Dr David Borenstein, LDN Radio Show 28 Dec 2016 (LDN, low dose naltrexone) from LDN Research Trust on Vimeo.
Linda Elsegood: Today we are joined by Dr. David Bornstein. Thank you for joining us, David.
Dr David Borenstein: Thank you for having me.
Linda Elsegood: For those people who haven't heard of you yet, could you tell us how you got involved in LDN?
Dr David Borenstein: Absolutely. I'm an integrative physician. My office is in Manhattan, right here in New York; and about ten years ago, I had a patient come to me who was interested in being put on this medication known as LDN, low dose naltrexone.
Now the first thing I said was, like many people who do not know about LDN is, “Oh, we use naltrexone for drug addiction. What's this LDN?” And he said to me that he would give me literature, and I said, you know what, let me take a look at it; and on your next visit, we can talk about prescribing it.
I did some research. I made a few phone calls. And I said, okay, let me give this a try. And the patient just wanted it for general health. They didn't want it for any particular disease. So I prescribed it, and he was happy. No side effects; work beautifully. And then I had patients come in with various different abnormalities or diseases: Crohn's, MS. So I decided to try it for these patients; and lo and behold, two, three, four, five patients, they're doing okay. The patients with MS weren’t progressing, the Crohn's patients are getting better. I put a few patients who had cancer on it, and I started using it, gaining experience with it. And now it's a very big part of my practice. All thanks to that patient who came in ten years ago.
Linda Elsegood: I can see on your website a list of conditions. There’s thyroid, autoimmune, menopause, andropause, hormone imbalance, adrenal fatigue, chronic fatigue syndrome, fibromyalgia, chronic pain, polycystic ovary syndrome, insomnia, sleep disorders, metabolic syndrome, obesity, Crohn's disease, irritable bowel, yeast overgrowth, candida, and allergies. That is quite some list. How do you go about assessing patients to see whether they are suitable for LDN?
Dr David Borenstein: Well, first of all, any patient who comes to see us gets a complete history and physical examination, and then we evaluate their condition.
We go over the lab work. At that point, I can discuss with them if LDN would be something they would want to consider. Now, remember, when they're coming to see me, they have many different symptoms: fatigue, weight gain, hair loss, dry skin, constipation, depression, mood swings, irritable bowel. They can have a laundry list of different symptoms. So what we first need to do is just evaluate, and treat these different symptoms. And then, especially on the first visit, it's a very long visit and we have to go over many things. I generally don't bring LDN up at the first or second visit. I usually wait until a couple of visits down the road, especially to monitor their response.
I mean, I don't want to use it initially for a first-line unless there are other things we can treat. At that point, a couple of visits later, we see how the clinical condition of the patient is improving or not improving, and then we can throw in LDN. And now remember, most of these people coming to me have no idea what low dose naltrexone is. A few do; I’d say less than 10% of my patients know exactly what I'm talking about. The other 90% have a natural inclination. And what did they tell me? I will Google it. It's the first thing: I will Google it. I say beautiful, Google it. I give them a couple of websites, give them your website. I give him some keywords to use, and 90% of the time they come back and say, “I want this.”
Okay, what conditions do we popularly treat with low dose naltrexone Crohn’s, any inflammatory bowel disease, irritable bowel disease, multiple sclerosis; Parkinson's is very popular; fibromyalgia, and chronic fatigue - it's a biggie now, and we have a lot of that, as well as certain types of malignancies that a lot of patients come in for, for LDN. As you can see, we can treat a wide variety of diseases. But we generally have either autoimmune disorders, or malignancies, or certain neurological disorders. Those are the most common reasons for me to put patients on LDN.
Linda Elsegood: We have a caller here, called Christina, who would like to discuss LDN with you. Would you like to ask your question, Christina, yes?
Patient: Hi. Thank you. Can you guys hear me?
Linda Elsegood: We can; or I can, yes.
Patient: Yes. So, doctor, I have a few things. I have postpartum thyroiditis, I have hypothyroidism, I have pericarditis. And I have Sjogren's syndrome. I started LDN, and I was on it for about a month, and I got very sick. I got flu-like symptoms, a burning feeling in my stomach, and all of my symptoms came back. I also have vertigo, so they think it's autoimmune, inner ear disease. So my chest pain came back, and my vertigo came back, and I went off of it because it got intolerable. I've read a lot that starting off on a very low dose and working slowly can be beneficial. My doctor doesn't want to do that because he feels that it isn't a therapeutic dose unless it's at least 1.5 mg. So I've read a lot of posts in forums, about LDN, where people have had to try three or four times before they can successfully be on LDN; and that they could have a Herxheimer reaction. And, I did the very sensitive test for Lyme, and I am negative for Lyme. So I'm wondering, is a Herxheimer reaction something that does often occur with LDN? And have you found that people have had to go on it several times before they can successfully be on it? And is a low dose, very low dose, like 0.5 mg beneficial?
