How to Titrate Low Dose Naltrexone (LDN)

Titrating Low Dose Naltrexone (LDN)

I'm pushing for initiation at a half milligram and titrating up every seven days by a half milligram at a time.  

I want to ensure that we hit the right dose without overshooting, and I'm seeing more and more patients, especially the long COVID patients, not necessarily needing as much as 4.5. 60 to 70  percent of patients are getting a good response, but maybe we'd still optimize that dose.  

And so, this is the patient-specific response. This is why a good compounding pharmacy is so important to the mix and making sure that the compounding pharmacy isn't just take it and go. We want to have that relationship between the clinician, the provider, and the patient so that we can find that optimum dose. I'm being asked, "where do you start?" and I always start at 0.5. You can give a bunch of one milligram and a bunch of half milligrams, and they can add different doses. But it's all really specific to that patient's response if they're starting to see exaggerated side effects or a worsening condition—too much backdown. 

We also get asked for doses for all kinds of disease states. How do you dose that? And it always depends on um I think, the disease state. Suppose you've got somebody who's got a chronic disease, and it's killing their quality of life, and they may not be clinically depressed but have depressive-like symptoms. In that case, adding a daytime dose is a huge benefit because if you split that out as a separate dose not related to their autoimmune disease or their pain control, you can also affect quality of life nicely.

So, for example, I have a patient who we titrated in they were on  4.5 and had fibromyalgia. They tried 4.5 and didn't see any changes early on, but when they added the daytime dose, they saw improvement in their quality of life. They felt better, the mood was better, and if you think you feel better and your mood is better than that you know attitudes everything kind of thing. I've also got one post-traumatic stress syndrome patient who's on a milligram twice a day and doing fabulous at a milligram twice a day.

So it doesn't always take as much to see the response, and depending on the disease, where do you start?

Well, I'm with Sabastian. I always started a half milligram. I think half milligram increments. Although I got to be candid with it, when I first started doing Naltrexone back around 2010, I can't remember exactly when I first started dispensing it, but we were doing 1.53 and 4.5. I didn't get a lot of flack from hardly anybody.  I had one or two people that couldn't take it at bedtime because of the sleep disturbance of the vivid dreams and that sort of thing. We just switched to the daytime dose, and it seemed to take care of the problem. So other than that, I never saw a massive amount of adverse events, although they do occur.

If you're going up in half milligram increments, then you can recognize that as it happens, you can back up a notch and go. Okay, let's stay here for a  little while and see what happens. You know like we keep telling everybody in our lectures, it's not a race to 4.5, right?. And kind of the extension of that is 4.5 is a very fuzzy target. Some patients will do better with more. Some patients will do better with less. It's just kind of like let's aim there but let's  see where you land. It's like an arrow shot where we're kind of looking at the target but we know it's going to arc up and over.