nutrient Dense Diet  Adequate Pure Water, Rest, Exercise, Stress Reduction 3/31/2008 Suggested Clinical Work-up and Protocol for a Patient with Pain and Inflammation  Check morning urine/saliva pH – Correct Acidosis if present – Ideal pH (6.4 - 7.0)  R/O Digestive deficiencies and Intestinal Dysbiosis – Rx stool analysis (Digest/Microbial/P1,2,or3)  Routine Labs/Procedures for DDx (if no definitive Dx) and monitoring 3/31/2008 Suggested Clinical Work-up and Protocol for a Patient with Pain and Inflammation  Liver Detoxification Evaluation – Assess Phase l and Phase ll functional detox capacity  Oxidation/Reduction – Assess ability to quench ROS 3/31/2008 Laboratories Providing Suggested Tests  Some labs to contact for information on available screening tests: – Doctor’s Data, Inc  (1-800-323-2784) www.doctorsdata.com Digestive/Microbial Stool testing, Toxic minerals screening – Metametrix Clinical Laboratory  (1-800-221-4640) www.metametrix.com  Organix, Food/Inhalant allergy panels, Oxidative Stress Indicators, Nutrient and Toxic Elements testing, Amino Acids, Fatty Acids, Bone Resorption, Estronex, ION Panel  3/31/2008 Suggested Clinical Work-up and Protocol for a Patient with Pain and Inflammation  Nutritional Rx:  Balanced Hypoallergenic Functional Food for detoxification support, reduction of inflammation and correction of nutrient deficiencies – Rx: (BioG) BioInflammatory Functional Food  Combination of GS, CS, MSM (if connective tissues, especially if joints involved) to supply 1500 - 2500 mg organic sulfur/day – Rx: (BioG) ArthrogenX 2-3 BID - TID with meals – Rx: (BioG) PainX 2-3 BID – TID between meals 3/31/2008 Suggested Clinical Work-up and Protocol for a Patient with Pain and Inflammation  Natural Anti-inflammatory Standardized Botanicals (Typically given in a combination capsular form):  Rx: (BioG) ArthrogenX 2-3 BID - TID with meals or Rx: (BioG) PainX 2-3 BID – TID between meals – Or single herbs: • Ginger 150 - 300 mg QD, Turmeric 300 - 600 mg QD, Boswellia 300 - 600 mg QD  Single Ingredient or BioG Combination Formulas: – Nettles 300 - 500 mg TID (if environmental allergies present) Rx: (BioG) Allergy Plus – Ginkgo 60 - 120 mg QD - BID (if (+) for vascular insufficiency) Rx: (BioG) Ginkgo Plus – Feverfew 3/31/2008 50 - 100 mg QD (if (+) for vascular headaches) Rx: (BioG) MigraClear Additional References Novel Approaches to Managing Pain and Inflammation     Brod SA. Unregulated inflammation shortens human functional longevity. Inflamm Res 2000 Nov;49(11):561-70. McCary MF. Interleukin-6asa central mediator of cardiovascular risk associated with chronic inflammation, smoking, diabetes, and visceral obesity: down-regulation with essential fatty acids, ethanol and pentoxifylline. Med Hypotheses 1999 May;52(5):465-77. Kremer JM. n-3 fatty acid supplements in rheumatoid arthritis. Am J Clin Nutr 2000 Jan;71(1Suppl):349S-51S. Upritchard JE, Sutherland WH, Mann JI: Effect of supplementation with tomato juice, vitamin E, and vitamin C on LDL oxidation and products of inflammatory activity in type 2 diabetes. Diabetes Care 2000 Jun;23(6):733-8. 3/31/2008 Additional References for Novel Approaches to Managing Pain and Inflammation   Langlois M, Duprez D, Delanghe J: Serum vitamin C concentration is low in peripheral arterial disease and is associated with inflammation and severity of atherosclerosis. Circulation 2001 Apr 10;103(14):1863-8. Horton JW, White DJ, Maass DL: Antioxidant vitamin therapy alters burn trauma-mediated cardiac NF-kappaB activation and cardiomyocyte cytokine secretion. J Trauma 2001 Mar;50(3):397-408. 3/31/2008 Novel Approaches to Managing Pain and Inflammation Conclusion  Natural nutritionals along with a healthy diet and lifestyle can have dramatic positive benefits for patients with acute and chronic inflammatory conditions!  Start integrating natural anti-inflammatory therapies into your patient management today.  David B. Wood, ND – dwoodnd@bio-genesis.com – dwoodnd@trinityclinic.com 3/31/2008 Stuff to Take Home 3/31/2008 Clinical Protocols 3/31/2008 Allergies (Food)     R/O with laboratory testing (IgG ELISA or Elimination/Challenge diet. This is a good time to do the BioCleanse Detox program. Avoid 3+ or higher foods, Rotate others Desensitize with homeopathic dilutions of allergens (Apex) Run Digestive/Microbiol/P testing, Organix or Lactulose/Mannitol testing to assess level of gut dysbiosis, permeability and/or digestive enzyme deficiencies 3/31/2008 Allergies (Food)    Remove any bowel pathogens with ParaBiotic Plus (2 TID) Consider reforestation of bowel with products such as: Florastor (Biocodex) (2 BID) and ProFlora Plus caps (3 BID). Initiate this treatment after completing ParaBiotic Plus phase. Repair mucosal barrier/gut lining with: Intestinal Repair Complex (1 tsp BID-TID) 3/31/2008 Allergies (Environmental)   Seasonal? – Late February to Mid April? Probably Deciduous Tree Pollens – Mid April to Mid July? Probably Grass/Weed pollens – Year around? Probably dust mite or mold allergy Evaluate symptomatically or allergy test with IgE serum testing or skin testing. 