Deanna Windham, DO - Pediatric and Geriatric Dosing for LDN (2017 Conference) (LDN, low dose naltrexone)
Hello everybody. I'm glad that you're all here and I hope that you don't get tired of me over two lectures back to back. First we're going to be talking about pediatric and geriatric dosing and the considerations in those two special classes of patients. First of all, I'd like to say that a lot of kids who are on LDN, and a lot of geriatric patients, whether they're on LDN or not, are chronic care patients. They have chronic caregivers that are stressed out. I do actually find myself treating caregivers a lot too, for their chronic stress, chronic sleep deprivation, increased rates of illnesses.
But that's not what we're here to talk about today. We're here to talk about the patients. There's a huge social impact on people that are chronically ill. With kids, they've actually shown in research that they develop less social skills than other children do. And in geriatric patients that are chronically ill, they tend to withdraw from society. Both of these things are very detrimental to mental health and to overall health, and anything that we can do that helps to improve their overall health and their chronic disease states, enhances every aspect of their lives. I want to encourage all the practitioners here to be good advocates for your chronic care patients. By definition of being here at the LDN Research Trust conference, you probably already are, but it's a very time-consuming thing to do, to take on these chronic care patients, whether they're pediatric, geriatric or other ages.
Children that grow up with chronic diseases face a lot of stigma. They have less social interactions with other children. They are less able to have normal interactions, and don't have as many friends. Simple approaches to disease processes are often ignored. Contributing factors are usually not addressed in chronic disease states. We have a kid with juvenile arthritis and they're on the disease modifying drugs, but no dietary discussions, no treatment of their gut issues, no treatment of sleep. These are things that a primary care advocate can really help with. For a lot of my patients that I see, their primary care advocate is their gastroenterologist. I was just talking to a lovely gastroenterologist just a few moments ago who takes on a lot of these patients that are dealing with multiple disease states. And I'm seeing a lot more specialists beginning to treat patients who have chronic disease states and trying to treat them with overall health and wellness. That's what I really want to stress: the importance of treating these overall conditions, and how low dose naltrexone can be a part of that.
Very many patients who have chronic diseases have nutrient deficiencies from the medications that they're on. There's a great book Drug-Induced Nutrient Deficiency Handbook, and it lists each drug and the nutrient deficiencies that are known to occur from chronic use of these medications. And this is something that I think is important. Low dose naltrexone does not cause any nutrient deficiencies, I believe because it's so low dose. But other long-term medications do. Treating these nutrient deficiencies that result from the long-term medications actually can decrease the side effects of the medications. Geriatric patients that are on more than 3 medications are highly likely to be experiencing some interaction or some side effect that is not noticed. Anything that we can do, like low dose naltrexone, that decreases their medication usage, helps to improve their overall outcomes and their disease states.
Low dose naltrexone helps in a lot of chronic conditions in patients of all types. It has virtually no harm. It stabilizes inflammation, which is an important part of every chronic disease process. It improves sleep. I know that sleep is one of the biggest side effects we often talk about when low dose naltrexone is started, but with new research that I understand is about to come out, low dose naltrexone may not have quite the detrimental impact on sleep that we understand it to have. Most of my patients on long-term use of low dose naltrexone that I've observed, once we've tapered up, they are actually sleeping better and deeper. Now this is super important, right? Because sleep is when your body repairs and regenerates. It's when your immune system is most functional. We know from research that it's when the glymphatic system, which is the lymphatic system in your brain, is most functional. Decreased sleep or interrupted sleep is a trigger, or a factor, that worsens most, if not all disease processes. So treating sleep is important. And I really want everybody to understand that low dose naltrexone over a long term can actually help sleep. It also improves moods. If people's moods are better, they're more likely to be socially interactive. They're more likely to be out and doing things. They're more likely to be interacting positively with the world. The changes that your brain undergoes with depression are detrimental to chronic disease states.
Something that I like to focus on is that low dose naltrexone actually decreases the methylation damage to DNA that creates the epigenetic changes that lead to disease. Let me try to explain that a little bit. Epigenetic changes means that it's how your genetics are changed over your lifetime. Most disease states are epigenetic diseases. That means that you're born with the genetics that increases your risk for disease, but you can think of that risk factor as being turned off when you're born. Methylation is what turns that disease state on. Low dose naltrexone actually blocks that methylation change to DNA. That's a pretty powerful treatment.
I like to use low dose naltrexone as a first approach in my patients. If they get to me before they've been started on other disease modifying or immunosuppressing or anti-inflammatory or steroid drugs, low dose naltrexone is my go to. It's often my go-to even if they are started on those things, but it's my go-to treatment as a first line. I like this because it can prevent the use of more dangerous, side-effect ridden medications. It’s capable of actually treating some of the root causes.
We've been hearing this morning from some of these wonderful presenters about the modification of the TH-1 and TH-2 pathways, how low dose naltrexone decreases these inflammatory cytokines and interleukin overproduction in autoimmune diseases. And then I'm just bringing up about methylation with the DNA. So, low dose naltrexone is actually treating the modifying states, or the first steps, that are leading to these disease processes.
Very often there's good compliance because the lack of side effects, especially in patients, of course, that aren't having side effects with it. Again, as we've heard this morning, patients with a very good response will go off of it when they think they're feeling better, but once they go back on it, you can usually keep them on.
It can be used long term with no risk of side effects. Although being considered more and more by specialists right now, there aren't too many specialists or mainstream doctors or PCPs considering it. Because of the building research on it, it's easy to defend to colleagues. And so I've had patients that go into the hospital, going to a psychiatric facility, I can get their doctor on staff to prescribe this medication if I get a chance to talk to them in person. This is something that I find easier to defend than some of the other integrative therapies.
