Invivo Botanical Medicine Women and Children - Invivo … · • Associated symptoms (sinus...
Transcript of Invivo Botanical Medicine Women and Children - Invivo … · • Associated symptoms (sinus...
Botanical&NutritionalMedicineforWomen&Children
AvivaRomm,M.D.
ComplexPatients…Sigh...
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THECONVENTIONALRESPONSE?
FunctionalMedicineApproach
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RootCauses,RootSolutions
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RootsCauses
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46-year-oldWomanwithFATIGUE• Day2mesomnolence
• Hastonapforhoursduringtheday• Evenifhasagoodnight'ssleeps2llneedsanapintheaCernoon
• “Tiredallthe2me”• Brainfog–can’tconcentrate• Musclefa2gue
• Withexercise
• NightEa2ngSyndrome• Insomnia
• HasanxietyaboutgePngsleep• Wakesupduringthenight-3am-7amthengoesbacktosleep
Let’sgoontoroo+ngoutthecause(s)offa+gue…
TheFatigueHistory
• Understandingtheroleoffa2gueonyourpa2ent’sQOL• Describingfa2gue
• Onset(gradual,sudden,relatedtoanillness,exposure)• Loca2on(muscleweakness,“inmyhead,”generalized).• Type(heavinessinbody,brainfog,sleepy,deeplyfa2gued)• Timing(morning,day2me,aCernoon,nighPme)• Course(stable,improving,worsening)• Frequency(daily,constantly,cyclic)• Associatedsymptoms(sinusconges2on,bloa2ng,jointpain)• Associatedbehaviors(exercise,postprandial)• Allevia2ngbehaviors(sleep,ea2ngprotein)
• Primarysymptomorsecondarysymptom(i.e.,2red,or2redofbeingsick)
TheFatigueFocusedPhysicalExam
• Generalappearance:levelofalertness,psychomotoragita2onorretarda2on,grooming
• Presenceoflymphadenopathy• Thyroidfindings:Goiter,thyroidnodule,ophthalmologicchanges
• Cardiopulmonaryexamina2on:signsofconges2veheartfailureandchroniclungdisease
• Neurologicexamina2on:musclebulk,tone,andstrength;deeptendonreflexes;sensoryandcranialnerveevalua2on.
CommonFatigue-AssociatedConditions• “Adrenalfa2gue”• Anemia• Autoimmunecondi2ons• Caffeineuse• Cancer• ChronicFa2gueSyndrome• CVD• Depression• Diabetes,Dysglycemia• Fibromyalgia• Foodallergies,intolerances• Generalizedinflamma2on• Hypothyroidism
• Hyperthyroidism• In2matepartnerviolence• Lymedisease• Medica2ons(pains,bloodpressure,an2depressants)
• Obesity• Restlesslegsyndrome• Sleepapnea• Sleepdisorders• Stress,SESfactors• “UNEXPLAINED”• ViralInfec2ons(EBV,HSV,CMV)
RuleOuttheBigBadThings
• CVD,cancer,i.e.,newonset/recentfa2gueinwomen>45• MS,MG,etc.,Progressiveorrecurrentmuscleweakness• HIV,i.e.,fa2guefrequentinfec2ons• Leukemia,i.e.,Bruising
InQlammation:TheRootofFatigue
InitialConventionalLabsforFatigue
• Completebloodcountwithdifferen2al• Chemistryscreen(includingelectrolytes,glucose,renalandliverfunc2ontests)
• Thyroids2mula2nghormone• Crea2nekinase,ifpainormuscleweaknesspresent• ConsiderESR
• Addi2onallabsconven2onallyrecommendedonlyifhistoryorphysicalexamfindingssuggestaneed.