3/31/2008 Allergies (Environmental)  Reduce exposure (air cleaners, electrostatic precipitators, etc.)  Desensitize with homeopathic allergens (Heel, Apex, Professional Complimentary Health)  Rx: BioAllergy Plus capsules (2-4 caps TID - QID between meals)  Rx: NAC (1-2 BID without food)  Rx: Immune Balancing Complex (T cell balancing)  (1-2 BID with food) 3/31/2008 Adrenal Insufficiency  Check for postural hypotension (Lying to standing blood pressure evaluation). I consider it significant if the systolic pressure drops by 8 points or more.  Serum Sodium less than 140. My optimal is 140-142  Test Salivary (or Serum hormones) Hormones to check for deficiency and/or circadian rhythm disturbances.  Fatigue after exercise and history of slow recovery. Takes 2-3 days to recover from stress, exercise, etc. 3/31/2008 Adrenal Insufficiency        Rx: BioAdreno 2 with breakfast and 1 with lunch. Do not give later in the day. Rx: BioAdaptogen 1-2 capsules up to TID between meals Rx: Adrenal Support Plus 1-2 per meal Rx: Celtic salt to replace regular table salt (to taste) Rx: Lipopure PS/PC oral spray to enhance HPA axis regulation (2 sprays before bed) Rx: Zone balanced regular meals. UltraLean (powder and bars) or UltraPure Whey protein to assist (1SVG/day) Rx: Stress reduction, gentle exercise 3/31/2008 Arthritis R/O DJD vs. RA – exam – family history  Zone Balanced Diet  3/31/2008 Arthritis  Rx: – BioInflammatory Functional Food (1 Svg/day) – ArthroGenx capsules (2-3 TID with meals) – PainX (2-3 TID between meals) – EPA/DHA (2-3 BID with meals) – OsteoGenesis regular or E.S. (2 TID with meals)  Labs recommended: – Organix or Digestive/Microbiol/Parasite – Allergy evaluation (Elimination/Challenge, IgG ELISA) – Urine/Saliva pH screen (r/o acidosis) – serum autoantibodies (if unsure) 3/31/2008 Autoimmune Disorders   Run labs to further assess patients nutritional needs: – Organix – Allergy (IgG, Elimination/Challenge) – Zinc Tally taste test – Postural Hypotention Adrenal Insufficiency Screen – urine/saliva pH Correct Dysbiosis – (ParaBiotic Plus, Florastor, ProFlora Plus caps, Intestinal Repair Complex) ParaBiotic Plus and IRC can be given together. Florastor and ProFlora Plus caps should be started after completing the prescribed course of ParaBiotic Plus. 3/31/2008 Autoimmune Disorders   Treat T Helper 1/T Helper 2 cell imbalance: – (Immune Balancing Complex, Moducare (Th), Tocotriene Complex (PRL) Quench Inflammatory Mediators and assist in balancing Phase 1/Phase 2 detoxification pathways: – (BioInflammatory Functional Food, BioInflammatory capsules, BioAlkalizer, PainX, ArthroGenx, EPA/DHA) 3/31/2008 Breast Disorders  CRT testing to further define breast cancer risk  Estronex urine testing to evaluate 2OH Estrone/16alphaOH Estrone ratio (risk factor)  Breast exam  Mammogram (if warranted) 3/31/2008 Breast Disorders  Hormone balancing: often reduction of estrogen dominance symptoms. – BioCleanse powder detox for 2 weeks followed by ongoing use of BioCleanse caps (Calcium DGlucarate, Broccoli extract) (2 BID to TID) – BioIsoflavone caps (Soy Isoflavones) – DIM PRO PLUS (FIT) (1 BID) – EPA/DHA (2-3 BID with meals) – Lipopure Progesterone especially if patient also has PMS, uterine cramping, and/or heavy prolonged menses (dosage varies - see product sheet) 3/31/2008 CFIDS  R/O the basics: anemia, clinical or subclinical hypothyroid (labs + temps), hypoglycemia, circadian rhythym disorders (sleep/melatonin, adrenal hormones/postural hypotension), chronic virus (EBV, CMV), pleomorphic organism (Chlamydia pneumoniae, Mycoplasma fermentens), intestinal dysbiosis, allergy/leaky gut, T Helper 1/T Helper 2 imbalance, depression. 3/31/2008 CFIDS   Clean up the diet (Zone balanced whole foods) and establish a routine – often patient eats on the run. Eats fast food. Doesn‟t eat on a schedule Rx: depending on findings – Possible use of: (BioCleanse Functional Food, BioAdreno, BioAdaptogen, Adreanl Support Plus, Lipopure Melatonin, Lipopure PS/PC, GlucoTone, MycoPotent Immune Complex, Immune Balancing Complex, ParaBiotic Plus, Florastor, ProFlora Plus caps, UltraHematinic and/or Lipopure B12/Folate oral spray) 3/31/2008 Cholesterol Elevation  Diet: Low fat, high fiber. Zone balanced. Whole foods. Variety of fresh fruits/vegetables.  Exercise: 3-5 x/week combination cardio/weights. Duration/intensity according to doctors instructions  Rx‟s:  BioLipotrol (2 TID) or (3 BID) lower dosage if mild elevation.  