ÖRNEK VAKALAR İLE KRONİK HASTALIKLARDA FT YAKLAŞIMI

Doç. Dr. Mehmet Mahir Atasoy

MALTEPE ÜNİVERSİTESİ TIP FAKÜLTESİ

Girişimsel Radyoloji & Meme Radyolojisi

Fonksiyonel Tıp Kliniği

17 K

• Aniden kişilik değişiklikleri

• Uykuda vahşet içeren konuşmalar

• Ciddi insomnia

• Psikiyatri ilaçlarına cevap vermiyor

• Romatolji, endokrin,nörolog vizitleri sonuçsuz

• Standart Lyme testleri +

• Ig M WB pozitif IgG negatif

• 2 hafta doksisiklin ile düzliyor.

• 1 ay iyi gidiyor

• Semptomlar tekrarlıyor.

• Doktoru tekrar antibiyotik vermek istemiyor

• Yalvararak tekrar antibiyotik alıyorlar.

• 1 ay Doxisiklin ile yine düzeliyor.

• 1 ay iyi gidiyor sonra yine tekrarlıyor semptomlar.

• Ailenin ısrarlarına rağmen antibiyotik verilmesi

istenmiyor.

• Sonra hikayeyi değerli bulan bir nörolog 3. kez

antibiyotik vermeyi kabul ediyor (1 aylık tedavi)

• Sonra Lyme ı bilen bir doktora gidiyorlar.

• Ko-infeksiyonlardan ve daha uzun tedavilerden

bahsediyor.

• Tekrar iyileşiyor.

• 9 aylık antibiyotik tedavisi

Ceftin, Doxy and Flagyl plus Mepron for Babesia found

on FISH.

3 ay iyi durumda ancak sonra semptomlar tekrarlıyor.

BİR YIL SONRA FTDOKTORUNA GELİYOR

• CBC, CMP, ESR, CRP, RA, ANA all normal

• CD57 <20, C4a 40,000 (<2800)

• Metabolic, nutritional and toxicology testing sent

• A repeat WB is now IgM Neg but has 41 Kd Band +, IgG shows 3 + Bands 31, 34, 41

• iSpot is negative BUT the positive control is low at 74 (Normal>400)

Multiple markers of:

• Malabsorption

• Bacterial Dysbiois

• Yeast Dysbiois

• Persistent Organic Pollutants in urine

• Toxic Elements in RBC (lead, Hg, Cd)

• Oxidative Stress (low GTX, high lipidperoxides, high 8-OH-DG)

• Mitochondrial dysfunction

GTX = glutathioneperoxidase

• Omega 3 Fatty Acids: low

• Candida serology IgG, IgA, IgM positive

• CMV, EBV (IgM and IgG) positive

• O+P Endolimax nana

• IHC Cult + at 16 weeks for Borrelia sp.

Patient: JANE DOE ID: D4280028 Page 10

Essential and Metabolic Fatty Acids Markers (RBCs)

Omega 3 Fatty Acids Omega 6 Fatty Acids

0.06 >= 0.09 wt % 10.2 10.5-16.9 wt%

1.74 >= 0.16 wt % 0.05 0.03-0.13 wt%

1.90 >= 1.14 wt % 0.73 >= 1.19 wt%

4.3 >= 2.1 wt % 16 15-21 wt %

8.0 >= 3.8 1.49 1.50-4.20 wt%

0.10 <= 0.26 wt%

Omega 9 Fatty Acids 29.0 30.5-39.7

13 10-13 wt %Monounsaturated Fats

4.3 2.1-3.5 wt %

17.5 13.3-16.6 0.23 <= 0.64 wt%

0.83 <= 1.13 wt%

Saturated Fatty Acids

0.19 <= 0.59 wt%

21 18-23 wt%

19 14-17 wt % Delta - 6 Desaturase ActivityUpregulated Functional Impaired

0.27 0.22-0.35 wt %14.0 6.0-12.3

0.91 0.92-1.68 wt %

0.25 0.12-0.18 wt %Cardiovascular Risk

2.5 2.1-3.8 wt%

0.15 0.07-0.15 wt % 3.6 3.4-10.7

0.38 0.22-0.37 wt % 9 12-125

44.3 39.8-43.6 6.0 >= 4.0

© Genova Diagnostics · A. L. Peace-Brewer, PhD, D(ABMLI), Lab Director · CLIA Lic. #34D0655571 · Medicare Lic. #34-8475