Dr David Borenstein: Well, it's a very good question. The first thing I would tell you to do is before you even consider the LDN, is you seem to be having some reaction. I think you need to clear up some of the other issues that you're having. For example, you mentioned to me the Hashimoto's. I think that when I hear Hashimoto's, I hear autoimmune. The first thing I would strongly recommend, way before taking LDN, is cleaning up your gut: I can't stress the importance of gut health. You have to clean up your gut. And what do I mean by that? I mean, adding things like probiotics, digestive enzymes, gut change to improve your gut function; looking to see if you have any parasites, bacteria, any sort of viruses.
Gut health is extremely important in treating autoimmune disease. I'd also recommend some treatments possibly for candida, yeast overgrowth. Looking to see if you have leaky gut, and if you have an autoimmune disease, by definition you probably do have leaky gut, and treating the leaky gut with a gluten-free diet, cleaning it up with adding things like L-glutamine and zinc and aloe, and all these sorts of things. So I think the first approach is, before you even consider going on LDN, is cleaning up the gut. Now, that's a lot harder to do than what I just said. I mean, it takes a lot of work; and you would probably need to find some sort of practitioner to help you with this. But again, cleaning up the gut is key to success with LDN. That's number one. Now, starting LDN, even at a very low dose after that's done, I think the issue is not so much the therapeutic effect. You need to build up your LDN tolerance. So even if 0.5 mg may not be very therapeutic, I don't think that matters. I think you just need to build up the dose so you can get up to a therapeutic dose, and I agree you're probably not going to get very much benefit below 1.5 mg. Maybe not, but I think you just have to have the ability to grow tolerance. So the quick answer is clean up your gut, to start slow, work your way up, and you'll get there.
Patient: All right. Thank you, Doctor. Do you notice that you see a Herxheimer reaction, or flu-like symptoms in patients that maybe start to build up too quickly?
Dr David Borenstein: It's very rare. You know, when I start patients off at 1.5 mg, and then I go up to 3 mg; and after that, it depends on their condition. For example, with MS I don't try to go up above 3.0 mg unless I have to, because there are issues with spasticity; and remember, we always talk about doses. We have to remember these are doses, but it's going to be different for every person. A person who is 250 pounds is going to need more than someone who's 150 pounds. So you give them the same dose, okay; when you go per kilogram, it's a very different dose. So we have to also remember that. In all the LDN pages, and on the Facebook pages and the Yahoo groups, they will talk in doses. And the problem is it's not the most accurate way of dosing, because you need to consider the weight of the patient as well. So 1.5 mg for me is going to be very different from 1.5 mg for you or another person. That's also another important point to remember when prescribing LDN. Also, some of the practitioners like to go up to 4.5 mg. I like to keep it a little bit below that. We're finding that you're getting the opioid blockade at around 4.0 mg, and after that, it's not as effective. So recently, in the past year, year and a half, I've been keeping my maximum dose to about 4.0 mg; and I don't really go above that unless the patient has been on LDN 4.5 mg for many years. I don't want to touch it. I leave it alone.
Patient: Okay, and thank you. I appreciate it. Could I just ask one more quick thing? I do a lot of great things for gut health, the L-glutamine and probiotics; and I stay away from gluten and dairy completely. Could you explain a little bit about how one would go about testing for parasites, bacteria and viruses?
Dr David Borenstein: There is a test called the CDSA 2.0, from a company in North Carolina; I'm trying to remember the name of the company. I use it all the time, I can see the box. But these are special stool kits you can get, and actually, insurances will help pay for a part of the test. You collect a stool sample for three days. The test looks for parasites. It looks for your digestive enzymes. It looks to see how well you're absorbing food. It looks for bacteria and other viruses. It's a very good test. It's called a CDSA 2.0.
Patient: Great. Thank you so much, doctor.
Dr David Borenstein: My pleasure. Thank you.
Patient: Bye-bye.
Linda Elsegood: Well before we go to the break, I have another question here that's come in. It's from Susan, and she says, “When do I need to stop taking LDN prior to a minor medical procedure which requires anaesthesia?”
Dr David Borenstein: Excellent question. We know that LDN and its metabolites have a half-life of approximately 59 hours. So 60 hours; you know, technically it's two and a half days. I would at a minimum do probably a week before, and that would be a minimum I would do. Yeah, I'd say two and a half days; or at least about a week before you'd play it safe. And that would be a good thing to do, especially if you're receiving any sort of narcotics before or after the procedure. So I just say a good solid week would be a good number. You know, you can do a little more. Wouldn't hurt, but I think to keep it safe at least a week.
