LDN Video Interviews and Presentations

Erin Panian, PharmD, BCPS - LDN Radio Show November 2023 (LDN; low dose naltrexone)

Have you always wanted to be a pharmacist? 

I wanted to be a doctor first and foremost but when I got into college, I did an internship in the ER and figured out quickly that I tend to pass out when there's blood.  It wasn't the right path for me.
A non-hands-on approach would be a little bit better. My mom was a pharmacist and I shadowed her a few times. I thought it was neat, the knowledge of medications and what they were doing and I thought it was a fun field to get into. So, that's when I went to pharmacy school. I had a compounding rotation in my sixth year of pharmacy school. I just thought it was so fun. It's something new every day.
We get to figure out problems. Helping somebody figure something out was a lot of fun for me. To this day, it's still something I enjoy the most about the job. We always get the patients who have trouble finding help anywhere else, we're always able to try and help them. It's a very rewarding and fun job. I've been doing it now for 17 years.
Could you explain to our listeners what it is you do in pharmacy school and how many years? I know you said in your sixth year I believe seven isn't it now?
When I went to school it was six years, it's seven now. Each school is a little bit different. When I went to a pharmacy school you could start from day one and just finish, whereas a lot of other places have you do like a pre-pharm program. You might do two or four years in pre-pharm and then actually enter pharmacy school for three or four years. Mine was six years and then I did a residency training afterwards. That was at the VA. I switched over to compounding but did some more residency training after school. Some people do a year or two. I did one year and then I just entered straight into compounding from there.

What kind of things do you learn in pharmacy school? Walk us through it so we can understand what training a pharmacist has to have to become a compounding pharmacist.

It's not a lot of compounding. You get a class on compounding. One class out of those six or seven years and you learn the basics. I think the pharmacy school here has a couple of newer machines and technology that we use currently, but back when I went to school it was all very antiquated in terms of what they taught you for compounding because they didn't teach you much. It was still using an old ointment slab, a very sort of old-school Pharmacy. I always talk about compounding being an old-school Pharmacy, but with new inventions and fancier machines to help us make it more accurate, and a little faster. A lot of pharmacy school is going through all these other medications that you would see anywhere, whether it be at the hospital, Walgreens, or  CVS. It’s going through different medical conditions and learning about those, learning how the drugs work for those conditions, learning how the drugs work in the body and how they break down and get to the different tissue levels. It doesn't prepare you fully for compounding.

I always say when somebody comes to work for us it's about 75% on-the-job training because with compounding there's a lot of stuff out there that people haven't done before. A lot of what I depend on is kind of a network of compounders that you can communicate with.
I'm part of a list of Compounders from across the world and people would send an email out to everybody:” I have a patient that needs this, I can't find any data on it. What have people done? “
You kind of take your background information of conditions and different disease states, then you take your information of the drugs that you're able to utilize or the bulk chemical powders that you're able to get. Through that information, sometimes you have to figure out a unique way to give the medication to the patient or a unique dosage. It's a lot of on-the-job training and it's one of those jobs that the longer you do it the better you are. You've done a lot more. As experience goes along you get used to some of the questions, a little bit faster at being able to figure out some of the problems.

What about drug interactions? I mean that must be part of your course.

It definitely is, and it's one of the trickier parts, to be honest. As a cash-only pharmacy, we do have to make sure to take a good medication history with the patients. With people that bill Insurance, a lot of times insurance does that drug utilization review and that interaction review for you automatically.  So, when you bill the insurance company it will see even if the patient didn't get that drug at your pharmacy, it will see they got it at another pharmacy and it will alert you to the fact that it's going to interact.  Here, we don't have that because we're cash only and we don't bill insurance on that, but we're able to take a thorough medication history of the patients and there's a lot of stuff that are your common interactors that will interact with a lot of drugs.  So, anytime we see that we always make sure to be even more thorough and make sure that they give us everything they're on so we know to be able to check through those interactions and make sure it's not something that's not going to work out for the patient. 
In your pharmacy, just go through the different options that a patient can have for LDN.  
Our most common form is tablets because a lot of times patients are going to begin on a lower dose and then work up.  Tablets make it very convenient because you can split them in half.   I even have some patients that split them in quarters. Therefore, they can start with one tablet or a half tablet and then increase up as gradually as they need to, to reach their target dose.  I do find the tablets are the easiest and they are the most common with us. We also do capsules.  The only downfall with that is you can't split them. You're kind of stuck with doing one or two or three multiples or something like that. 
We can make different liquids. Liquids are nice in terms of being able to dose them because with liquids the options are endless.  If you have a 1 milligram per 1 milliliter, you could use 1 mil to get the 1 milligram dose.  If you wanted to start at 0.1 milligrams, you'd only have to use 0.1 ml. If you wanted to go up to a target dose of 4.5 then you could go up to 4.5 MLS.  You could do all your doses with just one liquid.  The only downfall is the taste.  It's not the worst-tasting medicine.  It's not the best-tasting medicine. Everybody is different in their palatability tolerances.  You've got excipients. If somebody is sensitive to the excipients. Storage it's not as convenient. Some of them are room temperature but still just keeping a liquid around can also be a little messy.  If you spill some it can be sticky. A lot of times people just prefer taking a tablet or a capsule over a liquid. We've also done cream, so any sort of topical.  We can do gels and creams. 
There is an LDN eyedrop.  That is something we were looking into providing to patients.  Being an eye drop, it comes with a little more stringent rules and testing. We do have a sterile room that we can make it in.  It's about getting the formula down and getting the testing done on it and getting that out to patients. Suppositories. I mean LDN I've seen done in almost every single dosage form we have available. We've done a sublingual, something that you can dissolve underneath your tongue.  Some patients get some GI side effects from Naltrexone so the sublingual dosing under the tongue is a good way to help mitigate those side effects.

What about fillers that you use in your preparations? 