Functional Food (if needed): BioCleanse or UltraLean or Metabol-X  Garlic 7000 (1-2 BID) 3/31/2008 Cognitive Dysfunction      Patient complains of Simple Memory disorder (short term) Zone balance diet to protect against hypoglycemic short term memory loss BioFocus (1 SVG/day) Ginkgo Plus (1-2 BID) Contraindicated if patient is on anticoagulant Tx. Lipopure PS/PC (2-4 sprays BID, swish, hold in mouth 2-3 min. swallow) 3/31/2008 Cognitive Dysfunction      EPA/DHA (2-3 BID with meals) R/O anemia, hypothyroid, atherosclerosis (lipid panel) Anemia: UltraHematinic (1 TID with meals), if macrocytic- Lipopure B12/Folate oral spray 2 sprays BID) Hypothyroid: BioThyro 2 caps QD-BID without food and possible Rx natural thyroid medication Elevated Lipids: BioLipotrol 2-3 BID to TID with meals 3/31/2008 Colon Disorders (IBS, Colitis, Crohn‟s)      Labs: Organix (urine) or Digestive/Microbiol/Parasite (stool) Allergy (IgG, or Elimination/Challenge) Hemocult (if DMSP above not done) Colonoscopy (if indicated) 3/31/2008 Colon Disorders (IBS, Colitis, Crohn‟s        Rx: Intestinal Repair Complex - 1tsp BID to TID L-Glutamine powder 1tsp BID to TID Intestinal Repair Caps 2 TID with meals Vitamin E 400 1-2 QD to TID (high levels can be used to enhance SIgA production in patients with low levels. Also Dr. Bastyr recommended to stop bleeding within 4 days!) UltaPure Whey protein - 1-2 SVG/day (if tolerant to Whey) good source of glutamine and very high in immunoglobulins Hypoallergenic/soluble fiber (FIT) 3/31/2008 Detoxification (Heavy Metals)  Assessment: Urine DMSA Challenge or Hair Elements Analysis. Questionnaire indications of environmental or drug toxicity. In office screens – high probability score on multisymptom questionaire or S.O.S. questionaire.  Typical Rx‟s: – Metal Cleanse oral drops: ½ tsp BID – Toxi HMF 2 - 3 capsules BID without food 3/31/2008 Detoxification (Heavy Metals)  Rx‟s continued: – BioCleanse Functional Food: – follow BioCleanse diet/dosage recommendations in handout or ½ to 1 SVG/day for longer duration of time (1-3 months) – UltraPure Whey protein: 1 SVG/day – Occassional (rare) use:  Captomer (Th) 1 capsule daily 3/31/2008 Detoxification (Heavy Metals) – Possible dysbiosis treatment, intestinal reforestation and intestinal repair (ParaBiotic Plus, Florastor, ProFlora Plus caps, Intestinal Repair Complex) – Encourage exercise, pure water to hydration, adequate sleep, blood sugar balance through regular balanced (40/30/30), organic food based meals and stress reduction (prayer, meditation, Heart Math (www.heartmath.com), etc.) 3/31/2008 Fibromyalgia  R/O conditions such as: acidosis (urine/saliva pH), allergies, blood sugar dysregulation, electrolyte imbalance (serum, calf cramp challenge testing), EFA deficiencies, infection (approx. 50% or our patients show + to CMV) 3/31/2008 Fibromyalgia  Most common Rx‟d supplements: – Rx: Super FMS (1-2 per meal) – Rx: PainX (2-3 BID to TID w/o food) – Rx: UltraMuscleEze (1/2 to 1 teaspoon twice daily) – Rx: BioInflammatory Functional Food (1 SVG/day)  and encourage a zone balanced diet – Rx: OsteoGeneis ES (1-2 per meal) (if serum calcium less than 9.0, and calf cramp test less than 200 (goal 200-240 with no cramp) – Rx: EPA/DHA (2-3 twice daily with food) 3/31/2008 GERD  R/O: hypo/hyperchlorhydria, Helicobacter pylori, food allergy  If acids aggravate: Avoid (vineger, caffeine (coffee, chocolate, colas, black teas), tomatoes, citrus, alcohol, spicy foods, high fat foods)  If acids ameliorate: Encourage – apple cider vinegar (1 tsp in glass of water with meals) to aide digestion 3/31/2008 GERD        Rx: Gastric Repair Complex (chew or swallow) 2 tablets with meals and before bed Intestinal Repair Complex 1 tsp BID to TID ParaBiotic Plus (if + H. pylori) 2-3 TID for 1 month followed by: Florastor (Biocodex) 2 BID for 2-4 weeks ProFlora Plus caps 3 BID for 1 month Mastic Gum caps 1-2 per meal (if + H. pylori) 3/31/2008 Headaches       Diet: Hypoallergenic, zone balanced Exercise: 3-5 x/week, combination cardio/weights Rx‟s: Muscle Tension: UltraMuscleEze (1 tsp BID) or Tri Mag (1 BID with meals, according to bowel tolerence) OsteoGenesis ES (2 TID with meals) 3/31/2008 Headaches            Migraine/vascular: MigraClear (1 TID) PainX (2 TID) OxyATP (1 TID) EPA/DHA (2-3 BID) Sinus Headache: BioAllergy Plus (2 QID between meals and before bed) PainX (2 TID) NAC (MM) (1-2 BID between meals) Euphorbium (Heel) or QC (Th) nasal spray Nasal rinse with ProFlora Plus caps 3/31/2008 Heart Disorders       Cardiac Arrythmia: Ultra CoQ10 100mg (1 BID with meals) UltraMuscleEze (1 tsp BID) Taurine (MM) (1-2 BID) Vitamin E 400 (1-2 QD with a meal) OxyATP (mitochodrial support) (1 BID with meals) 3/31/2008 Heart Disorders        Mitral Valve Prolapse: TriMag (1 per meal) Hypertension: Garlic 7000 (1 TID with meals) TriMag (1 TID with meals according to bowel tolerance) OsteoGenesis ES (2 TID with meals Carditone (Ayush) (2 BID) 3/31/2008 Immune Enhancement      Diet: Low in sugar, hypoallergenic, zone balanced Exercise: 3-5 x/week. Combination cardio/weights Stress reduction: set goals, prioritize, prayer, meditation, good sleep and eating habits, work on communication skills, organize Possible Rx‟s: Lipopure Melatonin oral spray (enhancement of thymus & sleep cycle) – 1-4 sprays before bed nightly 3/31/2008 Immune Enhancement       MycoPotent Immune Complex (20-30 gtts QD) Immune Balancing Complex (2 caps BID) Currently sick?: BioPotent C (2 TID or 1 tsp BID) PhytoImmune (3-4 TID) viral ParaBiotic Plus (2-3 TID) bacterial/fungal 3/31/2008 Menopause/Perimenopause         Zone balanced hypoallergenic diet Cardiovascular protection: – Ultra CoQ10 100 1 QD, OxyATP 1 QD, Vitamin E 400 1 QD with meals Bone loss protection: – OsteoGenesis or OsteoGenesis ES Labs: Bone Loss Resorption (urine), DEXA scan Natural HRT: Lipopure Progesterone 15-30 gtts BID, BioIsoflavone 1 BID - TID or BioFem HRT 1 BID TID Lab: Estronex (urine), salivary or serum Est/Progest and FSH 3/31/2008 Osteopenia/Osteoporosis       Labs: Bone Resorption (urine), Bone density (Dexa Scan) Weight bearing exercise HRT (if indicated: low or menopausal) – Lipopure Progesterone 15-30 gtts BID (osteoblast enhancement) – BioIsoflavone 1-2 BID (osteoblast enhancement, osteoclast inhibition) Soluble minerals and bone specific collagen for remineralization/remodeling of bone matrix – OsteoGenesis 2-3 TID UltraGest (if low stomach acid) 1-2 TID mid to end of meals MetabolX Functional Food (if overweight or needs help in improving protein intake, insulin/cortisol balance) 3/31/2008 Premenstrual Syndrome  Diet:  Zone Balanced, hypoallergenic, low in sugar, caffeine  Evaluate hormone status: (often a progesterone deficiency)  Lipopure Progesterone 15 gtts BID days 11 - 25. Depending on the severity of the PMS, I may have patient start earlier than day 11.  BioFem PMS caps: 2 caps TID (days 10 to 3)  Ultra B Complex 1-2 BID (coenzyme form for greater biological activity)  TriMag 1-2 BID  MetabolX Functional Food 1 SVG/day 3/31/2008 Prostate Disorders  PSA laboratory testing. Blood draw before digital exam  Physical exam of gland  Benign:  Rx: BioInflammatory Functional Food for 2-3 weeks to detox and determine any possible food intolerences 3/31/2008 Prostate Disorders  Rx: BioProstate 1-3 BID  Rx: EPA/DHA 2-3 BID  Rx: DIM PRO PLUS (FIT) 1 BID -TID  Malignant: Above recommendation as well as: – Proteolytic enzymes: BioPan or Vegizyme, Immune enhancers: MycoPotent Immune Complex and Immune Balancing Complex – Pulsed antioxidants (if on chemotx or radiotx treatment) OxyATP, BioPotent C – Anti-metastatic agents: Fractionated Pectin (Th) 3/31/2008 Case Histories 3/31/2008 Janet – CFS (Courtesy of Eleanor Barrager, DNFS, PGDD, Dip Ed)  37 yo female; 1/2 pack per day smoker  CC:CFS Duration: 5years  Hx of moderate depression; Paxil for 5 months no effect, d/c by pt.  Sx: no energy, sleep disruption, awakes tired, poor memory, stiffness in joints, HAs with blurry vision during PMS, day and night sweats, intermittent nausea and vomiting off and on past 5 yrs 3/31/2008 Janet - CFS  Major stressors in last five years: 2 children, breast feed both for at least 6 months, Mom & Dad both passed away, 20 year old son incarcerated and dishonorable discharge from military, parents dog died.  Activity level: prepare food for self and family; care for 1 yo, 4 yo and 5yo children full-time; 3/31/2008 Janet - CFS  No Hx of previous illnesses or hospitalizations except for 3 live births;  Uses no-scent hair spray with no ill effects  Household cleaners and air-freshners not well tolerated - Headaches,  brain fog, and  fatigue  No current medications, no supplements  Hx of anemia after each child birth 3/31/2008 Janet - CFS  Diet 24 hr recall (No food cravings) – B/F , coffee with sugar and milk – Lunch: white bread with ham or beef, cheddar cheese, occasionally tuna and potato chips, glass of milk; coffee with sugar/milk – Canned vegetables: greens beans or carrots, potato, rice or pasta, with beef chicken or pork; coffee with sugar and milk; – No food cravings; snacks diet coke; little water; no regular consumption of fruit/veggies 3/31/2008 Janet - CFS  Sleep 6-8 hours; does not remember dreams; complains of night sweats;  Energy level: 1-2 (VAS 1-10)  Initial visit: patient appeared tired with dark circles under eyes; physical exam: WNL except for dry skin; B/P 110/70 and HR:84 and regular. Wt:170 Ht:67.5”  Initial SOS Score: 156 3/31/2008 Xenobiotic Detoxification PHASE II Conjugation reactions *sulfation *glucuronidation *glutathione Intermediary conjugation Metabolite *acetylation More polar *amino acid More water-soluble conjugation (glycine, taurine, glutamine, etc) *methylation Excretion in some instances Nonpolar