Linda Elsegood: And how long would you say to wait after you'd had narcotics before you restarted LDN
Dr David Borenstein: Let's see, two and a half days. So I would say at least five days afterwards would be a good number. From the last point of taking a narcotic.
Linda Elsegood: Okay. Thank you. We'll just have a quick break. If anybody would like to call in with their questions or email them, and we'll be back in a moment.
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Okay. Welcome back. I have a question here for you, David, from a lady in Turkey or a gentleman. They have a five-year-old son who was diagnosed with nephrotic syndrome at age three. He takes 4 mg of steroid every other day. They would like him to try LDN, but the doctor said no. And through a year, they've looked for a doctor who would prescribe LDN, without success. They say their son's on steroids, and it's very troublesome. He becomes very sick easily at home, and next year he starts school. So they would like to find a permanent solution. The question was, can LDN be prescribed for a child who takes 4 mg of steroids; and do the steroids affect the LDN.
Dr David Borenstein: Well, the second question first. Yes, it can, and that's why I like to keep the steroid dose as low as possible. In adults, I like to keep Prednisone below 10 mg per day as a rule, and that's just an arbitrary number. I just find that it works best below 10 mg a day. Many of my patients have a lot of autoimmune immune disease and are on much higher doses. So what I do is I start them on LDN, and I have them slowly taper their Prednisone while the LDN is kicking in, in the hopes that, as the LDN dose increases and the steroid dose decreases, the LDN will start working. So far, it's worked pretty well.
Now with kids, you have to be very, very careful, especially for nephrotic syndrome. And you would need a physician to really keep on top of this. But you could, in theory, try the LDN, 80 micrograms per kilos. You do depend on the weight. He's probably gonna need a lot less than most adults would. And with a child, they tend to like to use the transdermal - just easier to use. And you can certainly give it a try, but again, you're going to have to be under very close care of a physician when you're doing this, to make sure that everything is being watched. This is very different from a patient who's just taking it for fibromyalgia or for Crohn’s. You can have some flexibility. But with a child, you have to really keep on top of them. I definitely think it's worthwhile to try it and see if it has an effect; but remember, you have to keep on top of this, and finding a physician who's going to do that is not going to be easy. People have had a lot of trouble finding physicians prescribing LDN, just to get it for whatever disease they have. But for a child, needing constant watching, that's going to be a little bit tricky.
Linda Elsegood: Especially in Turkey where I think it's very, very difficult to get LDN prescribed anyway.
We also had a question from Taja, and she says that she was diagnosed with rheumatoid arthritis in December 2015 and she started LDN in March. Her questions, she's got three. The first one is, do anti-inflammatory drugs have an effect on the efficacy of LDN?
Dr David Borenstein: They generally don't. The main issue when you're taking low dose naltrexone is going to be high dose steroids. Not so much the nonsteroidal anti-inflammatories, generally not. But here's the problem. When you're taking a lot of NSAIDs or nonsteroidal anti-inflammatories, it's not good for you.
It's not good for your liver, it’s certainly not good for your kidneys, and certainly not good for your stomach. So LDN would certainly be of benefit to try to help reduce your need for these anti-inflammatory medications, but they're not going to interfere with LDN.
Linda Elsegood: And the second question is, have you seen any difference in how LDN works on patients following an anti-inflammatory diet?
Dr David Borenstein: Yes, no question, diet is key to helping patients with rheumatoid arthritis and other autoimmune diseases. Now, what do I mean by that? I mean, I always talk about LDN being a tool, not a cure of disease. It's a tool that one can use to help treat disease. Now, if you can approach disease in multiple different ways, then, of course, there's going to be a much better response. So diet is key, especially in rheumatoid arthritis. With diet, we want to make sure that the patient, especially with rheumatoid arthritis, keeps away from nightshades - tomatoes, potatoes; working on fixing the leaky gut we are treating, having a gluten-free diet. These are very key components for fixing the gut. Probiotics, digestive enzymes, stomach acid. And again, looking for parasites and bacteria in the gut. Treating the gut is extremely important in rheumatoid arthritis and other autoimmune diseases. That in combination with low dose naltrexone is a very powerful tool for treating rheumatoid arthritis and other autoimmune disorders.
Linda Elsegood: Okay. And her third question was, I take 4.5 mg of LDN. Should I change the dose if I feel my symptoms increasing? And if so, in what direction?
Dr David Borenstein: Well, I don't know the patient's weight or their age, so I really couldn't give a super-accurate answer. That being said, you're not going up.
I mean, that's it. 4.5 mg is the max. As a matter of fact, I would probably recommend the patient lower the dose down to 4.0 mg. I wouldn't be surprised if the response improves, because if you lower the dose to 4.0 mg there may be a more effective opioid blockade. So I would probably give a trial of lowering the dose to around 4.0 mg, not 4.5 mg and see if that works a little bit better, especially if the patient is low weight.