Our most common filler is cellulose.  We do have some patients that are allergic to cellulose and from there if they need something else done, we work with them.  Generally, if just a lone script comes across, we're going to default to cellulose unless the doctor or the patient has alerted us that the patient needs to be worked with and they don't want a cellulose filler. Many times, we'll work with the patient and see what they want or need.  Whether it be with a capsule, the possibilities are pretty much endless.  We can choose something of their liking. 
Probably the second most common filler would be rice flour.  We see that a lot, but we can also do tapioca.  I've done inulin before, crushed salt, arrowroot, all sorts of different fillers, oat flour, the possibilities are endless with capsules. Fillers for liquids get a little trickier. Naltrexone is water soluble so theoretically you can just put the Naltrexone in water and dispense it to the patient. However, when it's just in water without a preservative, it can only be good for 14 days and it has to be refrigerated.  Not only do they have to get it refilled every 14 days, but they have to pay for it every 14 days. That can get a little cost-prohibitive, considering a lot of times we're dispensing up to three months for a patient and not just 14 days at a time. 
Fillers for non-water liquids. We can do oil, if they're tolerant of different oils. Again, we just come across different palatability and tolerances.  Some people just don't like that oil feel. Another liquid's available that has data on it and it's a little bit better mouth feel, but it does have different excipients in it that people may not be able to tolerate. 
So, there are lots of different options that we can work with patients to try to figure out what's going to work best with them.
We want them to get the advantage of the medicine without reacting to the excipients. We want to make sure that they're going to get the advantage of the medication. 

What disease states would you say your patients are using LDN for? 

The most common we see is any sort of autoimmune disease and that can kind of run the gamut. We have some doctors that if their patient has any sort of autoimmune condition, Low Dose Naltrexone is one of the first lines for them. GI diseases, so anything from all sorts of colitis to Crohn's, IBS, IBD.  We see a lot of Naltrexone for that. Restless leg syndrome is another common one. 
Fertility. We see a lot in women's health and we have some doctors that will prescribe it for patients having trouble conceiving or having trouble keeping pregnancies, or having a lot of miscarriages.
Depression. We see it from some different psychiatrists around town. Those are probably the most common ones that we see and then you'll have random ones thrown out there because it can be used for so many different things.  Pain is another one. We see it a lot for anything from fibromyalgia to nerve pain, to CRPS (chronic regional pain syndrome). 
We do see it a lot for pain too. I think those are the main things.  That doesn't encompass everything it can be used for.
When you talk to patients, what do you tell them about LDN and the expectations? Some people are so desperate to find an answer, they want it to work on day one. 
Oh, I know. I feel so bad for them when I tell them it's probably not going to be day one, this can take several weeks to work.  You know it is working, it's not just a Band-Aid, it's helping to work in the underlying mechanisms with inflammation and modulating the immune system.  I have had some patients call me after one day and they're like:” This stuff is miraculous!” but that is not the norm. 
Normally it's going to take a little bit to work and some patients get frustrated, because like you said, they're so ready to have an answer and they want to feel better and they've already been through so many other things. Generally, I always tell patients to give it a good three-month trial at their full dose.  Don't just give the one milligram a shot for two weeks, make sure to work up if you're able to tolerate it.  Make sure to work up and then give it a good shot at the full dose. I tell them it's not going to work for everybody but it is a great option that we've seen change lives.  It's not expensive, and the side effects are minimal and mild, generally.  I always tell them it's worth a shot. Especially with some of these patients that have just been through the gamut of doctors and treatments.  Many of them do give it a shot.
We see it very successful in a lot of patients and then I have some patients that will stop it just to say, “Oh I think I can come off of it now.”  Once they are off it for a while they are like:” Oh no I can't, I need that back.  I feel much better on it.”  It kind of helps confirm and reaffirm to them that it is actually helping them.  Well, I've been taking LDN nearly 20 years and people are worried about the long-term effect of taking LDN, but LDN generally is in your system for like four hours.  So, every day you're getting like a 20-hour break.  

What do you say to people when they ask you how long can you take LDN?

It's been studied in Low Doses now for probably about 40 years.  I always tell them that we do have data over 40 years now and that it's still not showing any long-term adverse effects. The benefits of it should outweigh any potential effects. I can't even really think of any long-term effects that they've seen from patients being on it for a long time.  You may get side effects at the beginning.  Whenever you're on it you might have some of those as you're working up, however, generally, I'm not seeing any and I don't think there's any data out there on the long term that there is any harm to taking it long term. after 40 years of studies. I always refer them to the LDN Research Trust because it kind of shows all the different studies that have been done. They love that source because a lot of my patients want to look this up, they haven't heard of it before.  So they'll see the studies for themselves and see what’s all being done and see no adverse effects of it.  It helps give them a little peace of mind also. I think that does help. They are also used to, here in America, all those commercials on TV and these drugs that come up and all the side effects are like death and brain tumors. We haven't seen any of that with this over 40-plus year study. You can feel a little better with that also. 

Well, being English, when I come to America, you have a lot of commercials on your stations and there's a really nice advert promoting some drug.  Then very quickly at the end they're saying:” Possible side effects could be heart attack, stroke, cancers.” 

I know it's terrible, possible death! You think:” Why would anybody, after such a lovely advert that makes you think you’re to feel so much better, add that you could die?
I know. I know. People just remember that jingle or something that was at the beginning.

With LDN, when you said that you could potentially have some side effects while you're titrating up when you first start, what do you tell people those side effects could possibly be? 