TheMatrix&SymptomOrganization
FoodJournalReview
TheMatrix&Labs
LeakyGutandInQlammation
Matrix:OrganizeaRootCauseAssessment
Matrix:OrganizeTreatment
UsingtheMatrixtoTrendResults• Mind/Mood
• Sleepimproved,fallingasleepmoreeasily,nonightwaking• NoNESonmelatoninand5-HTP• Rarelyneedsmorethanabriefrestintheearlyevening• Lavenderoilandadrenalsupportwithashwagandhabeforebed
• Assimila+on• SIBO–resolvedaCer1coursexifaxan,nauseaimprovedalsoonHCLnowandan2microbialbotanicalsforsupport• 4+yeast–clearedonrepeattes2ngs/pnysta2n,nogas,bloa2ng• GERDsxresolved,offPPI,takingDGL,dietarychangesmade• Offofdairy
• Defense/Repair• Takingcurcumin1000mgBID
• Energy• Anemiaresolved;Hct>30à37.4,ferri2nfrom14à23à53
• Biotrans/Detox• Taking5mgmethylfolate/day• TorevisitHglevelsandamalgams
• Transport• LDL-P1817,LDL-C103,LDL-p1084• A1Cà5.6• GlucoseF93,1hr166,2hr.116• Ins1hr127s
• Communica+on• VitaminDnow61s,reducedto2000units/day• TSHàstartedonArmouràTSH1.0FT32.9• Haslost20lbs,severalpantssizes
• Structural• Jointpainimproved,con2nuingcurcumin
GIFXPostTreatment
SIBO
WhatCanHappen…10monthslater…• Lost25+LBSandhaskeptitoff.• Says"Con2nuetofeelmuchbeserbecauseofyou”• “Anxietyhascompletelydisappeared.”• “Mystomachdoingsowell”-abletotakehersupplements• “Armourhashelpedsomuch”sexdrivereturning!• “Sleepisperfect”• “Nojointpain”• “Moodbeserthan[I]believedpossible”• S2llget2redaround5pm• Increasedself-awareness:Diet-for3mowassoreligiousandlostsomuchweight.Startedea2ngyogurtandglutenagain-aCeraweekstartedfeelingunwell,couldn'twalkproperly-sowentbackoffcompletelyandwithinaweektheinflamma2onisgone.
2yearoldgirloldw/JRA• 2yogirlold,dgwithpolyar2cularJRA• Feverx1week,ATCtylenolandibuprofen• àGastri2s,PPIx8months• Developedpolyar2cularpainandswelling• Diagnosedclinicallybyrheumatologistage18mo• Chroniclimp,painàchronicNSAIDuse• BornbyNSVD,motheroninsulinforpoorlycontrolledGDM• Liverurally,?pes2cideexposure,heavymetalcontamina2onofwater,?arsenicexposure
• RheumatologistreadytostartS.onmethotrexate
AdditionalAssessments&DiagnosesforSarah
• Eczema• Diges2vesymptoms,especiallybloa2ng,bellyaches• An2bio2cUse• GlutenIntolerant• Irondeficiencyanemia• Lead-ElevatedBodyBurden• MTHFR+/-
THEGUTCONNECTION• Immunologicaldysregula2onisthecauseofmanynon-infec2oushumandiseasessuchasautoimmunity,allergyandcancer.
• Thegastrointes2naltractistheprimarysiteofinterac2onbetweenthehostimmunesystemandmicroorganisms,bothsymbio2candpathogenic.
• Disturbancesinthehealthybacterialmicrobiotaofthehumangutduringcri2calwindows,andgenerally,resultsindysregula2onofadap2veimmunecelldevelopmentandresponse.
• Increasedintes2nalpermeabilityleadstosensi2za2onoftheimmunesystemduetobreachofbarrierbetweenresponseto“self”and“other.”
CommensalBacteriaandImmuneDevelopment
TheTimeline
THEMODERNTIMELINE
SampleTriggerData• Infan2lecolicaharbingerofatopyinchildren.• Posi2veassocia2onbetweenthelactulosetomannitolra2oandtheseverityoftheeczemaaCerac2vetreatmentwithprobio2cs.Impairmentoftheintes2nalmucosalbarrierappearstobeinvolvedinthepathogenesisofatopicderma22s.
• Meta-analysisof8studiesexaminingrela2onshipbetweenexposuretoan2bio2csanddevelopmentofchildhoodasthmacomparedexposuretoatleastonecourseofan2bio2csinfirstyearvs.noexposure(12,082children,1,817asthmacases).Riskofasthmawassignificantlyincreasedinchildrenreceivingoneormorecoursesofan2bio2csduringfirstyearoflife:ORwas2.05(95%CI1.41-2.99).Dose-responseanalysisshowedincreaseinORof1.16(95%CI1.05-1.28)foreachaddi2onalcourseofan2bio2cs.
• Cesareansec2onposi2velycorrelatedwithdevelopmentofobesityandautoimmunityinchildren.
3KEYAREASOFGUTPERTURBATION
• Dysbiosis• Hyperpermeability• Chronicinflamma2on
WhatisDYSBIOSIS?• Dysbiosisislossofbiodiversity,species,andreserves,“Lossofancestraldefenses.”