Linda Elsegood: Thank you. And we have a question from Jen, and she says she has MS, and she has taken LDN for three months with some improvement to her bladder.
She said she started at 1.5 mg, then increased to 3.0 mg. Should she increase the dose or wait longer, because she's only had some improvement to the bladder? Nothing else.
Dr David Borenstein: Okay. Well, here's the thing with MS. You have to be concerned about spasticity. Many times we have patients with MS, they have spasticity, but if spasticity is not getting worse, then you can experiment with going up at very small doses - 3.25 mg try that for a little while. Then go up to 3.5 mg, and you can go up a little bit till the spasticity increases. And that's probably the max you want to take.
So yes, that would probably be a way to go. Now, remember, although we've had patients who felt better, the goal in low dose naltrexone for MS is more to prevent exacerbations and to keep disease stable, rather than actually feel a little bit better. So if you had numerous exacerbations in the past, LDN in many cases would prevent exacerbations. If it prevents exacerbations, then LDN has done its job. Okay. So it's more for preventing the disease from coming back and halting in its tracks rather than feeling better. So three months is a little bit short. We'd have to see over a longer period of time. I don't know how many exacerbations this patient has. So the answer will be if the patient has fewer exacerbations than she did, we know the LDN is probably doing its job.
Linda Elsegood: Okay. Thank you. We have another question from Paula, and she asks if LDN is a problem with candida? She took <a medication> to help and it allowed her to get up to 4.5 mg. She stopped the <medication> several months later and some of her old autoimmune symptoms have returned. She says, “Am I getting symptoms of candida, and what would you suggest I do?”
Dr David Borenstein: Well, the first thing I want to do is, and sometimes patients with severe candida can have problems with LDN. I think the thing you have to do is just clean out your gut and especially with candida. The same treatments that we have getting gluten and dairy-free diets, keeping away from fruits that can contribute to candida, and we all know what they are.
Anything that tastes good or isn’t good for you, it's probably good for candida. And some doctors give a course of Diflucan for a period of a month or two, that may be beneficial. It's not a cure, but it can give what I call an artillery barrage to at least lower the symptoms and then change your ability to do with the candida, with dietary changes and other supplements, cilantro, oregano, garlic, all very good for treating candida.
And just one more, which. I have a little bit of a mental block, but it also works - berberine, berberine-containing substances are very good for treating candida. Treat the candida for a month or two, even three, and then try and restarting the LDN and you'll probably get a better response.
Linda Elsegood: and we have a question here from Alec. She says, “Could LDN help with prostate cancer and other prostate issues?”
Dr David Borenstein: We've had patients with prostate cancer who've taken LDN. However, again, when you're treating cancer, you have to use a very combined approach. I've had patients who basically have prostate cancer, but they're not treating it because it's either low-grade cancer or its small cancer, and they don't want treatment yet, but it's certainly worth a try. And as long as your PSA doesn't go up and there are no changes in a digital examination, it's certainly something to consider. That being said, if the patient has received hormone treatments, those who are in a later stage or towards the end stage of receiving hormone treatment, we’re finding the LDN really doesn't work too well with that subset of patients. But as a rule, it's certainly worth a try, as long as you follow the rules, keep away from opioids and do the proper dosing. I think the question is, do you tell your oncologist about it? People ask me this all the time, and you know, I would, and just explain to your oncologist, or your urologist that you're on it and just give them a five-minute debriefing. Bring them some literature. But a lot of the time, urologists and oncologists are not crazy about it. But there'll be someone understanding at least in 2016, 2017. Ten to fifteen years ago, forget about it. Everyone’s mind was closed. I think we're living more open-minded today. So, again, short answer, you should always use LDN with the knowledge that your attending physician, your oncologist, your primary care doctor, whoever's treating you should probably know about LDN and that you're taking it, and just make sure that you don't only use LDN if it's something serious, a more serious disease. Because again, there are other treatment options available for more serious disease.
Linda Elsegood: And we have a question from Leanora. She says, “What are your thoughts on LDN and a person's genetics, SNPS, and methylation pathways. Are you familiar with MTHFR, COMT, or SNP called CYP-2-D-6?”
Dr David Borenstein: Well, here's the thing with the MTHFR and the other genetic mutations, there's no problem using LDN with that. You do have to treat the issues of those particular mutations. For example, I'm going to use MTHFR, because that's certainly by far the most common that we see. How do you treat the MTHFR? Even this is controversial, and I think this is going to change, so this is not in stone. When we have MTHFR gene mutations, you have to first evaluate to make sure homocysteine levels are normal. This other test you can use, I'm not allowed to use it in New York state, but there are better ways of checking homocysteine levels than just measuring homocysteine, but that's the tools we have, we have to use it. And making sure that you have the B-6, B-12 and methyl folate - make sure that in all your vitamins there is methyl folate - and use trimethylglycine and cleaning up the gut to detoxify.