I see vivid dreams the most. A lot of times I warn them about the vivid dreams right off the bat and a lot of times the doctors have done that warning too.  It seems to be the most common one that the doctors warn them about, too.  We have seen that it works as well in the morning, so a lot of doctors will just proactively write for it in the morning rather than having a patient take it at bedtime. It does work on those endorphins that come at night so it does make sense that the dreams would be more vivid because those endorphins are coming out then.    I tell them that's the most common. 
The majority that I see might be dizziness, jitteriness, constipation, or diarrhea.  General stomach upset is one is one of the main ones. I tell them it's fairly mild if they do experience it, give it a couple of days before they increase their dose.  Hopefully, those side effects will kind of disappear.  If they don't and if they're up at a dose like three to four milligrams, that might be the dose they stay on. We don't have everybody that gets up to the target dose of the 4.5 but that may just be something they have to do lower than that.  I’ve seen a couple of people with anxiety, but I don't see that as much. The vivid dreams that come out probably more than anything but usually that can be mitigated by taking it in the morning. 
I never had vivid dreams, but some say these dreams are so fantastic they don't want them to end.
I have had a couple of people that enjoy them so well. I'm sure that your body gets used to it and the vivid dreams stop anyway.  Good if you can enjoy it while you can. I can't really remember dreaming. I can probably remember one dream every three years.  I'm sure I dream but I just can't remember.

Could you tell us what you think is the most common dose when somebody is stabilized on LDN? 

Four point five (4.5)  is the most common we see. Many of our patients can get up to 4.5.  It is by far the most common that we do.  The one milligram and the 4.5 are probably the two most common doses that we do. The one milligram is for when they're just starting to work up and they need that smaller dose to be able to tailor their work up. We do have a majority of patients who tolerate and can stay on the 4.5.  The two to the four milligrams anywhere in there, whether it be 2, 2.5, 3, 3.5, 4.  We do have some patients that stay on there and they're probably all about the same, to be honest.  It seems like our majority of patients are at 4.5 and then after that, it's anywhere from two to four, and those are all about the same in terms of quantities and where patients are stable. So, 4.5 is generally the most common. 

Now there are a few doctors that prescribe a higher dose than 4.5. Do any of your doctors do that?

They do, but not as much.  I do see it occasionally, like a 4.5 twice daily. Every once in a while, we do have some doctors that will go up to a five or a six. I do see the five or the six in some doctors and patients feel they're so close on the 4.5, they have faith that five or that six is going to really push them to feel they're optimal.  When they get put on the five or the six, they find it works better for them so they do stay on that. So, we do see that occasionally.  I don't know that there's much data on going above 4.5 but we do see every once in a while, for patients or doctors who think that extra little push will help. 
 

Christian Stella, PharmD, ABAAHP, FAAMM - LDN For Depression - 2022 Conference (LDN; low dose naltrexone)

Elizabeth Livengood, NMD - Major Depressive Disorder - 2020 Conference; Bahamas (LDN, low dose naltrexone)

Linda Elsegood: Today we're joined by pharmacist Dr Dawn Ipsen who's the owner of two pharmacies in Washington state. Kuslers Pharmacy and Clark Pharmacy. Could you tell us what it was that inspired you to become a pharmacist? 

Dawn Ipsen: I knew early on as a high schooler that I wanted to have a doctorate degree in something and was sort of a little bit torn between pharmacy and optometry and with long heartfelt discussions and soul-searching I became a pharmacist and very early on in my career not only was I trending towards being a pharmacist but I had an opportunity to intern at a compounding pharmacy and just absolutely completely fell in love. It was the art and the science and the way of being able to help individual patients in manner of which no other pharmacist in my area was able to do so, of providing very personalized therapies. I was able to really listen to patient needs and work with their doctors, to formulate the exact therapeutic tool that they needed to improve their quality of life. That is really what has driven me in my career. 

Linda Elsegood: When did you open your first pharmacy? 

Dawn Ipsen: I had been a pharmacy compounding lab manager for about 10 years for the Kusler family. When they were ready to go do other things in their life I was given the opportunity to purchase Kusler's Compounding Pharmacy. It had been a pharmacy I had worked at as a staff member for 10 years and took over as the owner and I've now owned that pharmacy for almost 10 years. In January it will be 10 years. That was my first pharmacy. 

I was doing all my good work up at my Snohomish Pharmacy and suddenly had a random phone call on a Friday afternoon in which the Clark family was looking for a new owner for their pharmacy. They were ready to retire and go do other things as well. I've also owned Clark's compounding pharmacy down in Bellevue Washington for six years. I've been an owner for almost 10 years total and have had multiple locations now for about six years. We service not only the entire state of Washington but we also work within nine other states as well. Our boundaries go quite deep and it's a really great way to help all types of patients all over the nation. 

Linda Elsegood: What would you say is the most popular form of LDN that you use the most? 

Dawn Ipsen: I would say primarily we use the most customized strengths of capsule formulations of low dose naltrexone (LDN). It gives patients really great consistency yet opportunity to get the doses titrated in appropriately where they need it to be. What's really great about how we approach our making of capsules is we use hypoallergenic fillers. We're also able to work specifically with patients who have sensitivities. We can customize what that filler might be and I think that's really what sets our pharmacies apart and why doctors and patients choose to work with us. 

We are experts in autoimmune and chronic inflammatory diseases and therefore we're very used to working with patients where the normal just isn't what they need and isn't what's best for them. We can customize that to be appropriate for them. Along with capsules of course, we are able to do transdermals. That's really popular in pediatrics, especially for patients with an autism spectrum disorder. We are able to make flavored liquid tinctures of it so patients are able to use various small doses to titrate up doses. We also make sublinguals. I would say capsules are pretty popular for us. 

Linda Elsegood: What kind of fillers are you asked to use? 

Dawn Ipsen: Most of the time I will steer a patient towards microcrystalline cellulose (which is a tree based cellulose). It is very hypoallergenic for a lot of patients. However, some patients know they have tree allergies and those patients primarily prefer rice flour. I do have a couple of patients, but very very rare that actually do better on lactose filler. They tend to not be my autoimmune patients. They tend to be patients in the chronic pain spectrum area. 

We have also worked with other fillers, like tapioca flour. We can be very customized into our approach of how patients need it. I've got one patient that comes to mind that loves magnesium as their filler and that's very relaxing for their muscles. I've also seen probiotics being used. There is not one right answer to how we do things. We are that pharmacy that is able to have a conversation with a patient. We talk about what their needs are and customize it based on that approach. 

Linda Elsegood: From the prescribers that you work with, do you have many consultants that you fill scripts for? 