Some of the special considerations in dosing that you need to consider with this class of medications in pediatrics and geriatric patients is that in children, body weight may not be the best way to decide what their dosing for low dose naltrexone should be. We're seeing higher rates of obesity in children. I haven't been checking obese children for Lyme, but I might want to start doing that based on Dr. Holtorf’s discussion. Often times we'll see kids, or adults too, that have a low muscle mass and are obese. What we should consider in children is a little bit different. We'll get to that on the next slide. Also, patients that are sensitive to medications or who have had vaccine reactions, we need to consider a dosage change on them. Compliance has a small impact in low dose naltrexone, and route of administration needs to be considered.
For body weight in patients who are obese, as I mentioned, they can have muscle wasting, so body weight can be an unreliable way of getting a dosage for them. In obesity, especially for children, what I like to do is to use the ideal body weight. I had an 8 year old and he weighed 130 pounds. And so this very sick child. At 130 pounds, he should have been on LDN 4.5 mg dosing - this was before I realized this. When I tried to do that, he had problems. He didn't sleep well. He had stomach upset. He wasn't doing as well in school - I don't know if that it was because he wasn't sleeping well at night - but his side effects never got better after a couple of weeks. So that's what prompted my research into this area. We used ideal body weight for him. And on that dosing, he did much better. And he was able to get on the low dose naltrexone and to stay on it.
In adults, if we're talking about the geriatric population, what we're looking at, if they're obese and sometimes also if they're underweight, consider their muscle mass. If you have say an elderly person who's very underweight, you might dose them lower. With underweight, with muscle wasting, I tend to decrease the dosage by 1.5 to 5 mg, to between 3 and 4 mg.
In regards to sensitivity: if patients have a sensitivity to medications, if they have multiple food sensitivities, multiple sensitivities to supplements and herbs, if they have sensitivities to chemicals, additives, smells - your multiple chemical sensitivity patients - very often they need to be dosed at lower dosages. Patients that have a history of a vaccine reaction, or certainly, multiple vaccine reactions, also. If any of these are true for your patient, you want to consider starting them on lower dosages and tapering them up more slowly.
If they have primary or a serious gastrointestinal illness, you may want to consider doing creams or gels. They may not be absorbing things very well through their gastrointestinal tract, with the enteric damage. Dosing them with creams and gels can be of big benefit to them.
Compliance. I'm going to talk about the actual dosing schedule in just a minute. Compliance is not much of a problem with low dose naltrexone, but I do like to tell my patients that going on and off low dose naltrexone will prolong their side effects. If they have difficulty sleeping as they taper up, and then they go off for a couple of weeks while they're on vacation, and come back home, they're probably going to have to start tapering again. They won't be able to go back on the 4.5 milligrams. Side effects are usually minimal and usually short-lived. I'm talking about the majority. There certainly is a minority of my patients that have difficulty with long-term side effects on low dose naltrexone, or unusual side effects. But it very certainly is the minority of my patients. And so assessing willingness to be compliant and consistent with the protocol is important.
Route and dosage administration. For patients that can't swallow pills, or again, that have gastrointestinal problems, pharmacists here can tell you a lot more about this, but when I was like looking into liquid dosing for my patients, I found that it was much more expensive to do it that way. and the liquid dosage expires sooner, so you can't get as much of it at a time. I'm usually prescribing the pill form or cream form in a three-month prescription so they can get three months at a time. With the liquid form, it’s my understanding and this may need to be corrected, but my understanding is that liquid form only lasts for about a month, so they can't get those extended prescriptions that help to reduce the cost. Creams and gels are usually preferable in this instance. The way that you want to dose a cream or a gel is very similar to the dosage in pill form. You start with the full dosage, whether that's going to be 3 or 2 mg/ml, and they start using it at a quarter of the dosage. This is fairly easy to do if it's in a syringe. You start at a quarter of a gram. Every week to two weeks, you increase that dosage until they're taking a full milliliter, and that full milliliter is their full dosage. For children, remember that it's ideal body weight and not overall body weight if they're overweight. Your dosing is 0.1 mg/kg of body weight. For adults, I like to decrease that. Depending on how sensitive they are, depending on how much muscle wasting they have, I may start at 0.05 to 0.075 mg/kg <there should be a zero in front of the seven five on the slide>; I decrease that to 0.05 or 0.075 mg/kg of body weight. That's their full dosage. For sensitive patients, you start at a quarter of the dosage, leave them at a quarter of a dosage for 2 weeks before you taper up by another quarter. Let's say it's a 4 mg dosage that you're tapering them up to. You would start at 1 mg, or one quarter of a milliliter if it's a gel form, and they would stay on that for a week. Then you would go up to 2, then 3 and then 4, every 1 to 2 weeks. If I have a very sensitive patient, we start them at 0.05 mg/kg. If they're on that dosage for 1 to 3 months and they're doing well, but we want to see if we can get a better benefit on a higher dosage, I usually wait at least a month before I will increase them to the next dosage.
I think I practiced this before I started. I think I got within the time slot allotted. If any of you have any questions about this, you can email me. That slide is very hard to read under these lighting conditions, it's firstname.lastname@example.org or DoctorWindham@icloud.com. You can reach me at either of those places.
Keywords: LDN, low dose naltrexone, chronic diseases, nutrient deficiencies, children, geriatric, methylation, obesity