Low Dose Naltrexone (LDN) Titration

Low Dose Naltrexone (LDN) Titration

I've been harping on this one now, and I think Matt's heard me talk about this and a couple of our attendees may have heard this.  I'm really pushing for initiation at a half milligram and titrating up by every seven days by a half milligram at a time. I know the LDN Research Network Trust has got a really good dosing protocol and I'm stepping out of line mainly because I just really want to make sure that we hit the right dose without overshooting, and I'm just seeing more and more patients, especially the long hauler patients, not necessarily needing as much as 4.5.  As I said, 60 to 70 percent of the patients they're getting a good response but maybe we'd still optimize that dose and so this is the patient-specific response.  This is why a good compounding pharmacy is so important to the mix and making sure that the compounding pharmacy isn't just, "Yep, take it and go."  No, we want to have that relationship between the clinician, the provider and the patient so we can really and truly find that optimum dose.  

 I'm being asked where do you start and I always start at 0.5.   You can give a bunch of one milligram and a bunch of half milligrams and they can kind of add different doses.  But it's all really specific to that patient's response. If they're starting to see really exaggerated side effects or a worsening of their condition, then it is too much back down, back down. We also get asked for doses for all kinds of disease states, too.  Right.  You know, what do you take, how much do you dose this or how do you dose that?  It always depends on, I think, the disease state and it also depends on does the patient have, you know, decreased quality of life or comorbidities involved with their disease. Right? If you've got somebody who's got a chronic disease and it's killing their quality of life and they may not be clinically depressed, but they have depressive-like symptoms then I think adding a daytime dose is a huge benefit because it can, if you split that out as a separate dose, not related to their autoimmune disease, or their pain control if you will, then you can also affect quality of life nicely.  For example, I have a patient who we titrated in.  They tried 4.5 and they had fibromyalgia.  They tried 4.5, really didn't see any changes early on but when they added the daytime dose, they saw improvement in their quality of life.  They felt better, mood was better and if you're if you think you feel better and your mood is better than you know attitude is everything kind of thing. 

I've also got, depending on what we're treating, one post-traumatic stress syndrome patient who's on a milligram twice a day and doing fabulous at a milligram twice a day. It doesn't always take as much to see the response and it depends on the disease. 

Where do you start? I'm with Sebastian, I always started a half milligram.  I think half milligram increments, although I got to be candid with it, when I first started doing Naltrexone back around 2010, I can't remember exactly when I first started dispensing it,  but we were doing 1.53 and 4.5.  I didn't get a lot of flack from hardly anybody. I had one or two people that couldn't take it at bedtime because of the sleep disturbance of the vivid dreams and that sort of thing.  We just switched to the daytime dose and it seemed to take care of the problem.  Other than that I never saw a massive amount of adverse events.  Although they do occur, but if you're going up in half milligram increments then you can recognize that as it happens you can back up a notch and go, "Okay, let's stay here for a little while and see what happens." You know like we keep telling everybody in our lectures, "It's not a race to 4.5,"  Kind of the extension of that is 4.5 is a very fuzzy target.  Some patients will do better with more, some patients will do better with less.  It's just kind of like let's aim there but let's see where you land.  It’s like an arrow shot.  We're kind of looking at the target, but we know it's going to arc up and over. 

Now I  also have to say I actually got a private message which was, "Hey what are we doing with our slides? So Linda I'm actually pitching this question to you.  Some people are going to request slides and they're just wondering if they are going to be made accessible to anyone after the lecture?  They are.  No pressure.

I'm totally fine with you sharing any of my slides.  This is your program and it's your decision.  Okay.  Are you happy, Nat?  Absolutely.  No problem.  Be glad to share.  Yeah. There's another question just popped up if one of you would like to answer it.  I think it's probably about a chronic wound. For chronic wounds we've done it topically a lot.  Both Sebastian and I have used Naltrexone.  In fact I was just talking to a pharmacist down in Georgia today and they were seeing that they kind of stalled out on closure of the wound and when they added Naltrexone in it it closed up almost immediately.  We're doing like a half a percent or less in a lot of the wound formulations but it depends on what else is going on with the wound.  As a as a single standalone ingredient, I don't usually use it as a single standalone, as Sebastian mentioned earlier when you see patients because of that snip and their tlr4 receptors and the genetic predisposition you don't know who's going to respond well, who's not going to respond well.  We've actually seen a few patients when they're treating, you know topically, that to get some  paradoxical inflammation from it, right.  So we try to make sure that I think that oral is always the safest route to go.  Just saying from a reduced adverse event perspective and to get the immune modulation because a lot of times wound closure is hard especially in older patients because their immune system is not as happy, their hormones are not as happy, it's kind of hard to close a wound if you don't have adequate androgens on board. It's a bigger picture thing for a lot of people and I'm going to roll along with this one for any chronic wounds.

Orally works extremely well.  We've seen patients using things topically  and it really and truly depends upon the patient and what success you're having.  So the nice flexibility within the group, that of compounding pharmacists, is this way, doesn't work well we always have an option.  We have a cream for that or we have a capsule for that. Take your pick but we can, we can adjust the patient's best outcome at the end of the day.