Dawn Ipsen: We definitely do. What's also kind of a little side thing that I do. I've always been very passionate about teaching. I'm on faculty at University of Washington School of Pharmacy and also Bastyr University which is one of the top naturopathic doctor schools in the nation. I teach there during summer quarter. I teach nationally to providers continuing ed-based content that is often LDN in nature or ties into LDN. Especially with autoimmune and chronic pain and chronic inflammatory conditions. We consult a lot with doctors. I probably work with three or four hundred functional med type providers on any monthly basis even on being able to customize therapies for their patients. We are really big in the post COVID syndrome arena of helping patients that are really struggling and LDN. We're finding it pairing quite nicely in that condition as it's very inflammatory based. 

We work quite heavily within the MCAS arena for patients who have a lot of mast cell instability and need other therapies. LDN is one of the tools that is used quite frequently by those types of providers and for those specific kinds of patients. 

Linda Elsegood: Do you work with any pain specialists, dermatologists, rheumatologists, gastroenterologists? 

Dawn Ipsen: We do. Honestly, I'm quite proud of our little Seattle area of Washington because we do have MDs that are pain specialists that are now really turning towards using LDN in their toolbox of things they have available for patients. They're getting quite savvy at it. They're doing a really great job. It is super exciting. I have some dermatologists. I consult a lot with my functional med providers that are seeing dermatology conditions like psoriasis. I have an email I need to work with a doctor on after this to help them with this patient with a psoriasis case. We are seeing it in the GI world as well for Crohn's and irritable bowel disorder. Those chronic inflammatory conditions. I would say the MD pain specialists are really turning around over here. Obviously with the opiate crisis that has occurred in our nation I think most doctors of any type of credentialing or medical training or experience are quite interested in what LDN is doing for their communities and what opportunities it affords for patients who are trying to make sure they aren’t addicted to opiates but yet have something to improve quality of life and their day-to-day living. Low dose naltrexone (LDN) has been an amazing tool for that. 

Linda Elsegood: I'm always excited to meet different LDN prescribers and nurse practitioners who are providing lots of scripts. When you get an MD or a DO that is prescribing LDN and it is completely out of their comfort zone, I always think yes, you know we've got another one on board. We're making it right. We're getting it. MDs are already working outside of the box. That is normal for them to look into LDN it's not normal for MDs to look at LDN but as you know I've interviewed so many people and so many MDs when they have a patient that they can't help and fix their issues. They've tried everything and they feel as if they've failed this patient and then they try LDN. Once they have had amazing results with the first person it's then so easy for them to look into prescribing not only for other patients with that condition but for any autoimmune disease, chronic pain, mental health, etc. I mean it's really amazing and this is where people like yourself come into play. The hand-holding with doctors because a lot of them haven't got time to do the homework. They're very busy and they need somebody to tell them exactly what it is, how to prescribe it, what to look for, what to do and have somebody on hand to say, like you said, I've got a patient with psoriasis. What do I do? Can you help me? That is the way to get more doctors involved is the pharmacist doing the hand holding. 

Dawn Ipsen: There is a local psychiatrist in our area that works with younger adults with substance abuse disorders and teenagers that are having a lot of trouble with mental health. I had an opportunity to get him thinking about LDN and his patient population. I love when I get to reconnect with him every few months because he just raves He finally has a tool that actually does something. He felt the antidepressants and all these other things were not really fixing any of the issues or fixing the symptomatology. We still have the same abuse issues, we still have the same addiction issues and we still have the same levels of depression and suicide risk. But with LDN he's finding that he's actually causing positive change in his patient population and that's the only thing he really changed within his practice. 

We're really affecting the health of our community in a very positive manner with something that's really safe and low risk and not expensive. It doesn't get any better than that. It's the best compliment I could ever have. 

Linda Elsegood: It's really nice when patients take all their information to the doctor. Once you've got a doctor really hooked on prescribing LDN they can change the lives of hundreds of patients. Dr Phil Boyle uses LDN in his fertility clinic He also uses it in women's health for things like endometriosis, polycystic ovary, painful periods, heavy periods. Right across the board he uses LDN. He gets patients coming to see him with women's health problems who also have Hashimoto's or long COVID etc. 

Dawn Ipsen: I refer to his work all the time. I get questions a lot from local providers such as we have somebody who wants to become pregnant or they did become pregnant and they're on LDN and they want to know what the standard of care is and can we continue, and what's the risk and benefit are. It is so great to have providers like him out there that have been doing this work for so long that we can very confidently share those case experiences and history of using the medication long term for those patients. 

Linda Elsegood: There have been so many of our members who were skeptical about using LDN during pregnancy. Doctor Boyle is always very generous with his time. I will send him details and he will answer the patient and share his experience. You know we used it once up until birth rather and breastfeeding, etc. We have those people who have done two or three pregnancies using LDN who are happy to talk to other people. This is my experience with 20 years as the charity next year, which is totally amazing, but I’ve found that word of mouth and with the education it is just spreading. 

Dawn Ipsen: Linda, you've done an amazing job with the LDN Research Trust and I thank you for that. You have made the Research Trust, its website, resources and its books into a trusted referral point that I can use with our doctors and our patients who are wanting that next level of information beyond what I'm able to say to them. They want to go see those studies themselves. They want to go read the book themselves and I know that without a doubt I can send them to your resources for them to receive complete in-depth and correct information. Thank you, Linda. You're doing amazing things and this is all because of you. 

Linda Elsegood: How can people contact you? 

Dawn Ipsen: We have two locations in Washington State. We have Kusler's Compounding Pharmacy in Snohomish Washington and the website there is www.Kuslers.com; and then we have Clarks Compounding Pharmacy in Bellevue Washington. That website is www.clarkspharmacywa.com. The WA stands for Washington. We are happy to help patients all over and talk with doctors that need guidance and assistance in learning more. I love being an educator and I love being here to support my community. 