So that's the best you can do. That being said, if you do all that and use the LDN, there shouldn't be any issues.
Linda Elsegood:. Okay. And she said, “Would know a person's genetic hiccups help determine the dose of LDN.”
Dr David Borenstein: Not really. We've been dosing LDN well before MTHFR became popular, well before. And I know Dr. Bahari when he was doing it, I, I speak with his wife from time to time also, who is in New York; and again, in the eighties and the nineties, we didn't really use MTHFR, and nothing changed. I mean, the dose is going to be basically based on the disease you have, your weight, and your tolerance. MTHFR and other genetic mutations are really not gonna make a big difference in the way we dose you.
Linda Elsegood: Okay. And she has another question, and she says” Have you seen success with LDN and endometriosis?”
Dr David Borenstein: I generally don't use LDN for endometriosis. Remember, endometriosis by definition, in most cases, is an excess of estrogen: estrogen dominance, as opposed to anything LDN would treat. So when I have endometriosis, I have to look for estrogen dominance and balancing the hormones. So I really wouldn't be using LDN for that.
There are many other things you can do to improve your hormone balance, like measuring the hormones, either through salivary testing; you can do urinary testing; in some countries, all you have is blood testing. And you have to do it on certain days of the month, balancing the hormones. And in most cases, the problem is either too much estrogen to too low progesterone or both. So balancing the estrogen, treating insulin resistance, and that's a biggie. And once you do that, that tends to be some sort of improvement in the endometriosis. So I would do that before throwing LDN at the problem.
Linda Elsegood: Okay. And she has one more question, and it says, “LDN might not always help or improve a person's condition, but are you aware of any conditions that are known to exacerbate, or worsen, a condition or disease?
Dr David Borenstein: I have not seen that. I've only seen certain side effects from taking LDN - the vivid dreams, the difficulty sleeping, the increasing candida, and Herxheimer reaction. But I've never seen a condition get worse from the LDN. Now, of course, diseases do progress naturally, and if you don't treat them, they tend to get worse, not get better. So many times, this is the natural course of the disease. But as a rule, no, I've never—seen any detrimental effects from LDN.
Linda Elsegood: Okay, lovely. Well, we'll just have a quick break, and we'll be back in a moment.
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Welcome back. We have some questions here from Dr Leonard Weinstock, and he says, “Have you measured pre and post LDN antithyroid antibody levels?”
Dr David Borenstein: Well, the answer is yes, we have, because anytime I have a patient who has Hashimoto's and hypothyroidism, I always measure their antibodies. So, and as a rule, they come down, and they can come down sometimes quite quickly. And you have to be very careful with these patients because if you have them on thyroid medication and their antibodies come down, and the amount of medicine they take may be the same, but their antibodies come down. That can actually cause them to become hyperthyroid. Think of it as driving a car and all of a sudden you're driving with the accelerator halfway down and the brakes halfway down, right?
So all of a sudden you're lowering the antibody, so the brakes, you're reducing the brake and what happens - the car zooms forward. That's exactly what happens. So you have to watch it, and watch it closely. Now here are some of the problems we have in monitoring the antibodies. Many of my patients’ antibodies are through the roof and the lab that I use, which is a very common lab that most integrative doctors in the New York area use, if it's above a certain level - if the anti-TPO is above a thousand and an antithyroid globulin is above 3000, it just says greater than a thousand, greater than 3000. So if the antibodies dropped from 5,000 down to 3,500, I have no way of knowing that. All I'm seeing is that it's above 3000 or when it gets below 3000, and I can see if it's dropping or not. But as a rule, LDN is a very effective tool for treating Hashimoto's, and the antibodies can drop, and it can drop quickly, so you have to watch these antibodies very closely to make sure the patient does not become hyperthyroid. Now, if the patient's not taking any thyroid medication, then it's a very different story than if it drops, it drops, and then you have to still watch them make sure that they're not becoming hyperthyroid, but it's less of a concern because they're not taking any thyroid medication.
Linda Elsegood: Just out of interest, how often do you check the levels if they're on thyroid medication?