Xenobiotic PHASE I Cyt.P450 oxidation reduction hydrolysis Conjugated Metabolite Polar Water-soluble Excretion Serum-kidneys-urine or Bile-faeces Janet - CFS  Intervention: – BioCleanse Functional Food: 1 scoop bid – BioCleanse Detox Caps: 2 bid with above – OxyATP: 1 bid with B/F & Lunch – UltraGenesis with iron: one with each meal – D/c activities that exacerbate fatigue – Reduce cigarettes to six or less per day – Increase intake of fresh fruit/vegetables and water 3/31/2008 Janet - CFS ROV: 3 weeks  Feeling much better, less issues with fatigue;  Sleeping better at night, less night sweats, daytime sweating has resolved;  Headaches reduced in frequency and severity;  Decreased # of cigarettes and requested help with quitting; 3/31/2008 Janet - CFS ROV: 3 weeks      Increase BioCleanse Functional Food to 2 scoops bid Con‟t BioCleanse Detox caps at 2 bid Increase OxyATP support to 2 bid UltraGenesis with iron: one with each meal Commence quit smoking “goop” - solid extracts Eleutherococcus:Glycyrrhiza, 1:1; patient instructed to dip toothpick into goop and use in place of cigarettes. 3/31/2008 Janet - CFS ROV 6 weeks  Smoking cessation program successful;  Fatigue considerably reduced  Energy level: 5-6 (VAS 1-10)  ENT and eye symptoms reduced by 50%+  GI symptoms reduced, improved appetite  50% + reduction in arthralgia/myalgia  Less brain fog 3/31/2008 Janet – CFS SOS scores 35 30 25 20 15 10 5 0 EENT 3/31/2008 GI S/S M/S Enrg M/M 3 weeks 6 weeks Slp Baseline Lan – Fibromyalgia, MCTD  Age: 51 y.o. female  CC: Fibromyalgia (by referral from PCP), Mixed Connective Tissue Disease (possible Sjogrens or Lupus)  Duration: 10 years  Hx: Symptoms started in 1993 when dx with EBV. Hasn‟t been the same since then. Dx Fibromyalgia 1996. Dx. MCTD 1998. Started with fatigue in 1993. Stressful year. Working part time only (court clerk). Setting up parents 50th wedding anniversary 3/31/2008 3/31/2008 Sx: deep muscle aches (flu like), joint pain – comes in „waves‟. Dx EBV months later in same year. Anemia. Dx sleep apnea 1997 – uses CPAP. Helps sleep and slightly helps pain. Headaches from hunger. Photophobia, PAT, flushing hot flashes, chest pain, IBS, bloating, belching, dermatitis, exhaustion, back pain, butterfly rash. Water retention. Limbs feel like 100 lbs.  Activity level: moderate. Walk, stretch, nordic track 20-40 min. 3-4x/wk.  pHx: tonsillitis 1957  Medications: Nadalol for PAT, Amitryptilene for Fibromyalgia, Prozac for stress.  Diet: B- Oatmeal, raisins, milk Snack – apple, chocolate graham cracker w/peanut butter. L- lean meat, starch, fruit, veg. Snack- froz yogurt, popcorn, sweets. Dmeat, veggies, grains. Drinks 8 glasses of water per day. 1 glass of milk per day.  Sleep: Barely enough. Uses CPAP. 10PM to 7:15AM. Wakes tired.  3/31/2008  Initial visit: 65 inches, 152 lbs. HEENT- nl, BP108/70, pulse 78, RR nl. Skin – slt. mild Flush over nose/cheeks. Non-pitting edema mild lower extremities.  Tender points 9/18. Dysbiosis questionaire score 377.  Review lab hx: Sed rate range 63 (recent) to 124. Borderline to frank iron def. Anemia. Elevated gamma fraction (serum protein electrophoresis), hyperlipidemia (Cholesterol 240-270, Triglycerides 160-180, LDL 156-182, HDL 50-58), T4 4.8-5.3. CRP nl at 0.7. Calcium 8.7 (ideal 9.2-10), Sodium 136 (ideal 140-142) 3/31/2008  Intervention: Anti-inflammatory tx with Concentrated Ginger extract. Immune support with MycoPotent Immune Complex. Connective tissue support with ArthroGenX. Dysbiosis tx with ParaBiotic Plus and ProFlora Plus. Taurine/K/Mg formula for Cardiac support. 3/31/2008 ROV – 1 months  Fatigue up/down overall some improvement. Energy was 2-3 (0-10) now 5.  Joint pain/deep muscle aches. Waves of pain – much less  Edema- no change yet 3/31/2008 ROV – 2 months Jt/Muscle pain – con‟t to improve now 4 (0-10, 10 worst) was 8-9. Feeling hopeful. Decided to add massage therapy. Dreaming. Dreams more vivid. Reduced Amitryptilene by ½.  Relates hx of Raynauds disease. Complaint of hands going to sleep when lying down. Has lost 15 lbs on Weight Watchers program.  Walking 2-5x/wk.  Exam: tender pts. 2-4/18 (2 mod. 2 slt), extremities – no edema, nl circulation.  3/31/2008  Tx: Add MSM, CMO to tx. Finish dysbiosis tx (within next 2-4 weeks)  ROV 4months  Leg aches stopped 1 wk ago. 1st time in ages! Hands – numbness reducing. Sleep – improved. Con‟t with massage tx. 3/31/2008 ROV – 4 months  MVA days after last appt. While stopped rearended by truck and pushed into truck in front of her. Suffered Whiplash. No fractures. Developed neck/upper/lower back pain. Massage 2x/wk. Leg pain returned – slt. Overall not as bad as before. Recovering quickly from injury.  Exam: tender pts 4/18. C2-3 R. Sublux 3/31/2008  A/P: adjusted neck to correct sublux.Recommended „Ma Roller” for paraspinal muscle relaxation. Supplemental tx: no Δ.  