Linda Elsegood: Any questions or comments you may have please email me Linda linda@ldnrt.org. I look forward to hearing from you. Thank you for joining us today. We really appreciated your company. Until next time stay safe and keep well.

D

Today we're joined by pharmacist Dr Dawn Ipsen who's the owner of two pharmacies in Washington State, Kuslers Pharmacy and Clark Pharmacy. Could you tell us what it was that inspired you to become a pharmacist? 

I knew early on as a high schooler that I wanted to have a doctorate degree in something and was sort of a little bit torn between pharmacy and optometry and with long heartfelt discussions and soul-searching I became a pharmacist and very early on in my career not only was I trending towards being a pharmacist but I had an opportunity to intern at a compounding pharmacy and just absolutely completely fell in love. It was the art and the science and the way of being able to help individual patients in manner of which no other pharmacist in my area was able to do so, of providing very personalized therapies. I was able to really listen to patient needs and work with their doctors, to formulate the exact therapeutic tool that they needed to improve their quality of life. That is really what has driven me in my career. 

When did you open your first pharmacy? 

I had been a pharmacy compounding lab manager for about 10 years for the Kusler family. When they were ready to go do other things in their life I was given the opportunity to purchase Kusler's Compounding Pharmacy. It had been a pharmacy I had worked at as a staff member for 10 years and took over as the owner and I've now owned that pharmacy for almost 10 years. In January it will be 10 years. That was my first pharmacy. I was doing all my good work up at my Snohomish Pharmacy and suddenly had a random phone call on a Friday afternoon in which the Clark family was looking for a new owner for their pharmacy. They were ready to retire and go do other things as well. I've also owned Clark's Compounding Pharmacy down in Bellevue Washington for six years. I've been an owner for almost 10 years total and have had multiple locations now for about six years. We service not only the entire state of Washington but we also work within nine other states as well. Our boundaries go quite deep and it's a really great way to help all types of patients all over the nation. 

What would you say is the most popular form of LDN that you use the most? 

I would say primarily we use the most customized strengths of capsule formulations of low dose naltrexone (LDN). It gives patients really great consistency yet opportunity to get the doses titrated in appropriately where they need it to be. What's really great about how we approach our making of capsules: we use hypoallergenic fillers. We're also able to work specifically with patients who have sensitivities. We can customize what that filler might be and I think that's really what sets our pharmacies apart and why doctors and patients choose to work with us. We are experts in autoimmune and chronic inflammatory diseases and therefore we're very used to working with patients where the normal just isn't what they need and isn't what's best for them. We can customize that to be appropriate for them. Along with capsules of course, we are able to do transdermals. That's really popular in pediatrics, especially for patients with an autism spectrum disorder. We are able to make flavored liquid tinctures of it so patients are able to use various small doses to titrate up doses. We also make sublinguals. I would say capsules are pretty popular for us. 

What kind of fillers are you asked to use? 

Most of the time I will steer a patient towards microcrystalline cellulose (which is a tree-based cellulose). It is very hypoallergenic for a lot of patients. However, some patients know they have tree allergies and those patients primarily prefer rice flour. I do have a couple of patients, but very very rare, that actually do better on lactose filler. They tend to not be my autoimmune patients. They tend to be patients in the chronic pain spectrum area. We have also worked with other fillers, like tapioca flour. We can be very customized into our approach of how patients need it. I've got one patient that comes to mind that loves magnesium as their filler and that's very relaxing for their muscles. I've also seen probiotics being used. There is not one right answer to how we do things. We are that pharmacy that is able to have a conversation with a patient. We talk about what their needs are and customize it based on that approach. 

From the prescribers that you work with, do you have many consultants that you fill scripts for? 

We definitely do. That's also kind of a little side thing that I do. I've always been very passionate about teaching. I'm on faculty at University of Washington School of Pharmacy and also Bastyr University, which is one of the top naturopathic doctor schools in the nation. I teach there during summer quarter. I teach nationally to providers continuing ed-based content that is often LDN in nature, or ties into LDN. Especially with autoimmune and chronic pain and chronic inflammatory conditions. We consult a lot with doctors. I probably work with three or four hundred functional med type providers on any monthly basis, even on being able to customize therapies for their patients. We are really big in the post-COVID syndrome arena of helping patients that are really struggling and LDN. We're finding it pairing quite nicely in that condition as it's very inflammatory based. We work quite heavily within the MCAS arena for patients who have a lot of mast cell instability and need other therapies. LDN is one of the tools that is used quite frequently by those types of providers and for those specific kinds of patients. 

Do you work with any pain specialists, dermatologists, rheumatologists, gastroenterologists? 

We do. Honestly, I’m quite proud of our little Seattle area of Washington because we do have MDs that are pain specialists that are now really turning towards using LDN in their toolbox of things they have available for patients. They're getting quite savvy at it. They're doing a really great job. It is super exciting. I have some dermatologists. I consult a lot with my functional med providers that are seeing dermatology conditions like psoriasis. I have an email I need to work with a doctor on after this to help them with this patient with a psoriasis case. We are seeing it in the GI world as well for Crohn's and irritable bowel disorder. Those chronic inflammatory conditions. I would say the MD pain specialists are really turning around over here. Obviously with the opiate crisis that has occurred in our nation I think most doctors of any type of credentialing or medical training or experience are quite interested in what LDN is doing for their communities and what opportunities it affords for patients who are trying to make sure they aren’t addicted to opiates but yet have something to improve quality of life and their day-to-day living. Low dose naltrexone has been an amazing tool for that. 

I'm always excited to meet different LDN prescribers and nurse practitioners who are providing lots of scripts. When you get an MD or a DO that is prescribing LDN and it is completely out of their comfort zone, I always think yes, you know we've got another one on board. We're making it right. We're getting it. MDs are already working outside of the box. That is normal for them to look into LDN; it's not normal for MDs to look at LDN but as you know, I've interviewed so many people and so many MDs when they have a patient that they can't help, and fix their issues. They've tried everything and they feel as if they've failed this patient, and then they try LDN. Once they have had amazing results with the first person it's then so easy for them to look into prescribing, not only for other patients with that condition but for any autoimmune disease, chronic pain, mental health, etc. 