Dr David Borenstein: It depends. If they're on LDN and I'm starting it, I probably would do it every four to six weeks, and I tend to be very, very conservative in the way I give the LDN. I like to start off at 1.5 mg, and then after a month go up to 3 mg and then go to 4.0 mg. However, sometimes I'll do it a little bit slower than that. Especially when I know the antibodies can drop quickly and they're on a high dose of thyroid medication. So you do it very, very slowly. Sometimes I'll just put them at 1.5 mg and have them come back in two months to see how the levels are. And then, all right, they've dropped, we're going to put you on 3.0 mg. But you know what? We're going to change your medications a little bit. Drop your medications a touch, come back in two months. But when we do it that way, you require a lot of constant monitoring. That's the best way to do it. And the safest now, thank goodness, no problems, but you know, there's a theoretical risk of hyperthyroidism, which you have to watch out for.
Linda Elsegood: Okay? And he also says, “What are your thoughts on using low dose oral methylnaltrexone for systemic inflammatory conditions without CNS pain?”
Dr David Borenstein: You know, generally I don't use it. Most of the time I use straight LDN, and I treat those other conditions other ways. As I said, I don't use the LDN only for treating pathology. I use various different ways to reduce inflammation, and there are many different ways we can reduce inflammation in outpatients. Obviously diet is very big. We know that certain foods are more inflammatory than others. High fructose corn syrup is huge. Red meats, certain nuts are huge. Dairy is huge. All inflammatory foods, so you want to change that. Use of anti-inflammatory supplements like fish oil, curcumin, Boswellia, bromelain; there are many different supplements you can take to reduce inflammation. One of the least evaluated, but very, very commonly associated with inflammation, believe it or not, is insulin. Insulin - you have to be very careful with insulin. We know that people who have hyperinsulinemia are very inflamed, and a lot of doctors aren't aware. Physicians treat blood sugar. They look at glucose. They never look at insulin. And while there is a relationship between the two, it's certainly not direct. You can have perfectly normal blood sugar and very high insulin, and that insulin can be very inflammatory. So I like to treat inflammation, look at the root cause of the inflammation, and then I add the LDN to help for any other issue that we're treating.
Again, not the primary treatment for what I do. But it's just a tool that aids in helping me treat disease.
Linda Elsegood: And he had one more question, “Did Dr Bihari compare measurements of enkephalins with PM versus AM dosing of LDN?”
Dr David Borenstein: I believe he may have, and it's usually about a third. As I remember, about a third less in the afternoon than in the evening. So, for example, let's say 2:00 AM in the morning is when you have the peak. It's probably three times as much at two in the morning than it is at two in the afternoon, at least three times, maybe a little bit more than that. That's why we don't recommend taking LDN in the morning. I have this question asked all the time because you don't have anywhere near the amount of endorphin peak at 2:00 PM in the afternoon than you do at 2:00 AM in the morning.
Linda Elsegood: Okay. We have another question here. Can you explain how LDN effects and regulates Th1 and Th2 rather than boosting either one?
Dr David Borenstein: Here's the thing. I've seen the charts on them, and it's probably better to explain visually. I think theTH-1 and TH-2, you know, the humoral immunity versus cellular immunity, I think a lot of this is overblown. But basically, the answer is it does affect the relationship between the two. But there's a huge chart that has all this stuff, and I probably have to do a more of a visual presentation than I can explain over the radio. It would be a very visual thing, but there are charts out there that will explain how LDN may affect the Th1 versus Th2 immunity.
Linda Elsegood: Okay. Thank you. And how does LDN affect allergy testings?
Dr David Borenstein: Well, in theory, it really shouldn't. I have patients on LDN get allergy testing and they certainly still come up positive, so we've never seen it. I mean, it could very well be, I've never done a study, but just from anecdotal evidence, I don't see how it affects the IgE modulated immune response.
Linda Elsegood: Another question: we're always being asked, while we're talking about testing, people say if I have to have a drug test for my work, would LDN show up?
Dr David Borenstein: No. Remember, it's not an opioid, it's an opioid blocker. So there's going to be no problem with you going in and taking LDN and having issues at work.
Linda Elsegood: And does LDN right serotonin levels in the brain?
Dr David Borenstein: As far as I know, the relationship is not proven. There may be some relation to that because remember, it's working more on the opioids and met 5-enkephalin. The met 5-enkephalin somehow may have some effect on serotonin, but I haven't certainly seen that in my patients. But that would be something that research can definitely look into.
Linda Elsegood: And we have a question from Kirsty, and she says, a week ago she started on 1.5 mg of LDN for lichen sclerosis, and she’s curious about at what point should she expect to see some relief of symptoms, and when should she increase the dose?
Dr David Borenstein: Well I think it's still very early, but I would certainly recommend the next couple of weeks trying to go up to 3.0 mg and see how that works, and then moving up a little bit higher. And if you're not getting any results for a few months after that, it's probably less of a chance that it will work. As a rule, I think after three or four months if we’re not seeing results, either you have to clean your diet out and change what you eat, or it's probably not gonna work for what you're trying to use LDN for.