• Changesinspeciesdominancefromphysiologictopathologic
• Bacterialresistanceofpathogenicspeciesandevencommensalspecies
• Lackofproperimmunologicdevelopmentandresponse
WhatisLEAKYGUT?
BarrierProtection• Anextremelyimportantfunc2onoftheintes2neisitsabilitytoregulatethetraffickingofmacromoleculesbetweentheenvironmentandthehostthroughabarriermechanism.
• Togetherwiththegut-associatedlymphoid2ssueandtheneuroendocrinenetwork,theintes2nalepithelialbarrier,withitsintercellular2ghtjunc2ons,controlstheequilibriumbetweentoleranceandimmunitytonon-selfan2gens.
• Zonulinisthephysiologicalmodulatorofintercellular2ghtjunc2onsinvolvedintraffickingofmacromoleculesand,therefore,intolerance/immuneresponsebalance.
• Glutenisaknownup-regulatorofzonulinac2vitywhichleadstodown-regula2onoftheproteinoccludinandresultsinincreasedgutpermeability.
TheHealthyEpithelium• Commensalbacteriaplayaroleinmaintainingtheintegrityoftheintes2nalepithelium.
• Intes2nalepithelialcells(IECs)provideaphysicalbarrierbetweenluminalmicrobesandunderlyingintes2nal2ssuestocontroldefenseandtolerance.
• IECsexpresspasernrecogni2onreceptors(PRRs)andcanrecognizemicrobialpathogen-associatedmolecularpaserns(PAMPs)andrespondtointes2nalmicrobesthroughsecre2onofcytokinesandan2microbialproteinsandup-regula2onofsurfacemoleculesthatmediateintercellularinterac2ons.
• SecretoryIgAreducesintes2nalproinflammatorysignalsanddrivesdiversityingutmicrobiota.StressreducesSIgA.
• Adefec2vebarrierallowstransloca2onofforeignproteins,LPSs,andcanleadtoendotoxemia,an2bodyforma2onandfoodsensi2vi2es,allergic,andautoimmuneresponses.Inaviciouscycleitalsoperpetuatesdisorderedgutflora.
• Disrup2onsleadtodisrup2onsinnutri2on–manychildrenendupanemic,lowinvitaminD,depletedan2oxidantstatus(ieglutathione).
• Endotheliumalsoimportantforproduc2onofsystemicallyimportantan2oxidantsreduc2onofwhichincreasesoxida2vestress,asdoesthechronicgutinflamma2onsooverallburdenofoxida2vestressincreases.
LEAKYGUT&IMMUNEDYSREGULATION
STRESS&THEGUT• “Ifeelitinmygut,”“Ican’tstomachthis,”“Thismakesmesicktomystomach”…
• StressreducesSIgA• Stressdivertsbloodflowfromawayfromthegut• Knownimpactonpredominantspecieswithchangesseeninreduc2oninLactobacillusandBifidobacteriumspptowardColiformandEcoli.
• Stresschangesthechemicalmilieuwhichchangesthefoodresourcesavailableforgutflora.
• Changesinneuro-immunesystemnowknowntobeubiquitousandcompletelyinterconnectedandnotreallyseparatesystems.
GUTHEALTHYDIET• Smartstarttosolids;nofoodavoidanceunlessnecessary+/-dairyproducts
• Fooddiversity• REALfood• Fiber• Fermentedfoods• Lowsugar• Avoidan2bio2cexposuresinfoods• Healthydaily(orageappropriate)evacua2on
THE4RPROGRAM
• Remove:Triggersandirritants• Replace:Diges2veenzymesandhydrochloricacid,forexample,arereplacedinthisphase.LowBcomplexassociatedwithlowstomachHCL.
• Repair:Providenutrientsthatnourishandhealtheintes2nalmembranesandhealthyflora.ConsiderL-glutamine,turmeric,licoricerootextract(orDGL),marshmallowroot,zinc,querce2n,andlarch-arabinogalactans.