Omega 3 Fatty Acids Omega 6 Fatty Acids

0.06 >= 0.09 wt %

1 .74 >= 0.16

wt %

1.90 >= 1.14 wt %

4.3 >= 2.1 wt%

8.0 >= 3.8

10.2 10.5-16.9 wt

%

0.05 0.03-0.13 wt

%

0.73 >= 1.19 wt

%

16 15-21 wt %

1.49 1.50-4.20 wt

%

0.10 <= 0.26 wt

%

29.0 30.5-39.7

Cardiovascular Risk

Saturated Fatty Acids

Delta - 6 Desaturase Activity

Monounsaturated Fats

Omega 9 Fatty Acids

13 10-13 wt %

4.3 2.1-3.5 wt %

17.5 13.3-16.6 <= 0.64 wt %0.23

<= 1.13 wt %0. 83

0 . 19 <= 0.59 wt %

21 18-23 wt %

19 14-17 wt %

0.27 0.22-0.35 wt

%

0.91 0.92-1.68 wt

%

0.25 0.12-0.18 wt

%

2.5 2.1-3.8 wt %

0.15 0.07-0.15 wt

%

0.38 0.22-0.37 wt

%

44.3 39.8-43.6

1

4

.0 6.0-12.3

ESSENTİAL AND METABOLİC FATTY ACİDS

MARKERS (RBCS)

Upregulated Functional Impaired

3

.

6

3.4-10.7

9 12-125

6.0 >= 4.0

NORMAL İMMUN FONKSİONU OLAN BİR İNSAN DA LYME HAFİF GEÇER

• Gets the “Summer Flu” and gets over it• Gets sick, sees a Doc, and gets antibiotics…Why???• Gets sick, stays sick, gets a WB that is +, gets treated for 14 to30

days and is cured

Then there are our pts…

• What is different...• Antecedents: stress, SAD diet• Mediators: Detox, Immune dysregulation, heavy burden of

infectious agents, Stealth Pathology???WB = Western Blot

Increasingpathogen dominance

Increasingimmune system dominance

Tolerance/ Symbiosis

DysbiosisAllergy/

Atopy

Clinical Infection

Autoimmunity

IBS

Hepatitis C

Eczema

RA

İNFEKSİYONDANOTOİMMUNİTEYE

• Lyme: 3 mo and re-evaluate• Cetin 500 mg BID• Doxycycline 100 mg BID• Flagyl 500 mg BID

• Babesia: 1 mo• Mepron 700 mg BID• Zithromax 500 mg q day.

• Candida: 1 mo and re-evaluate• Ketaconizole 200 mg q day.

HERBALANTİBİOTİCS

Trial of…• Oregano 2 BID• Berberine 2 BID

Tolerated and continued

YAŞAM TARZI ÖNEMLİ

• Tekrar iyileştikten sonra bir süre herşey yolunda gitti. Ama üniversiteye başlayınca , diyet bozulmuş takviyeler bırakılmış ve BİNGO

• Semptomlar tekrarlıyor

• Candida diets have been around foryears.• Generally low simple carb diets

• Lyme may be diet-susceptible• BSK-H with 12% Rabbit serum and 100 mcg/dL

Dithiothreitol (DTT) is current best media (BSK-H has D-Glucose 5.64 G/dL)

KETOGENİCDİET

KETOGENİCDİET

• Dramatically alters the Microbiome

• Adapt physiology to burnketones• Anti-inflammatory• Anti-free radical• Anti-seizure• Reduces insulin resistance• ? Inhibits fastidious pathogengrowth?

KETOGENİCDİET

• Mary was placed on a Ketogenic diet

• Rapid reduction of yeast symptoms

• Improvement of• Energy• Muscle pain• Clarity of thinking

ANTİBİOTİKLER

Fonksiyonel Tıp

Eğitim ve Dönüşüm Şart!!

• Antibiotics are too toxic for her• Tolerated the FxMed items.

GI: 5RS

Remove• Elimination diet. Colostrum. Anti-Inflammatory Medical food.

Replace• Enzymes, Anti-Inflammatory Medical food,colostrum

Reinoculate• Probiotic 100 Billion CFU BID, Sac. b. 250 mg BID

Repair• Anti-Inflammatory Medical food. Extra Glutamine.Anti-

oxidants. Multivitamin.

