Treatment Based on Empirical Knowledge Rather Than Lab Results
Low-dose naltrexone (LDN): Originally, naltrexone was used at relatively high doses. At these dosages, it acts as an immunosuppressant. But at low doses, it was found to act as an immunomodula- tor.139 It rebalances the immune system, bringing it back to the “set point.” LDN was originally used primarily in multiple sclerosis patients. More recent studies have shown that LDN is an immune modulator and has been studied in a variety of disorders such as inflammatory bowel disease.140 In adults, dosing of LDN can start at 1.5 mg at bedtime and increase by 1.5 mg weekly to a maximum dose of 4.5 mg, and this is mainly in opioid-naive patients.
IV glutathione: Glutathione (GSH) is the most important low molecular weight antioxidant synthesized in cells and the most potent free radical scavenger in the body.141 The liver is a major producer of glutathione, and medications like acetaminophen tend to deplete GSH greatly,142 thus, the significant downside of using acetaminophen chronically. To give you an example of how important it is for the liver itself to have GSH, consider the case of somebody trying to commit suicide by taking an overdose of acetaminophen. A high dose of acetaminophen depletes glutathione from the liver so dramatically that the liver will die. In the emergency room, the glutathione precursor n-acetylcysteine (NAC) is given IV in an attempt to save the liver. Glutathione is also depleted dramatically by cigarette smoke as well as smoke from forest and brushfires.143-'45
GSH cannot be taken orally as the stomach acids will break it down. Liposomal products are available. Ideally, IV glutathione is highly preferable. The positive impact for patients with chronic pain as well as fatigue and/or brain fog can be dramatic. IV GSH is typically administered once a week. The first dose is 1000 mg, usually given over 30-45 minutes. Subsequent treatments may use 2500 mg.
Nature: Nature has a profound positive impact on human health and well-being.146 There are nearly 100 scientific journal articles about nature and its positive impact on human health. This can mean looking at a green space outside the window following gallbladder surgery decreasing the use of antibiotics and decreasing the length of the hospital stay. It can mean observing “charismatic macro fauna,” basically, looking at large animals whose personality traits we find appealing. Much of nature’s ability to improve human health and well-being comes from its impact on cortisol,145 and thus, its impact on pain and the immune system. People who work in high-rise office buildings in large cities but have a window that looks down on a green roof have lower cortisol levels and improved immune system function, for example. No matter where a person lives or works, there is always the ability to interact with nature. This can be as simple as having indoor plants in your home, looking out your window at a green space, or actually sitting under a tree. Nature done this way is typically free but profoundly impactful. I have devised a patient education trifold that can be accessed at http://online.flipbuilder.eom/cbgg/tosn/html.http://online.flipbuilder.com/cbgg/nxny /html.147-148
Case Studies
CASE STUDY 1. AD IN A TRADITIONAL SETTING.
A 55-year-old woman was diagnosed with Hashimoto’s thyroiditis in her 20s, psoriasis in her 30s, and rheumatoid arthritis in her 40s. Pre-diabetes has been diagnosed as well as insomnia, fatigue, urinary stress incontinence at times of large amounts, diarrhea, abdominal bloating and pain after meals, gastroesophageal reflux disease, nausea, memory and concentration issues, low mood, excessive anxiety and worry, dysmenorrhea, menorrhagia, premenstrual syndrome, ovarian cyst, breast cysts, fibroids, two miscarriages, dry skin, easy bruising, brittle nails, chronic sinusitis, recurrent vaginal yeast infections, occasional lightheadedness, palpitations, and allergies, and she has had skin cancer once.
Her main complaint includes diffuse joint pain involving the hands, wrists, elbows, knees, and ankles. The left knee and pain in the small joints of the hands are the worst. She has muscle pain involving the lower back and neck with frequent severe calf cramps at night causing her to jump out of bed when they occur. She also has tension headaches four to five times per week and migraine headaches one to two times per month. These migraine headaches used to occur with her menstrual cycles before she had her hysterectomy due to large fibroids. The hysterectomy occurred 18 months before the joint pain started that was later diagnosed as rheumatoid arthritis. She also has tingling, numbness, and burning pain in her feet that used to come and go but is now constant and getting worse. Also, her “sciatica” can be extremely problematic at times but seems to respond to “a steroid shot in my back and some physical therapy but it seems to always want to come back.” She also tells you that the menstrual cramps she had for many years prior to her hysterectomy “were just killer.”