I mean it's really amazing and this is where people like yourself come into play. The hand-holding with doctors because a lot of them haven't got time to do the homework. They're very busy and they need somebody to tell them exactly what it is, how to prescribe it, what to look for, what to do and have somebody on hand to say, like you said, I've got a patient with psoriasis. What do I do? Can you help me? That is the way to get more doctors involved is the pharmacist doing the hand holding. 

There is a local psychiatrist in our area that works with younger adults with substance abuse disorders and teenagers that are having a lot of trouble with mental health. I had an opportunity to get him thinking about LDN and his patient population. I love when I get to reconnect with him every few months because he just raves He finally has a tool that actually does something. He felt the antidepressants and all these other things were not really fixing any of the issues or fixing the symptomatology. We still have the same abuse issues, we still have the same addiction issues and we still have the same levels of depression and suicide risk. But with LDN he's finding that he's actually causing positive change in his patient population, and that's the only thing he really changed within his practice. We're really affecting the health of our community in a very positive manner with something that's really safe and low risk and not expensive. It doesn't get any better than that. It's the best compliment I could ever have. 

It's really nice when patients take all their information to the doctor. Once you've got a doctor really hooked on prescribing LDN they can change the lives of hundreds of patients. Dr Phil Boyle uses LDN in his fertility clinic. He also uses it in women's health for things like endometriosis, polycystic ovary, painful periods, heavy periods. Right across the board he uses LDN. He gets patients coming to see him with women's health problems who also have Hashimoto's or long COVID etc. I refer to his work all the time. He gets questions a lot from local providers such as we have somebody who wants to become pregnant, or they did become pregnant and they're on LDN and they want to know what the standard of care is and can we continue, and what's the risk and benefit are. It is so great to have providers like him out there that have been doing this work for so long that we can very confidently share those case experiences and history of using the medication long term for those patients. 

There have been so many of our members who were skeptical about using LDN during pregnancy. Doctor Boyle is always very generous with his time. I will send him details and he will answer the patient and share his experience. You know we used it once up until birth rather and breastfeeding, etc. We have those people who have done two or three pregnancies using LDN who are happy to talk to other people. This is my experience with 20 years as the charity next year, which is totally amazing, but I’ve found that word of mouth and with the education it is just spreading. 

Linda, you've done an amazing job with the LDN Research Trust and I thank you for that. You have made the Research Trust, its website, resources and its books into a trusted referral point that I can use with our doctors and our patients who are wanting that next level of information beyond what I'm able to say to them. They want to go see those studies themselves. They want to go read the book themselves and I know that without a doubt I can send them to your resources for them to receive complete in-depth and correct information. Thank you Linda. You're doing amazing things and this is all because of you. 

How can people contact you? 

We have two locations in Washington State. We have Kusler's Compounding Pharmacy in Snohomish Washington and the website there is www.Kuslers.com; and then we have Clarks Compounding Pharmacy in Bellevue Washington. That website is www.clarkspharmacywa.com. The WA stands for Washington. We are happy to help patients all over and talk with doctors that need guidance and assistance in learning more. I love being an educator and I love being here to support my community. 
 

Kristen Burris LAc, MSTOM - Acupuncture and Chinese Herbal Medicine(LDN; low dose naltrexone)

The LDN 3: To Purchase with discounts before 1st September 2022 Go to ldnresearchtrust.org/ldn-book-3 for full details

LDN Webinar Presentation 18 May 2022: Dr Masoud Rashidi - LDN, Dosing, Fillers and Compounded Options. LDN, ULDN and Pain/Opioid Issues

Sponsored by Innovative Compounding Pharmacy https://icpfolsom.com/

LDN Webinar 18 May 2022 (LDN; low dose naltrexone)

LDN Questions Answered Live by

Pharmacist Dr Masoud Rashidi - LDN Specialist
Dr Sato-Re
Dr Mathewson

Sponsored by Innovative Compounding Pharmacy icpfolsom.com

Pharmacist Michelle Moser, LDN Key to Success (LDN, low dose naltrexone)

Review: Michelle Moser has 35 years experience as a Pharmacist and is very experienced with the utilization of LDN (Low one Naltrexone). She volunteers her knowledge as an a LDN specialist with the LDNresearchtrust.org. Her 21 minute presentation covers how they supply a thorough service to their customers, with advice and council on dosing and related help for a variety of conditions. She explains how LDN can be used along with most other drugs, even opioids if the LDN is micro dosed and immediate release. All autoimmune conditions can benefit from LDN.

Review by Ken Bruce

Linda Elsegood: Welcome to the LDN Radio Show brought to you by the LDN Research Trust. I'm your host Linda Elsegood. I have an exciting lineup of guest speakers who are LDN experts in their field. We will be discussing low dose naltrexone and its many uses in autoimmune diseases, cancers, etc. Thank you for joining us.

Linda Elsegood: Today I'd like to welcome back our guest pharmacist, Michelle Moser who's also one of our LDN Specialists. Thank you for joining us today, Michelle.

Michelle Moser: Oh, thank you so much for having me. It's certainly my pleasure.

Linda Elsegood: So we're all keen and eager, and as people can see, you've put “Keys To Success” up there, so take it away.

Michelle Moser: Thank you, thank you very much. I appreciate the opportunity to share some information with everybody today that really goes over not only how patients can find their success, but how providers can also enhance patient outcomes. So here we go. The first thing I want wanted to address is that low dose naltrexone plays really well with other therapies. It's not necessarily medication that is used all by itself all the time, and that is a question that comes up from not only patients, but from providers as well, wanting to know, well, the patient is taking this this and this. Can I use LDN? And the answer almost always is yes, and the main reason is that even if we are using or prescribing opiates for patients with chronic pain, depending on how those opiates are being utilized throughout the day, LDN might still be an option. Very few times is it that LDN is not something you can start. It doesn't have very many drug interactions, so LDN is brilliant for a wide variety of indications. And as we know, as so many more autoimmune diagnoses are being found every year, I think now there's something like 100, 120 some, maybe even 140 autoimmune disorders, low dose naltrexone is a wonderful fit for most of those patients.