ROV – 5 months  Fatigue, aches, pains, crumby feeling-all improved. Complaint of vaginal dryness.  O: deffered  A/P: Rx: EPA/DHA, BioIsoflavone, Vit E 3/31/2008 . ROV – 7 months  Recent GI Sx. Diarrhea, bloating, gas, nausea. Fatigue worse since GI upset.  Aches/pains – much less. Knees, back, jts.much better. Gets tired from standing. Tired around 11 AM, feel hot during sleep, throws feet out of covers, must open windows, hot weather not well tolerated.  Exam: BP 92/58  A/P: added Sulpher homeopathic and Intestinal Repair Complex. 3/31/2008 ROV- 8 months  Great response to homeopathic sulpher and Intestinal Repair Complex. Energy up, strength up, able to stand longer without fatigue. Feels like “life going through her blood”. Diarrhea, nausea- gone. Gas reduced.  Exam: 4/18 tender pts. All mild.  Tx: Immune regulation tx begun using Immune Balancing Complex for T1/T2 cell regulation, for underlying stable autoimmune disorder. 3/31/2008 ROV – 16 months  8 months since last appt. Some recent flairs of symptoms. Stress high – son out of work living with her, 3 grandchildren. Extra activities. PCP referring over for Fibromyalgia, but Sx of autoimmune disorder predominate.  Pain feet/legs, hips – achy. Difficulty standing beyond 1 hour. Fell 3 times in last month. Dizzy, lightheaded, sugar cravings. No menses for last 4 months. Dx of diverticutitis. Tx with ABO then fiber. Doing fine now. Recent Sed rate 50, Na level 135. Ferritin 12 (low iron reserves). Cholesterol 262. Deep fatigue has come back. Occ. Slurring speech. MRI – nl. 3/31/2008 ROV – 16 months  Tx: disc. BioIsoflavone and move to Rx TriEst/Prog. Start anti-inflammatory ArthroGenX (Curcumin, ginger, boswellia, CMO, GS,CS,MSM, B3a), Con‟t on EPA/DHA, Immune Balancing Complex. Add ferritin. Add Arnica homeopathic. Patient wants to work on elevated lipids. Add BioLipotrol (inositol hexaniacinate, guggal, etc). Work on zone balancing meals 3/31/2008  Feeling much improved. Pain, inflammation down. Energy up. More active. Needs less sleep. Feel like I have a life again. Intestines – remain good.  Labs: ferritin 22 (10-291)  Exam: BP 120/78. P 68 R. HEENT nl, lungs clear, abd nl. Tender pts. 2-4/18  A/P: run allergy testing. Lan thinks certain foods may trigger aggravation. 3/31/2008 ROV- 19 months ROV – 20 months Allergy report – Reactions to beef, cane sugar, celery, corn, white potato.  Feeling great! Supplements working well. Has been on Elimination diet pending allergy results. Fatigue – paces herself. Doing well. Intestines – doing well. All Sx clear except fatigue  Recent labs: Chol 202, LDL 126, HDL 56, Tri 102, Sed rate 30, Ferritin 40, Na 140, K 4.0, CRP < 0.2.  3/31/2008  A/P: autoimmune disorder (MCTD) with fibromyalgia like symptoms.  Implement allergy diet.  Zone balance meals  Con‟t on: Natural Rx HRT, ArthroGenX, BioLipotrol, EPA/DHA, Immune Balancing Complex, ferritin formula.  Add: anti-inflammatory analgesic with homeopathic base- PainX (incl. Low potency arnica) to replace Arnica pellets. 3/31/2008 Current  Lan continues to do well. Following allergy elimination diet. On supplements as prescribed. To date her PCP and rheumatologist are not sure her exact Dx (MCTD, Lupus, Sjogren‟s). Lan does have evidence of mild dryness (mouth, eyes), but labs are neg. for Sjogren‟s. Diet/supplements have helped relieve dryness substantially. 3/31/2008 Cheryl – FMS (Courtesy of Eleanor Barrager, DNFS, PGDD, Dip Ed)  52 yo female;  CC: Fibromyalgia Duration: 3years  Hx of ongoing mild fatigue  Sx: seasonal allergic rhinitis symptoms, low energy, poor sleep awakes often due to pain, cognitive dysfunction with short term memory loss and reduced comprehension, stiffness in neck, shoulder, hip and knee joints, constipation alternating with occasional diarrhea, occasional indigestion, ongoing flatulence and straining to eliminate stools, dry skin, intolerance to alcohol preservatives and processed foods. 3/31/2008 Cheryl - FMS  Major stressors in last few years: son and daughter away at college, older daughter with grandson, works for ENT specialist as office manager, some financial issues.  Activity level: low level of exercise with occasional moderate walking on weekends at mall; no weight resistance or aerobic activity. 3/31/2008 Cheryl - FMS  Hyperlipidemia with elevated total cholesterol, depressed HDL, elevated LDL and elevated triglycerides;  Abnormal GTT with elevated 2hr glucose and insulin;  Food allergies: almonds, wheat, egg, milk, peanuts, and rye.  MCS to household cleaners and perfume, fertilizer odors:  brain fog, and  fatigue 3/31/2008 Cheryl - FMS  Diet 24 hr recall (CHO food cravings) – B/F Kashi cereal with milk and a cup of coffee – Lunch: wheat bread with cold cuts, coffee with milk, cup of vegetable soup (canned) or fruit – Chicken or meat with potato, rice or pasta and one green or yellow/orange vegetable; – Drinks diet coke and chew sugarless gum; poor water intake; usually one canned soup or stock on most days used in cooking. – Eats out 2-3 times a week – Mexican, TeriYaki or Chinese. 