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Case 1: 66yo female with documented SS based on a history of dry eyes and dry mouth, joint pain, and elevated anti-SSA and anti-SSB antibodies whose joint symptoms responded to treatment with LDN. She had previously been treated with plaquenil but had decreased the dose due to concerns about the risk of retinal toxicity, then she stopped plaquenil completely because she felt well. Within four months of discontinuing the drug, she developed mild joint pain and her ESR increased. Due to increasing pain she resumed plaquenil 200 mg daily. However, her symptoms persisted and her ESR remained elevated. She elected to try LDN after she improved with a one-week course of prednisone. Following one month of LDN 1 mg orally daily, she noted less pain and inflammation. Her ESR went down and CRP normalized. LDN was increased to 2 mg daily. Three years later, she remained asymptomatic with a normal ESR of 23 mm/h and a normal CRP of 2.1 mg/L.
Case 2: 24yo female with documented SS. She had a five-year history of chronic widespread body pain, fatigue, headaches, and brain fog, with very high measures of inflammation. She continued to be symptomatic, despite a gluten free diet, physical therapy, and antidepressants. Her medications included IV gamma globulin. Hydrocodone/acetaminophen 10/325 5 tabs daily, cyclobenzaprine, diphenhydramine, metformin, topiramate, baby aspirin, and metoprolol. She noted dry eyes and dry mouth. Lab work showed a positive anti-SSA antibody and elevated ESR at 90 mm/h and CRP at 14.2 mg/L. Her globulin was 4.8 g/dL (normal less than 3.7 g/dL). She was started on LDN 0.5 mg po daily which was increased weekly up. Five weeks after starting LDN she was taking 2.5 mg daily and her ESR and CRP improved to 42 mm/h and 6.8 mg/L respectively. She stated her joint pain and headache were significantly better. Six months after starting LDN she was taking 4.5 mg and noted fatigue. The LDN dosage was gradually increased over the next two months to 8.5 mg. One year after starting LDN, her headaches were better, but she had persistent pain which corresponded to trigger points consistent with fibromyalgia. The patient complained of fatigue. Her CRP was normal (3.5 mg/L) and her ESR was also normal (16 mm/h).
In the initial pilot study that used Low Dose Naltrexone (LDN) in the treatment of fibromyalgia, the baseline sedimentation rate was a significant predictor of clinical response to LDN. Dry eyes and dry mouth did not improve with the use of naltrexone in these two patients.