• Reinoculate:Prebio2csandprobio2cs,alongwithgoodqualityfiber
Remove Replace Repair Reinoculate
REMOVE:THEELIMINATIONDIET• Elimina2onphase:“classicalapproach”and“goldstandard”• 2-6weeks• Highlysimplifieddiet• Avoidingcommoncausesoffoodsensi2vity• Dailysymptommonitoring• Screenforea2ngdisorder• Prosandconsof“all-in”vs.stagedelimina2on
• Studyfindingsareequivocalbutsomestudiesfinddefiniteimprovementwithuseofelimina2ondiet
• Mostcommonfoodsinproducingallergysymptomsaremilk,eggs,chocolate,soy,citrus,nuts,wheatandcorn
• Skintes2ngforallergensdoesnotusuallycorrelatewithclinicalsymptoms
EliminationDiet• Provoca2on/”Tes2ng”phase
• Addonenewfoodevery3-5days• Startwithfoodseatenmostfrequently• Con2nuedailysymptommonitoring• Ifnochangeinsymptoms,foodcanstayindiet;ifsymptomsworse,foodshouldbeavoidedasapossiblecause
• Useof“rota2ondiet”concept
REPLACE• Nutrients–gutpermeabilityreducesnutri2on• Enzymes• BetaineHCL• B-6
REINOCULATE• Probio2cs,prebio2cs,symbio2cs
• S.Boulaardi• Bifidospp,Lactobacillusspp.• VSL#3(Bifidobacteriumbreve,Bifidobacteriumlongum,Bifidobacteriuminfan2s,Lactobacillusacidophilus,Lactobacillusplantarum,Lactobacillusparacasei,LactobacillusbulgaricusandStreptococcusthermophilus)
• KlareTherbio2cInfant
ProbioticBeneQits• Double-blinded,placebo-controlled,cross-overstudy,probio2clactobacilli(Lactobacillusrhamnosus19070-2andLreuteriDSM12246)wereadministeredfor6weeksto41childrenwithmoderateandsevereatopicderma++s.Significantdecreaseinthefrequencyofgastrointes+nalsymptomsduringac2vetreatment(39%duringtheplaceboperiodversus10%duringac2vetreatment,P=.002).
PreventionofAtopicDiseasewithProbiotics
• Doubleblindrandomizedplacebo-controlledtrial(n=132)ofchildrenwithastrongfamilyhistoryofatopicdisease
• LactobacillusGG(1X1010CFUs)tomothersfor2-4weeksprenatallyandthentoinfantspostnatallyforsixmonths
• Atopiceczemadxbyage2in23%(15/64)ofprobio+cgroupvs.46%(31/68)inplacebogroup(RR0.5195%CI0.32-0.84)
• Numberneededtotreat4.5
ReductioninAllergicRhinitiswithProbioticTreatment• Nineof12RCTsreviewedbyCochranethatevaluatedclinicaloutcomesinARshowedanimprovement(lowerreportedARscoresandlessmedica2onuse)duetotheuseofprobio2cs.comparedwithplacebo.
• Also,5ofthe8RCTsthatreferredtoseasonalARsuggestedanimprovementinclinicaloutcomes.
• NineRCTsthatreportedvariousimmunologicmeasurementsofallergyfoundnosignificantprobio2ceffectsandnoclearimprovementinasthma.
PreventionofAtopicDiseasewithProbiotics
• Perinataladministra+onoftheprobio+cLactobacillusrhamnosusstrainGG(ATCC53103),reducesincidenceofatopiceczemainat-riskchildrenduringthefirst2yearsoflife(infancy).
• Atage4,14of53childrenreceivingLactobacillushaddevelopedatopiceczema,comparedwith25of54receivingplacebo(rela2verisk0.57,95%CI0.33-0.97).
• Skinpricktestreac2vitywasthesameinbothgroups:tenof50childrenpreviouslygivenLactobacilluscomparedwithnineof50givenplacebotestedposi2ve.
PreventionofAtopicDiseasewithProbiotics
• 7-yearfollow-upconfirmedthatthecumula2veriskofdevelopingeczemaduringthefirst7yearsoflifewassignificantlylowerintheprobio2cgroupthanintheplacebogroup.
• However,atopicsensi2za2onwassimilarbetweenthegroups,sugges2ngthatthepreven2veeffectoneczemawasnotIgE-mediated.
PreventionofAtopicDiseasewithProbiotics
• Abrahamsson:cumula2veincidenceofeczemawassimilarinbabiesreceivingLactobacillusreuteribeforedeliveryandupto12monthsoldandthecontrolgroup.TheL.reuterigroupdidhavelesserIgE-associatedeczemaduringthesecondyear
• Kuitunen:1223motherswithinfantsathighriskforallergywererandomizedtoreceiveprobio2corplaceboduringthelastmonthofpregnancyandtheirinfantstoaddi2onallyreceiveprebio2cgalactoligosaccharidefrombirthun2l6months.Nodifferencesinthefrequencyofallergicdiseasesandsensi2za2onaCer5yearsoffollow-up.