3/31/2008 Cheryl - FMS      Sleep 7-9 hours - interrupted; awakes unrefreshed; Energy level: 4 (VAS 1-10) Initial visit: patient presented with dark circles under eyes; physical exam: WNL except for dry skin and dandruff; B/P 163/83 and HR:76 and regular. Wt:169 Ht: 64” RJL: 43% body fat, low intracellular water, high extracellular water, phase angle 5.6 Initial SOS Score: 108 3/31/2008 Cheryl - FMS  Intervention: – BioInflammatory Functional Food: 1 scoop bid for 4 days followed by 2 scoops bid for next 19 days – Anti-Inflammatory Diet but also avoiding known food allergens, MSG, artificial sweeteners, all refined carbohydrates, and high fat foods – EPA/DHA: 2 capsules bid with food on non-fish days – Regular exercise – moderate walking program 3/31/2008 Cheryl - FMS ROV: 19 days  Feeling much better, less issues with fatigue and myalgia pain; energy level: 5-6  More restful sleep at night;  Blood pressure 148/80 (previously163/83)  Weight: 162  Less irritability  Able to walk on treadmill at 3mph at 3.5% incline for 15 minutes daily 3/31/2008 Cheryl - FMS ROV:19 days  UltraMuscleEze: one level teaspoon bid  BioCleanse Detox capsules: 3 bid  Continue EPA/DHA: 2 bid with food  ProFlora Plus: first thing in the morning and just before bed with a little soy yogurt 3/31/2008 Cheryl - FMS ROV 6 weeks  Fatigue and pain considerably reduced  Energy level: 7 (VAS 1-10)  Weight: 159  Cognitive function much improved  GI symptoms totally resolved  No dark circles under eyes  MCS much improved able to tolerate limited exposures with no symptoms 3/31/2008 Cheryl - FMS ROV 6 weeks  Intestinal Repair Complex powder – 1 tspn bid in water or permitted dilute juice Continue UltraMuscleEze powder: one level teaspoon bid  Food reintroduction/challenges to identify “trigger foods”  UltraGenesis w/o Iron – 2 bid with food 3/31/2008 Cheryl - FMS ROV 9 weeks  Feeling very well, good energy: 8  Walking 20 minutes 5/7 at 3.5 mph at 4.5% incline  Weight: 156 B/P:140/78  Started on maintenance program: – 4-day rotation diet, – UltraGenesis w/o iron 2 bid, – EPA/DHA 2 bid on non-fish days, – UltraMuscleEze powder – 1 tspn per day, – ProFlora Plus probiotics 3/31/2008 Loretta – Migraines, MCS  Loretta - Migraines, MCS and Food Allergies  56 y.o. female  CC: headaches, allergies (food and chemical, hormones, digestive and joint pain  Hx: chemical sensitivity started in 1976. Moved to Colorado 1975 lived in moldy basement apartment and exposed to 2nd hand smoke. 3/31/2008 Loretta  Hx: HA‟s “all her life”, but esp. worse since son born in 1976. Had Bell‟s Palsy just prior to delivery. Tx with ABOs. Difficult delivery, rectal fissures. Tx with steroids, surgical repair. Developed yeast infection. For several years yeast infections. Always treated topical only. 3/31/2008 Loretta  Hx: Infection as a child treated for 3 mo. Straight with ABO. Since 1980‟s sees allergist for shots and elimination diet, challenges, testing and symptomatic Tx.  Sx: HA‟s daily at least 2 hours duration. Migraines – pulsing, beating. N/V. Irregular frequency, can be from 50 per month to 1 per month. 3/31/2008  Sx: Tried elimination diet with bowel cleansing enema – white mucus in stool  Reacts to: “all chemicals”, perfumes, tobacco, phenol, formaldehyde, garlic, dates, wheat, potatoes, baking powder. Allergies keep changing.  Major Stressors: marriage, health, work as a CPA.  Activity level: mild to moderate walking 30 minutes daily. 3/31/2008  PHx: Hysterectomy 1978, Hemorrhoid and polyp surgery 1983, Kidney stones 1991.  Medications: Imitrex PRN.  Nutritionals (Self Rx‟d): St. John‟s Wort, Mg, Chromium, CoQ10, Acidophilus, CaGS osteo/arthritis formula, barley green, flax oil, psyllium fiber.  Diet: Beans, non gluten whole grains, rice, salad or steamed vegetables, several fruits and some nuts. Essentially vegan. 3/31/2008  Energy level (1-10, 10 highest): 2-3  Initial visit: Ht. 62 inches, 170 lbs. HEENT nl, PERRLA, Lungs Clear to AP, BP 130/78, pulse 76 R. Heart RRR, Essentially normal exam with the exception of fatigued look, allergic eye lid creases, increased abdominal gas/bloating on auscultation, neck, low back and hip pain on ROM (stiffness and decreased ROM)  Dysbiosis questionnaire score 159. Had discontinued Premarin on her own and switched to Black Cohosh and then to only Natural Progesterone topical. 3/31/2008  A/P: Migraines, food/airborne sensitivity, probable dysbiotic bowel with probably increased mucosal permeability. Surgical Menopause, possible early DJD. Needs Bone loss protection program.  Rx:  Lab: Digestive/Microbial stool analysis.  