But we also have other dosing, such as very-low-dose, which is 50 to maybe 250 micrograms. And then we have ultra-low dosing, which stems from the oxytrial study where we were using only microgram dosing, one, two, three, four micrograms, alongside short-acting opiate medications to help reduce the need for those opiates and replace it with low dose naltrexone. Because we know that low dose naltrexone not only helps to intermittently block those pain receptors, but also helps to reduce not only inflammation and those pro-inflammatory cytokines, but we can also see that low dose naltrexone helps to modulate the immune system. And there's a wide variety of studies that have been published to emphasize exactly those parameters. So if you're needing those, either reach out to the LDN Research Trust or your local compounding pharmacist. Sometimes we have those available, as well some of the other things that we use in our compounding lab and compound on literally a daily basis, because low dose naltrexone is used for a lot of inflammation issues, autoimmune, chronic pain.

We can also use low dose naltrexone for some of those other nuanced areas such as traumatic brain injury PTSD, depression, and anxiety; and we've heard from a wide variety of wonderful practitioners during the LDN Research Trust conferences on those specific areas. But when we're able to use other medications in combination with LDN; I don't mean like in the same capsule or in the same liquid, I just mean side-by-side dosing; we can see that oxytocin, especially in a nasal spray, is incredibly helpful to help build that sense of connection, to help alleviate depression and grief, as well as go after some of those imposed pain areas. And oxytocin is one of those medications that is very easy to administer in a nasal spray, even in sublingual drops. But it is very sensitive to heat, so we have to be very careful about what dosage forms we're using. We don't use oral capsules with oxytocin. The stomach acid kind of wipes out its activity. So we need to find alternative forms for that.

But also if you're needing low dose naltrexone for dermatology issues then we can combine it with mast cell stabilizers like ketotin or either other anti-inflammatories, even tranexamic acid, to help decrease some of the redness, in that dermatology issue. And even the autoimmune dermatology products, we're very careful about the bases that we put low dose naltrexone in so that we can control exactly how deep we want that therapy to go. So not every base is going to work, because we really need to individualize that therapy for that condition.
Of course we use low dose naltrexone in a situation with ketamine, which is a non-opiate pain medication as well. And because ketamine works on different receptors than low dose naltrexone we don't see the withdrawal. We actually see the enhancement of that pain control. So there's a a lot of options here.

And lastly, I wanted to address synapsin, which is this wonderful combination of medications. It's a ginseng derivative along with an NAD that again helps to reduce the central inflammation in the brain. And when we use it in a nasal spray, of course that helps with the neural transmission directly to the brain.

As a pharmacist, when a patient is new to low dose naltrexone, or even comes to us because a provider would prefer to use our pharmacy, we emphasize that low dose naltrexone is not a cure-all drug. It actually doesn't really cure anything, but what it does do is it helps to trick the body to work on its own pathways, and much more effectively, and much more efficiently.

So when we set up the expectations, we want patients to know that this isn't like taking something like an aspirin or a Tylenol. It's going to take a little while for this medication to provide full benefit. And we also know that low dose naltrexone isn't for everybody. But when we start low with the dosing and slowly increase, that we can actually see patient outcomes in greater than 50, actually approaching 80 to 90 percent of the time, which as a pharmacist, I've been a pharmacist for over 35 years, I don't recall any other medication providing that high of patient outcome, and that high patient benefit. So we also let patients know that this is a therapy that we're going to start with a low dose, slowly increase over time, and when we find their happy dose, which may be 4.5 milligrams, might be less than that; in some situations we might actually split the dose and take some in the morning and some at night; again completely individualized therapies. We let them know that most respond in about 60 days, so you got to give it some time. And with that I try to emphasize that most of the time, by the time patients are finding low dose naltrexone either through their provider or through the suggestion of their pharmacists or other chat groups, that they have been years into their therapy without great outcomes, without great success. They've used maybe even a wide variety of providers, a wide variety of alternative therapies, and now they're going to give low dose naltrexone a shot. So don't expect everything to just magically go away in a week. That's not going to happen. And in some situations, even when we're dealing with the same disease state - so let's say we're talking about fibromyalgia patients - some respond very quickly, others do take about four to six months to respond. Even with Crohn's disease, we've heard from Dr Leonard Weinstock during the LDN Research Trust conferences, that most of his patients really respond somewhere around the four-month mark. So that is very important, so that we make sure that patients are compliant on their therapies, and that they understand that the pharmacy and the provider will be checking in with them to make sure that they're still doing well, and then if there are any questions, that come up, we can answer those right then and there rather than answering them after they've stopped their therapy.

One thing we've also learned over the years with low dose naltrexone is that often less is more. So increasing the dose frequency beyond twice a day is not necessarily very helpful, and certainly going above maybe even six milligrams isn't usually as effective as lower doses, especially when we're dealing with autoimmune conditions. Now if we're dealing with weight loss, then we then we move into a little bit different realm. But again that therapy is taken once or twice a day, so again it's about treating that individual and making sure that that individual is heard, is listened to, and is able to express their goals so that we can effectively meet those.