Rebalance• Sleep, Stress Management

A General Program to Decrease Toxic Exposureand Improve Biotransformation Should:

Reduce Toxic Load: Minimize exposure• Organic diet, Non-Toxic products

Optimize Biotransformation: Balanced,effective, and supported Phase I and II detoxification• Medical food, Cruciferousvegetables

Increase Mobilization: of various storedtoxins• Hydration, Oil Change

Decrease Redistribution and IncreaseExcretion: Bowel health and the 5R program

•After 3 mo on treatment she was again asymptomatic. We stopped the antimicrobial herbs and continued other support.

•After 3 mo off antimicrobial support she was still mostly asymptomatic.

•But her CD-57 still < 20

•C4a rising (28,000) After fallingto 9,800.

•An immunohistochemical culture was done. Results + forBorrelia sp.

Sapi E, Pabbati N, Datar A, Davies EM, Rattelle A, Kuo BA. Improved culture conditions for the growth and detection of Borrelia from human serum. Int J Med Sci. 2013;10(4):362-76. doi:10.7150/ijms.5698.

•She was much stronger and doing well so we decided to re-try antibiotic

•She was tx with prior antibiotics for 9 mo.

•Continues other support

•CD-57 improved to 60.

•(Q 3 mo: 20,40,60)

•C4a falling into normal range (40,000to 2450)

•(Q 3 mo. 40K, 10K, 2450)

TEKRAR İYİLEŞTİ

• Normal CD-57 and C4a• Antibiotics stopped• iSpot negative with normal positive control• Continued low carb diet• Continued lifestyle and supplements

• IHC Culture negative• Q 3 mo CD-57 and C4a remainnormal• Asymptomatic for 5 years

5 YILDIR İYİ DURUMDA

LYME FT NİN KRONİK HASTALIKLARINA YAKLAŞIMINDA İYİ BİR MODEL

• Total allostatic load

• Assimilation (GI Module)• Defense and Repair (Immune Module)• Energy (Energy Module)• Biotransformation (Detox Module)

• Transport (CM Module)• Communication (Hormone Module)• Structural integrity• Psycho-Social-Spiritual support (ANS +)

• Modifiable life style factors…

• All of the above - in that order!!

• Cycle anti-microbial treatment 6 weeks on and 2 weeks off. Expect Herx to reduce with each cycle.

• If not, consider adjustment or return to step 1.

• Add Stevia 15 drops BID

• Add Oregano Supplement• 110 mg of the Carvacrol component

• Add Colloidal silver 1 oz per day.

• Add Antibiotic (Biaxin summer, Doxy winter)

TEDAVİ SÜRECİ

enicide Mlanoitcnu Fro fetutits Ineh T7102©

ALERJİ TOKSİK YÜKÜN BİR BULGUSUDUR

Select associated toxins• Mercury• PCBs• DDT/DDE• Chlorinated pesticides• Chlorinated water

• Organophosphates• Volatile solvents• BPA & triclosan• Phthalates, parabens

Interaction effects on allergic sensitization were indicated between several GSTP1SNPs and traffic NOx exposure during the first year of life (p < 0.001–0.06).

Children with GSTP1 SNP were at increased risk of sensitization to any allergenwhen exposed to elevated levels of traffic NOx (for a difference between the 5th and 95th

percentile of exposure: odds ratio = 2.4).

MacIntyre EA, et al. 2014. GSTP1 and TNF gene variants and associations between air pollution and incident childhood asthma: the traffic, asthma and genetics (TAG) Study. Environ Health Perspect 122:418–424; http://dx.doi.org/10.1289/ehp.1307459

https://www.niaid.nih.gov/sites/default/files/peanut-allergy-prevention-guidelines-clinician-summary.pdf

EARLY İNTRODUCTİON OF PEANUT-CONTAİNİNG FOODS TO İNFANTS AT HİGH RİSK OF DEVELOPİNG PEANUT ALLERGY WAS SAFE AND LED TO AN 81 PERCENTRELATİVE REDUCTİON İN THE SUBSEQUENT DEVELOPMENT OF PEANUT ALLERGY. (2015 LEAPSTUDY)

http://pregnancy.thesfile.com/prenatalexperience/epigeneticsJournal of Allergy and Clinical Immunology Volume 121,Issue 2, Supplement 2, February 2008,Pages S384-S387; Chest 127 (2005), pp. 1232–1241.