So here is a “typical” AD patient when it comes to experiencing multiple types of pain and health issues beginning at a young age, with a gradual addition of new types of pain over the years as her immune system dysregulation got worse over time. Multiple organ systems are involved on top of all the pain. This can look like a very confusing picture to many practitioners. But the only way all these organ systems can be thrown off at the same time is if a really important central mechanism has been thrown off, or there are multiple important central mechanisms that are not doing the work that needs to be done.
Because we know she has an AD, we know exactly where to look to find out why. Then, whatever is causing the immune system dysregulation is also causing much if not all of the pain and other issues. Initial tests are run. Issues found are addressed. Retesting occurs at intervals. Fine-tuning of issues still present are taken care of. After proper assessment and addressing root cause, the patient reported dramatic improvement in symptoms. Now, whatever symptoms are still present enough to negatively impact her quality of life can be given more personal attention and addressed specifically. If the issues that still remain are pain problems, the other chapters in this book will give the vital information required to optimize management no matter what type of pain is involved.
CASE STUDY 2. “BILSTROM’S NUCLEARITIS.”
What to do with a person who has many of the symptoms and organ systems involved similar to Case Study 1 but no definitive, named ADs yet diagnosed? Antibodies are negative for rheumatoid arthritis and Hashimoto’s thyroiditis as well as other ADs. All the issues make people think that AD is a possibility, but repeated testing over and over again keeps coming back negative except for a positive ANA.
A positive ANA up to this point has not had a proper name. The immune system is attacking our own nuclear material, thus, the name anti-nuclear antibody. It is definitely not a good idea to attack our own DNA.
Thus, “Bilstrom’s Nuclearitis.” Definition: Bilstrom’s Nuclearitis. Noun. A chronic autoimmune disease characterized by the production of antibodies which mistakenly attack proteins in the nucleus of cells within the human body including structures such as DNA. First described by American physiatrist, functional medicine and integrative medicine physician David Bilstrom in 2018.
Now we have a named disease to go with a positive ANA. Now treatment can be initiated potentially years earlier, rather than waiting until additional body parts are attacked (new autoantibodies being produced) and the patient’s functional status and quality of life are so compromised that medications like immunosuppressants, NSAIDs, and opioids must be the first line of treatment. Thus, the not unsubstantial potential risks of these medications could be avoided when the AD process has a name and is addressed earlier, such as the potential for the immunosuppressants to cause a user to get a new AD as well.1317 These medicines will also increase your risk of getting cancer, such as lymphoma, or a life-threatening infection.1516149
Having a proper name for the disease, which occurs when the ANA is positive, helps to initiate proper treatment earlier than is usually done. Particularly when it is the first antibody to be produced, the autoimmune process can hopefully be reversed before the immune system starts to attack new body structures. If a person is producing thyroid antibodies along with the positive ANA, the TPO and thyroglobulin antibodies can be a nice way to track how well the immune system dysregulation process is being reversed right along with how the person is feeling; the goal being for thyroid antibody numbers to go down to normal levels and the ANA to turn negative.
CASE STUDY 3. LOSS OF IMMUNE SYSTEM SET POINT WITH NO AUTOIMMUNE DISEASE.
How about a person with many different types of pain but no autoimmune processes initiated yet, not even a positive ANA? They have right knee pain, right shoulder pain, bilateral hand pain, low back pain, neck pain, and headaches. This is where the detailed past medical history that has been taken on all patients with chronic disease can be so helpful. This is often the history of the patient type we discussed in case reports numbers 1 and 2 prior to the start of any autoimmune process. Patient birth history is significant for being born 4 weeks early, delivered by C-section, and not breast-fed. Babies delivered by C-section have their intestinal microbiome made up of a microorganism mixture similar to what is on the lighting fixtures in the delivery room and the skin of the nurses present.150 This is much different than the intestinal microbiome of children delivered vaginally. The intestinal microbiome will also not be well-established without being adequately breast-fed.151 Being delivered vaginally and breastfed are the two most important activities to establish early on for a healthy gut microbiome and a healthy immune system. Remember, 80% of our immune system surrounds the gut.