Linda Elsegood: What is the protocol that you suggest to your patients? I know you have said LDN is just one of the tools that you use and it doesn't always work for everybody, but if we were a new patient coming into you, how would you describe LDN to them if they weren't going to go off and Google it.
Dr David Borenstein: Well, here's the thing. Usually, if I'm going to prescribe LDN, we'd have a specific reason for doing that. So maybe give me a scenario, which type of patient - one with MS, a patient with Crohn's. You tell me, and I can give you better answers.
Linda Elsegood: Let’s say Crohn’s.
Dr David Borenstein: Perfect. Perfect. Well, most of the time, people with Crohn's maybe on Humira or other medications that would impair the immune system.
So I would explain to them it's very simple. I tell them that there's this medication that mostly integrative doctors use. It has very good success in treating Crohn's disease. It is inexpensive. A dollar a day on average. It has minimal side effects, and it works in most cases really, really well. So they say, doctor - the most common question I have for this - is, “How come my gastroenterologist didn't tell me about it?” This is the most common question I have. Why are you doing this and they're not doing it. So then I have to explain it again: most integrative doctors use this; this is compounded, not pushed by their pharmaceutical representatives. That, and explain the mechanism of action, that we know that opioids have a very important part of regulating the immune system. Then explain to them what opioid blockade is and the increase in met 5-enkephalin and how that can modulate the immune response. Now we also have to educate the patient that this is not a narcotic, because they think naltrexone, and they think drug addiction, so we have to educate them about that.
Now, especially with Crohn's, not only do I use LDN, but I also use some of the other techniques I mentioned: treating the gut, the inflammation. But here's some good news about LDN and Crohn's. A lot of my patients don't keep to their diet. A lot of my patients don't do what I tell them. All they do is just take LDN, and that's it. And you know what? They do really well despite not having to change their diet; despite not having to do anything I tell them to do; and they respond really, really well. So that's kind of a good thing. At the same time, patients who don't respond well, we may want to have them change their diet and follow my instructions for cleaning up the gut and taking the proper supplements and diet, and then they tend to respond as well. One thing about Crohn's that works so well in our patients. A lot of the patients don't even - that's it - I want my LDN and goodbye. And it works as they come periodically to see me get their refills, and they're the happiest people in the world.
Linda Elsegood: I have a question here that always comes up. Now, some doctors, pharmacists, think Tramadol is an opiate. Others will say it's a synthetic opioid and can be taken with LDN. Where do you stand on that?
Dr David Borenstein: It can be taken with LDN. Don't believe anything they say. If you're in pain and you need a painkiller while taking LDN, Tramadol is what you're going to take. It works. How do I know? I've tried it on myself. You know, it's not a problem.
Linda Elsegood: Okay. Any particular dose.
Dr David Borenstein: You know, it’s individualized. But the point is, the question is more in general, will Tramadol have a problem working with LDN, and the answer is no. The dose is as you need it. Every pain situation is different. Certain pains, you don't really need Tramadol, you just need Tylenol or Motrin. But other pain, heavy narcotics. In that case, that's where the Tramadol comes in. That being said, in many of our patients who need high dose narcotics, you may want to just get off of LDN for a little while and hope for the best. And then when your need for narcotics goes away, restart the LDN
Linda Elsegood: So would you say with Tramadol there has to be a gap when you take LDN or can they be...
Dr David Borenstein: No, no gap at all. Just use it as needed. But sometimes Tramadol will not be enough for the pain. You may need opioids, and that's when you're going to have to go off the LDN.
Linda Elsegood: Oh, that's good. Thank you. We have people ask us about weight. We know that LDN is used in some weight loss clinics; and some people say when they start LDN, they gain weight. Do you have any experience of weight with LDN?
Dr David Borenstein: Usually not. Usually, people don't gain weight. It's usually very well tolerated. I wouldn't use it, again, as a primary weight loss medication, although some patients have claimed that they have lost weight on it. Maybe they sleep better after a while on it, and that improves the metabolic rate. But weight loss is an entirely huge separate issue. We can have ten seminars on weight loss because it's such a complicated factor of hormones, adrenals, thyroid, lecithin, insulin. It's a huge, huge topic; and growth hormone; there are so many things that are involved in discussing weight loss, and that's just hormonally, and obviously, we have diet issues and exercise issues that we can discuss as well. But I think, for the most part, it may be a pleasant, side effect. And if you lose weight, that’s great.
Linda Elsegood: And does LDN help with sensitivities to fragrance or chemicals.