Tx: MigraClear caps, Quercetin, Bioflavonoids, BioAllergy Plus caps, topical progesterone. 3/31/2008  ROV (1 mo): Laboratory results: NL digestion/ absorption, Microbiology: Ø acidophilus, 2+ Non lactose fermenting E. Coli (poss. Pathogen), Ø yeast, 5.9 pH (6-7.2). NLF E. Coli sensitive to tannins.  Added Tx: antimicrobial tannin combination, ProFora Plus and Florastor. 3/31/2008 ROV – 2 mo.  Recent UTI. Saw local MD. Tx w/ABO q 5 days. Continued on Tannins and ProFlora Plus and Florastor  Migraines – less frequent. 10-12 days apart now. Intensity still bad. N/V. Top of head HA‟s less severe. Has feeling of hope now.  Counseled on marriage relationship with Loretta and spouse. Stress issues.  Rx: began desensitization homeopathic allergy drops (household dust/molds, chemicals (formaldehyde). Based on allergists findings. Urine/Saliva pH testing. 3/31/2008 ROV – 6 months later Intestinal dysbiosis – corrected  Migraines- less frequent, less severe, recovery faster. No Migraines in the last 2 months! Using only ¼ to ½ MD Rx medication PRN. No regular HA‟s  Eating more fish and veggies, less CHOs. Has lost 31 lbs in last 6 mo. Exercises 2-3 hours per day doing landscaping.  Notices gets migraine when pH drops too acid (5.65.8 range saliva). Less food and chemical sensitivities.  3/31/2008 ROV – 6 months later continued  Intestinal gas/bloating subsiding.  Tarred a roof – got HA, but no migraine.  Energy 7-8.  Excited about life.  Working things out with spouse. Communicating now. 3/31/2008 ROV – 12 months/current        Had a few 10 day cycles of HAs (1 q 10 days) but since last visit- none. (last visit ~ 3 mo earlier) Bowels regular (BM 1-3 per day) Weight – 134 (Ht.62 inches) lost 36 lbs total Eating large variety of foods with no reactions. Chemicals – still sensitive to cigarette smoke Arthritis: no joint pains since pH in 6.2-6-4 range. “Exciting changes in their marriage” 3/31/2008  Some hot flashes  Tx: New:  TriEstrogen phytobotanical formula,  Lipopure Progesterone  BioAlkalizer powder.  OsteoGenesis E. S. caps. Con‟t:  MigraClear caps.  Desensitizing oral drops 3/31/2008 ROV - Current Multiple Pathology Case CASE (Courtesy of Kathleen Matteson, ARNP, ND)    June 2001- Jan 2003 (treatment time frame) 76 y.o. white female CC: – CFIDS X‟s 15 years – FMS x‟s 12 years – Hyperlipidemia x‟s 15 years – Hypothyroidism – Sleep disturbance x‟s 2 years – IBS x‟s 10 years 3/31/2008 CFIDS      +EBV: IgG 4.74 high, EBNA >5.00 high +Chlamydia pneumoniae: IgG 512 (normal < 32), IgA 256 (normal < 16) - Lyme titer, - HSV 6, - CMV Rx: Targeted transfer factors (EBV, C.pneumoniae): 1 cap daily x 30 days followed by pulse therapy monthly at 5 consecutive days each month. All symptoms have resolved 3/31/2008 Hypothyroidism June 2001  Rx: Armour thyroid 45 mg daily  Successfully raised free T4 to 1.1, free T3 to 300 (230-420), TSH normal. 3/31/2008 Irritable Bowel Syndrome June 2001 Diarrhea predominant symptom  Allergy test: positive IgG1, IgG4 to Wheat (4+)  Rx: BioCleanse Functional Food powder: 2 scoops with bulk fiber 2 scoops daily. Disc. Wheat products  Symptoms resolved  3/31/2008 Hyperlipidemia January 2002 Had been on Zocor 40 mg QD from cardiologist for past 10 years that kept lipids @: – Cholesterol (total): 232 high – Triglycerides: 107 – LDL: 140 high – HDL: 32 3/31/2008 Hyperlipidemia January 2002 continued Rx: discontinued Zocor  Begin:  – Natural lipid lowering combination formula BioLipotrol:  2 caps TID – EPA/DHA  2 perles BID Also was able to increase exercise to 30 mins/day because chronic fatigue was better 3/31/2008 Hyperlipidemia March/April 2002  After 3-4 months: – Cholesterol (total): 206 (nl < 200) – Triglycerides: 79 – LDL: 113 – HDL: 77 3/31/2008 Fibromyalgia w/sleep disturbance January 2003 Klonipin nightly has helped slightly, but patient does not want to continue to take  Rx: discontinue regular use of Klonipin  Begin: Super FMS (Mg glycinate, malic acid, MSM) 2 caps TID  TriMagnesium (citrate, malate, glycinate form): 1 cap TID  Response: not completely pain free  3/31/2008 Fibromyalgia w/sleep disturbance February 2003  Rx: Anti-inflammatory pain relief combination formula: PainX (WBE, DLPA, Bromelain, Ginger, Curcumin, Boswellin, Guggal, proteolytic enzymes, homeopathic base)  2 caps at bedtime every night  Response: patient now is pain free and not waking @ night. Not taking Klonipin. First night on above formula patient slept 7 hours uninterrupted for the first time in 2-3 years. 3/31/2008 3/31/2008 Justice Arlin Adams of Pennsylvania, in a speech to a college, ended with the last words of the educator Horace Mann. “Be ashamed to die until you have won some victory for humanity” 3/31/2008 Let us go and do likewise! 3/31/2008 “Beloved, I pray that you may prosper in all things and be in health, just as your soul prospers.” 3John:2 3/31/2008