Childhood history includes colic as a baby with intolerance to formula. This person has already developed a dairy protein or the dairy sugar lactose intolerance, possibly due to the disrupted microbiome and too many not good bacteria. First antibiotic was used at two months of age, as early antibiotic use is much more disruptive to the gut.152 It doesn’t even take a whole course.
The child or teenager has recurrent ear infections, sinus infections, and strep throat. These are downregulated immune system issues. They also have developed some allergies and eczema and maybe even asthma. These are upregulated immune system issues. Already we can see the loss of the immune system set point before the age of 18. You can see that this individual is moving towards a future with not only AD and cancer but chronic diseases in general including pain. These may only show up years or decades later, but the process has already started. Now the person also developed mononucleosis in high school. People who have had “mono” more than double their chance of getting multiple sclerosis.84-85 If this person is a female, menstrual cycles began at age 13 and right away she developed bad flows, bad cramps, and bad premenstrual syndrome. Estrogen dominance is already established, and this is a big driver of AD. This is one reason why women are much more likely to get AD than men; 80% are women in fact.1
In her 20s, she developed mild hypertension, probably due to cortisol being stuck in the “on” position. “Running from a bear” tends to cause blood pressure to go up. Here comes an elevated LDL and total cholesterol. The liver, which makes LDL cholesterol, might be trying to feed the steroidogenic hormone production cascade. The liver is making more LDL cholesterol then would typically seem appropriate. With cortisol production high due to being stuck in the “on” position, progesterone levels start to drop, exacerbating the estrogen dominance. The body, always trying to self-correct, is trying to feed the steroidogenic hormone production cascade in order to make more progesterone or DHEA or testosterone, etc., in order to keep the person healthy and well-balanced, despite the cortisol issue. Unfortunately, in this situation, our response to an elevated LDL and total cholesterol might be to give a statin medication. If this is the reason why lipid numbers are running high, these medications will “cut off at the knees” the body’s ability to self-correct and fix the hormone deficiency and imbalance problem. This is one reason why we can see cholesterol numbers rise a couple years after statin medications are initiated. The body has found a way around the blockade and is trying to self-correct the hormone issues again. Our typical response? Increase the dose or change to a different statin medication.
Because the estrogen dominance has caused fibroids to be produced on top of the bad flows, the person has a hysterectomy. Unfortunately, a hysterectomy will tend to make the estrogen dominance worse.153 The person no longer has bad flows and bad cramps or fibroids. But the estrogen dominance will be even worse. The estrogen dominance has also probably produced, usually by the mid-30s if not earlier, insomnia and anxiety. Estrogen is like the “gas pedal” and progesterone is like the “brake pedal.” Too much gas or revving of the engine and not enough breaking or calming will cause anxiety and insomnia. Estrogen dominance is so common.
Because of the gut disruption, gastroesophageal reflux disease and constipation become issues. Acid-blocking medicines are started which guarantee vitamin and mineral deficiencies and the inability to digest food optimally.154 Constipation is now contributing to the inability to clear toxins from the body, both environmental toxins and internally produced toxic byproducts of metabolism. Old toxic estrogens dumped into the gut for removal from the body are instead reactivated and reabsorbed into the body, making the estrogen dominance worse. The gut and immune system issues have now allowed chronic infections to become established not only in the gut but systemically as well. A very common chronic systemic infection in this population is Candida or other mold species. Common symptoms of systemic mold include joint pain, muscle pain, brain fog, fatigue, sinus issues, and weight gain. Systemic mycoplasma may be driving the person towards rheumatoid arthritis and all that joint pain they are developing. That chronic Epstein-Barr virus issue may be trying to drive the person towards multiple sclerosis.
So now' we are back to the person w'ith the early disruption of the immune system set point. There is multiple organ system involvement, producing many different symptoms including pain. We need to recognize the loss of the immune system set point, do the proper testing, and address what is found. If any pain remains, we have many wonderful interventions to address the pain, whether it is joint, muscle, nerve, central sensitization, or mitochondrial dysfunction.