• BUT…LessIgE-associatedallergicdiseaseoccurredincesarean-deliveredchildrenreceivingaprobio2csmixture.
AlteredStates• GutmicrobiotaofchildrenwithatopycharacterizedbyapredominanceinC.difficile,Coliformspecies,andS.aureuscomparedwithnon-allergicchildren
Physiologicmechanismsforprobioticsinatopicdisorders• TH1vs.TH2regula2on:mayhelpdowngradeTH2responseswhichleadtoatopy(hygienehypothesis)
• Systemicdown-regula2onofinflammatoryprocessesbybalancingthegenera2onofproandan2-inflammatorycytokines
• Capacitytoreducethedietaryan2genloadbydegradingandmodifyingmacromoleculesinthegut
• Reversetheincreasedintes2nalpermeabilitycharacteris2cofchildrenwithfoodallergy
• EnhancespecificIgAresponsesfrequentlydefec2veinchildrenwithfoodallergy
REPAIR• Reduceinflamma2onfromdiettoallowhealingdiet• AppropriatesupplementsespeciallyzincandL-glutamine.• Botanicals
L-glutamine• Aminoacid• S2mulatesenterocyterepairandprolifera2on.• Increasesintes2nalvillousheight,s2mulatesgutmucosalcellularprolifera2on,andmaintainsmucosalintegrity.
• Preventsintes2nalhyperpermeabilityandbacterialtransloca2on.
• Ininflammatorycondi2ons,theavailabilityofglutamineasanenterocytefuelsubstrateisessen2alforthepreserva2onofafunc2onalbarriertomicroorganisms.
Zinc• Consideredtobeakeyfactorforthepreserva2onofstructuralintegrityoftheintes2nalbarrier
• Improvesenterocyterepair,aidsinrepairofcellswithrapidturnover–espmucosaandimmunesystem.
• Correc2onofzincdeficiencyleadstoafasterregenera2onofthegutepitheliumandincreasesthelevelsofenterocytebrush-borderenzymes
• Alsoan2oxidant• Zincabsorp2onisinhibitedbysomenon-diges2bleplantligands,suchascontainedincorn,cereals,rice,legumes,whichforminsolublecomplexeswithzincionsthatareexcretedinthestool.
• Theamountofproteinsisposi2velycorrelatedwithzincbioavailability.
• Someproteins,suchascaseininmilkandsoyprotein,havebeenreportedtohaveaninhibitoryeffectonzincabsorp2on
IgGAntibodies• Bovineorserumderived• Colostrumisthefirstnaturalfoodproducedbyfemalemammalsduringthefirst24–36hdirectlyaCergivingbirth.
• Chemically,colostrumisaverycomplexfluidrichinnutrients,an2bodiesandgrowthfactors.Incowsthean2bodiesprovidepassiveimmunitytothenewborncalf,whereasthegrowthfactorsespeciallys2mulatethegrowthofthegut.
• Theotheran2microbialcomponentsofcolostrumincludelactoferrin,lysozymeandlactoperoxidase.
• Bovinecolostrumhasalsobeenusedasarawmaterialforimmunonoglubulin-richcommercialproducts(immunemilkprepara2ons).
• Theseproductscanbegivenorallytopa2entswhoaresufferinginfec2onsofthegastrointes2altractorinordertopreventtheseinfec2ons.
• Severalanimalstudieshaveshownthatthegrowthfactorsinbovinecolostrum,especiallyinsulin-likegrowthfactors,s2mulatecellgrowthinthegut.
Stewagen,Ketal.Immunecomponentsofbovinecolostrumandmilk.JournalofAnimalScience[2009,87(13Suppl):3-9]Playforda,RJ.BovinecolostrumisahealthfoodsupplementwhichpreventsNSAIDinducedgutdamage.Gut1999;44:653-658.
Quercetin • Flavonoidinredwine,tea,onions,kale,tomatoes,broccoli,greenbeans,asparagus,apples,andberries
• An2-inflammatory• Mayinfluenceimmunesystemfunc2on
• Demonstratesac2vityagainstretroviruses,parainfluenza,andrespiratorysyncy2alviruses.