Li et al. found an increased risk (odds ratio 2.1) of an unexposed child having asthma if the grandmother smoked during the mother's pregnancy

www.nationaljewish.org/professionals/research/programs-depts/CGEH/figure/epigenetics-2

Swamy RS, et al. Epigenetic modifications and improved regulatory T-cell function in subjects undergoing dual sublingual immunotherapy. J Allergy Clin Immunol. 2012 Jul;130(1):215-24.e7. doi: 10.1016/j.jaci.2012.04.021. Erratum in: J Allergy Clin Immunol. 2012 Nov;130(5):1224.

“LONG TERM TOLERANCE ACHİEVED BY SLIT MİGHT BEİNDUCED BY EPİGENETİC MODİFİCATİONOF FOXP3 İN TREG CELLS.”

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• Toxins

• Hygiene

– Vaccines, antimicrobials, etc

• Cesarean sections

• Lowered rates of breast feeding

• Medications: NSAIDs, acidblockers

• Pro-inflammatory foods & GMO

• Stressful lifestyle

• Epigenetics/Genetics

ALLERGY ANTECEDENTS, TRİGGERS AND MEDİATORS

ALLERGİC DİSEASE

5 patients from my practice:

• 4 adult women (40’s and 50’s)

• 1 male child (5)

• Presenting with:• Eosinophilic esophagitis• Allergic sinusitis and asthma• Atopic disease x 2 (rhinitis, eczema,asthma)• Contact dermatitis

MOST PEOPLE WİTH ALLERGİES HAVE:

• Leaky gut

• Food sensitivities (IgG)

• Bacterial and fungal dysbiosis (antibiotics and steroids)

• Nutrient deficiencies (vitamin D, magnesium, zinc, B12/B vitamins)

• High stress

• Some toxin exposures

• (Many have inhalant allergies, too)

Therefore, most will respond well to 5R approach

45 Y KDİZ AĞRISI VE MEVSİMSEL ALERJİLER

• Yorgunluk

• İnsomnia

• PMS

• IR kilo verememe

• Stres yüksek

• Ciddi alerjiler oluyor mevsimsel

• Mevsimsel anozmi

• Sinüzit

Over the course of three months:

• 5R Protocol

• Guidelines for clean eating/living

• Identified & removed problem foods, lowered CHO (gluten, dairy, soy)

• GI botanical combo product: 2 caps BID

• HCL to titration

• Probiotic blend: 100Bill CFU/day

• Glutamine, Zinc Carnosine, DGL: 2Tsp QD

• EPA/DHA: 3 grams QD

• Vitamin D: 4000IU QD

3 AY SONRA TÜM ŞİKAYETLERDE İYİLEŞME OLMUŞ.

Over the course of three months

• B Complex: 2 capsQD• Magnesium glycinate: 600mg/day• DHEA: 20mg/day• Progesterone: 16-32mg QHS days 14-28• Cortef: 2.5mg QAM and atnoon

• (Turned down quercetin/nettles/C)

8 Y E ATOPİK DERMATİT

İNTESTİNAL PERMEABİLİTE

A BASİC 5RPROTOCOL

• Remove +2 and greater x 12 weeks• Nutrient depletion severe, long-term restriction

• Probiotic blend: 20bill CFU

• Bovine Immunoglobulin w/glutamine: 1 scoop/ day

• Zinc citrate 10mg/day

• Flax oil (providing alphalinolenic)

• Evening Primrose oil (providing gammalinolenic)

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PROBİOTİCS TO REDUCE SCORADINDEX

Administration of 109 cfu of specific probiotic strainsfor 12-weeks reduced SCORAD index and use of topical steroids in patients with moderate AD.