And I wanted to throw this in there too, that we had a gal who slowly increased her dose, and when she was at 3 milligrams she felt great. She got up to 3.5, she wasn't feeling as good, and she went up to 4 and she still wasn't feeling very good. So we bumped her back down to 3 and then we slowly increased with 0.1 milligram dosing, which is itty-bitty, but sometimes even that 0.1 milligram makes all the difference in the world. And her happy dose was 3.1 milligrams. So it was great, and that's where she stayed, and she's been at that dose now for a couple of years. We also let patients know that yes, the pharmacy will check in with you periodically, usually around week 3 or 4, but don't wait for us. If something comes up, please get a hold of us, please let us know how we can help you, because we'd much rather answer those questions sooner than later, or have them stop therapy altogether, and really have to start all back at square one. So when we're slowly increasing these doses, we try to make it as easy as possible for the patient to understand. So whether we're dealing with capsules or liquids, we've built these great handouts so that patients understand how to slowly increase their dose without taking literally a handful of capsules at a time. That isn't necessarily the best way to go about it, because then they have to wash it down with a lot of water, and if dosing is at bedtime, that could very much disrupt their sleep because they've got to get up in the middle of the night to use the restroom. So we provide these handouts, and we color code them, because we provide two different strengths in two different colored bottles, and we emphasize that as we are reading from left to right rather than using the columns top to bottom. Then we're going to be able to use a little bit of out of one bottle or the other bottle concurrently as we slowly increase that dose. But we also have liquids that we use, and this liquid starter kit includes a lot more color, mainly because we slowly associate the color with the gradation, and this is actually a twice a day dosing starter kit that we use with a liquid base, because liquids are a lot easier to manipulate and find those doses that are going to be specific to them. Not everybody uses doses that are the same in the morning or at night. Sometimes one end is higher than the other.

Also, using an oil suspension is going to give a longer dating for the patient. Their bottle is going to last longer than 30 days, and that's also very pleasing to the patient, because they're very cost conscious, as they should be, because the majority of the time these medications are out of pocket expenditures. We offer an almond oil base, an olive oil base, or an MCT oil base which is derived from coconut oil. We can splash it with a natural flavor like tangerine, lemon, mint, cinnamon; and then in some situations we might actually add a little natural sweetener like a Stevia. W at this pharmacy really steer away from artificial sweeteners because we find that sometimes that actually increases inflammation, and we're also really careful about the oils that we are using. These are not cosmetic or traditional food-grade, these are bases that are backed by the United States Pharmacopoeia with a national monograph behind those.

We also are really careful about the fillers that we put in our capsules, and we work again with that individual to ensure that we're using a filler that is going to best meet their needs. All of the capsules are immediately released. We do not use any extended-release product, because that does slow down the absorption. A lot of times there's absorption issues to begin with, and certainly if we do extend the release of the naltrexone, we are actually bypassing and negating the science behind how naltrexone actually works at that receptor site. Most of the time we're using a microcrystalline cellulose, but we do have other fillers as well, so again we let them know we try to make this as easy as possible. But if it is at all confusing when the patient goes over their medication, we ask that they call the pharmacy. Let's go over those questions right away to make sure that they are getting the best information for the greatest success possible

So with our patient follow-up programs, we identify those individuals who have recently received their medications, and we kind of look at where they're at in their in their dosing schedule. We give them a call or we send them a text, “Hey we'd like to check in with you. We want to make sure everything is going well”. And we also realize that not all patients are available 9 to 5 when the pharmacy is open. Sometimes we need to schedule conversations outside of business hours, and so we make sure that that is available to a patient so that all of their needs are being met. We check in with them at least once during their first month, but we always reiterate to the patient if something comes up, get a hold of us, and this is how. We have an email option, we have a texting option, and we have a phone call option as well.

We also let them know that as dosing adjustments are being made. sometimes side effects might crop up. and so we let them know exactly what those are. Sometimes it is vivid dreams, but often when we have vivid dreams we know LDN is working, because it's helping us get into that REM sleep cycle. But if those vivid dreams become disturbing or change our sleep patterns, then we want to move the dosing schedule. We also let them know that if there's a little bit of a headache, how to alleviate that, and how long that those side effects might persist, and when they should expect those to go away. And if they're having issues with perhaps constipation, we explain that as well, because sometimes even these very small side effects can allow a patient or cause a patient to back off of their therapy and abruptly stop.

Answering the questions as they come up again are keys to success. This is how we allow our patients to communicate so that we are acknowledging what is going on with them, and they feel heard and understood. Anytime that we can alleviate side effects only allows for a better health program and for greater success, and this is when really their prescriber or their provider becomes the hero in all of this, because they suggested a therapy that is finally working for them, maybe even after years or decades of them searching for a really good way to feel better, perhaps even feel normal.

When we enhance compliance, of course we see better outcomes. When a patient is heard, when they are allowed the time to explain what's going on with them, they take ownership of their own care, and in our experience at our pharmacy, we find that when a patient takes ownership over their care, they're more likely to then be fully engaged and follow other processes or programs that may be in place by the provider. Often that leads to less phone calls to the provider office, less insignificant or issues that could be dealt with over a simple phone call, maybe even less visits to the emergency room mental health, which is always a concern, and especially in the last couple of years with stress and anxiety and depression, we see that even using low dose naltrexone can be beneficial in helping some of those areas where patients may not have been using low dose naltrexone as a primary concern, but they realize that oh my gosh, these other symptoms have disappeared too. And that's always a great benefit. We see increased patient compliance, and always better patient outcomes.

But truly, because low dose naltrexone is such a low-risk, low-side-effect, it's a low dose and honestly, it's a very low cost medication. That safety margin is much better than most commercially available prescription medications. The minimal drug interactions make it a prime candidate for the use of low dose naltrexone in the majority of health concerns and diagnoses, and quite honestly, we have over 30 years of research behind low dose naltrexone. So if you're looking for great science in using a medication that is beneficial for many many people not just in the short term but over decades. This is where we really say, “Why not try low dose naltrexone. It's a fabulous way to really get after some of those chronic issues that maybe will enhance a lifestyle, and be able to allow somebody to cross things off of their bucket list.

So here we are. I want to thank Linda for the opportunity to chat with everyone today and certainly, if there's any questions that I can help with, please let me know. This is my personal email, and these are questions, and my cell, as well as my store phone number. So I'm happy to help. Thanks so much Linda.

Linda Elsegood: Thank you! Any questions or comments you may have, please email me, Linda, at linda@ldnrt.org I look forward to hearing from you. Thank you for joining us today. We really appreciated your company. Until next time, stay safe and keep well.