Dose:Typicaldietaryintakesarebetween5mgand40mg/day--250-500mg/daywithhighconsump2onoffruitsandvegetables,especiallyifea2ngpeel.Supplement250-500mg1-2xdaily.(Ques2onofnephrotoxicity>722mg/day)
Stoner,G,Wang,LS.(2013).NaturalProductsasAn2-inflammatoryAgents.InObesity,Inflamma2onandCancer(pp.341-361).SpringerNewYork.
Turmeric WhattheScienceSays§ NIH:posi2vestudiesforUC,Crohn’s,
rheumatoidd/o§ Invitroandanimalstudiesshowit
increasesphaseIIenzymesandinhibitsphaseICYP1A
§ An2oxidanteffects:DownregulatesCOX2,LOX,NFkB,AP-1,TNF
Safety§ Warfarininterac2on,bleedingriskat
highdosesDose(Adult)§ 1200-2400mg/dcurcuminforIBD§ India:averagedailyintake=60mg
curcumin(2.5gm/dofturmeric)§ 20mgblackpepper/1kgcurcumin->
approx2000%absorp2onincrease
ChandranB,GoelA.Arandomized,pilotstudytoassesstheefficacyandsafetyofcurcumininpa2entswithac2verheumatoidarthri2s.PhytotherRes2012;26:1719-25.TaylorRA,LeonardMC.Curcuminforinflammatoryboweldisease:areviewofhumanstudies.AlternMedRev.2011Jun;16(2):152-6.
Chamomile • Tradi2onallywidelyused• Evidencebasedusesincluded
• Anxiety/GAD• Colic(w/fennel,lemonbalm)• Pediatric“stomachaches”• Diarrhea(w/applepec2n)• Dyspepsia(inIberogast)• Oralmucosi2s
Dose:1mlTIDSafety• Maycauseallergicreac2oninsomeindividuals(rare).
McKayDL,BlumbergJB.Areviewofthebioac2vityandpoten2alhealthbenefitsofchamomiletea(Matricariarecu2taL.).PhytotherRes.2006Jul;20(7):519-30.RossSM.Generalizedanxietydisorder(GAD):efficacyofstandardizedMatricariarecu2ta(Germanchamomile)extractinthetreatmentofgeneralizedanxietydisorder.HolistNursPract.2013Nov-Dec;27(6):366-8.
Ginger WhattheScienceSays• Clinicalresearchshowsthattaking
gingerextractscanmodestlyimprovepaininsomepa2entswithosteoarthri2s
• Maybecomparabletoibuprofeninadoseof500mgtwicedaily
• Alsocomparedfavorablytodiclofenac+glucosaminesulfate
• Thereissomepreliminaryevidencethatgingermightbehelpfulfordecreasingjointpaininpa2entswithRA
Dose(Adult):250mggingerextractfour2mesdaily,dosingmayvaryaccordingtotheprepara2on
Licorice • Tradi2onaluses:cough,colds,sorethroat,GERD,gastri2s
• Compoundsinlicoriceincreaselocalprostaglandinlevelsthatpromotemucussecre2onandcellprolifera2oninthestomach
• Prepara2onswithoutglycyrrhizinarecalledDGL
Dose• 700-800mg(760mg)• ChewabletabletsSafety:AvoidinptswithHTN,hyperaldo,onsteroid.Likelysafeinhealthyadultswhenusedatdosesnotexceeding3grams/dforperiodsupto3-4weeks.
Sarah’sSupplements• Mul2vitamin• Proprietarylicoriceblendcontaininglicorice,ashwagandha,rehmannia,andwildyam.
• Chamomiletea• ProEFAJr-NordicNaturals,1,twicedaily• VitaminD3• Curcuminconcentratewithgingerandboswellia• L-Glutamine• Zinc• Probio2ccontainingLactobacillusandBifidostrains
Evaluation&Testing• Historyrevealsthecure• Diet&nutri2onreview• Diges2onevalua2on• (Known)toxicorinfec2ousexposures
• CBC,ironstudies,ANA,ESRLyme(WB)
• CeliacHLA,GlutenAbs• EFAtes2ng(omega3,6)• Leakygutvialactulose:mannitol
• Stooltes2ng• Detoxstudies
• CanconsiderIgGandIgMtes2ngthruspecialtylabs
SarahGetsHerLifeBack!• 8monthsnoneedforNSAIDs,methotrexatenolongerindicated
• Hashad1(prescheduled)jointinjec2on
• Perrheumatologist,only1joint(indexfinger)remainsslightlyswollencomparedto8jointsbeforestar2ngcare
• Abletorun,play,dancewithoutpain,justlikeotherkidsinfamily!
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