Dr David Borenstein: Here's the thing. It's certainly worth a shot, but chemical sensitivity, and I've seen a lot of chemical sensitivity in my life; it's a very, very, very difficult thing to treat. First of all, many physicians, if not most physicians in the United States, I don't know how it is in the UK or the EU, but most physicians here don't even think that it even exists. It just doesn't exist. Okay. And I think when we're treating chemical sensitivity, we have to work on detoxification of the body. Working on building the methylating pathways, detoxing with things like charcoal or other things. Also, when I hear fragrance sensitivity, when someone has a problem with perfume, the first thing I think of is candida. Candida is the first thing I think of. Look for yeast. Many times it's a very close clinical association. Now, if you want to try LDN that's great, but I don't think that's gonna cure the issue. I think we have to look at the root cause of the problem and address it. And the LDN may be a tool in fixing, addressing that issue, but I don't think it's a cure-all, but certainly worth a shot. Again, we have a medication that's cheap, little in the way of side effects. It may have good therapeutic potential. Why not use it?
Linda Elsegood: And another question that's always coming up, and I know you were saying about missing doses for a period of time before and after an anaesthetic. Some people say that skipping a dose is good on a regular basis. Some doctors will say once a week, some will say once a month. What is your view on that?
Dr David Borenstein: Well for the first few years, I don't think it's necessary to skip a dose, but we're finding probably after a number of different years, and patients who've been taking LDN for many years, it certainly wouldn't hurt to skip a dose maybe once a week. First of all, it saves you a few dollars if that's a concern. But if you can skip the dose once a week. Okay, now I wouldn't do this in the initial couple of years. It's just more people that have been on it for a long period of time. Skip a dose once a week and see how you feel, and see if your clinical symptoms change. We do this, believe it or not, in Parkinson's disease, we take as a drug holiday, and it works really well when the medicine for Parkinson's disease doesn't work very well. We take a drug holiday, and it's kind of like what you're doing here. It wouldn't hurt. I don't think there's an exact protocol. I think this is very anecdotal, and every patient is different, and everyone is different. But you know, 5-6 years of LDN - try stopping it one day a week and see what happens. What's the worst-case scenario? You have to go back on it every day. That's the worst thing that's going to happen.
Linda Elsegood: And you were saying about Parkinson's - we've got many members that are taking LDN for Parkinson's. What has been your experience with that?
Dr David Borenstein: Pretty well. Now I've been doing a lot of work with Parkinson's, and right now in my practice I've been doing a lot of work with Stem cells, and I find that Stem cells are very beneficial. And what I find is that I get the Stem cells to improve the symptoms of Parkinson's and then the LDN to keep it stable. So I've been using LDN and those patients recently with some good results too. We just keep the disease stable. So they may get a big boost in the way they function with the Stem cells, and we use the LDN to keep them that way. So I think it's a very powerful tool for treating Parkinson's and MS, and some other neurological diseases.
Linda Elsegood: We have a question for Mary, and she says, “Have you found LDN to be beneficial for Alzheimer's?”
Dr David Borenstein: I have not used LDN for Alzheimer's. The problem is you have a patient who may not have the best memory, and you have to be very careful with the medication. If there's a provider there with the Alzheimer's patients, you can certainly give it a try. I think there are many other things you can do for Alzheimer's patients: treating their vitamin deficiencies, B12, folic acid, lots of fish oil, making sure their thyroid is okay. And look for other deficiencies: low levels of vitamin D, look for MTHFR mutations, high levels of homocysteine. These are things that - aluminium toxicity is the thing that I would look for in treating patients with Alzheimer's. Again, if you have a physician who can work with you, this is very low risk. And very inexpensive. It's certainly worth a try. That being said, look for the other things that you need to address with patients with Alzheimer's and address those, and you'd be surprised just by giving some B12 shots, a little thyroid, and little fish oil - you may actually see some improvement.
Linda Elsegood: That's good. Well, we have time for one more quick question.
Debbie has bipolar, and she wants to know if LDN would help her.
Dr David Borenstein: I have not treated bipolar in my practice, and I have not had any patients who would be treated with, let's say, Crohn's or MS or cancer, and also have bipolar and have any change in their symptoms. So I honestly couldn't give you an answer to that.
Linda Elsegood: Well, that's us just about over David, and thank you very, very much for taking all these questions and for your time. It's been amazing. So thank you very much. And next week we're going to be joined by Dr Mark Shukhman, who's a psychiatrist, so maybe he'll be able to answer our question on bipolar. But thank you once again, David.
Dr David Borenstein: Oh, my pleasure. Thank you.
Linda Elsegood: Belmar Pharmacy is a nationally respected compounding pharmacy. They compound low dose naltrexone, LDN; bio-identical hormones, and custom amino acids, amino blends. They're based in Colorado and ship nationwide. Their goal is better patient outcomes through quality compounding, combining effective communication between practitioner, pharmacist, and patient. Call +1 800-525-9473 or visit Belmarpharmacy.com.
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