Navarro-López, V., et al. (2017). Effect of Oral Administration of a Mixture of Probiotic Strains on SCORAD Index and Use of Topical Steroids in Young Patients With Moderate Atopic Dermatitis. JAMA Dermatology. http://dx.doi.org/10.1001/jamadermatol.2017.3647

Bifidobacterium lactis CECT 8145, B longum CECT 7347, and Lactobacillus casei CECT 9104

Takip testi

21 Y E KRONİK BAŞAĞRISI VE SİNÜZİT

Basic 5R:

• Identify and remove problem foods

• Environmental allergytesting

• Probiotic blend: 100bill CFU/day

• Omega 3 fatty acids 3 grams/day

• Magnesium glycinate: 300 mg/bid

• Glutamine, zinc carnosine, DGL: 2 scoops/day

• Vit D 2000IU/drop: 3 gtts/day

• Digestive enzymes w/ HCL: 2 with meals

EV AKARI ALERJİSİ

TOZ MİTE PROTOKOLÜ

• Symptom diary - notice different buildings, outside, inside, time of day, foods, drinks,etc…

• SLIT – dust mites

• Saline nasal spray or neti pot daily

• Cover bedding in dustmite proof encasements

• HEPA filter in bedroom

• Remove bedroom carpet

TOZ MİTE PROTOKOLÜ

• Keep windows open as often as possible

• Wash bedding in HOT water.>160F every 1-2 weeks

• Vacuum or mop floors weekly(Better: have cleaner dust, vacuum, mop)

• Dust with damp cloth

• Minimize upholstered furniture (especially in bedroom)

NASAL IRRİGATİONPROTOCOL

• Berberine - Add contents of 1-2 caps to saline 1-3 times per day

• Liquid allicilin concentrate: 5-10 gtts added to saline BID (may be irritating)

Consider

• Intranasal ketoconazole 1-2% with 3% xylitol - 1 puff each nostril BID (compounded Rx)

• Intranasal glutathione 200mg/mL: 1-2 sprays each nostril twice per day.

Bleier, B. Nasal/Sinus Irrigation. American Rhinologic Society. http://care.american-rhinologic.org/irrigation. Accessed January 25, 2017.

✓Distilled, sterile or boiled/cooled (3 min) water✓½ tsp un-iodized salt per 8 ounces H20✓ 1/8 tsp of baking soda

Helms S, MillerA. Natural treatment of chronic rhinosinusitis. Altern Med Rev. 2006 Sep;11(3):196-207.

63 Y KPOLİMİYALJİA ROMATİKA VE EL EGZAMASI

• Presents with severe neck, R/L shoulder, R/L knee MSK pain (7-10/10) onset 1.5 years ago

• Difficulty w/ morning ADLs “feels 95 years old”

• RX: Oral steroids effective short term only; low-dose naltrexone & Plaquenil ineffective

• Severe atopic dermatitis (hands and nails)- lifetime condition, regular topical steroids• Worsens w/ dander, water exposure• FMH: allergic/atopic disease

Trachyonychia

POLİMİYALJİA ROMATİKATEDAVİSİ

• IFM Elimination diet x 6 weeks total

• AI/GI medical food: use through elimination

• 100 bill CFU probiotic blend

• Antimicrobial botanical combination 2 caps tid x 6wks

• HCL with enzymes: 2 tabs before meals

• Psyllium PRN constipation (at least 1 BM/day)

• EPA/DHA: 4 grams/day; GLA: 500mg/day

• Vitamin A: 10,000 IU/day; Vitamin D: 2000IU/day

• DHEA: 25mg/day

• Essential mineral formula & B complex – high dose

• Trialed various anti-inflammatory botanical and enzymecombinations

• Week 2: No significant change noted• Week 4: Mild reduction in pain• Week 6: Pain resolved completely (0/10)

• Dermatitis – temporary improvement, then returned during reintroduction of foods- but pt notes relapsing/remitting pattern long term

• Treatment for dermatitis:• GLA 1500mg/d• A: 50,000IU x 1 month• D: 10,000IU x 1 month• Zinc: 50mg/day x 1month• Continue Omega 3

“This is what happened since I stopped the cortisone cream…the itching has been horrendous as

has the discomfort. There is also swelling. I can't even get my ring off my finger. This just is not

working despite doing the treatment plan. I will see my rheumatologist in another week & have

decided to go with the methothrexate. At this point the body pain is gone but the dermatology

pain & itching is more than I can tolerate.”

•Atopic dermatitis in US: 12 billion dollars annually

•Rx: steroid topicals DOC- but permeability in 2-3 days, ensuring rebound

•Refractory AD: tacrolimus, MTX

• >50% of US and Europe are allergic to 1+ antigens

• >40% in US with atopic disease

1. Dermatitis A. Atopic Dermatitis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 2018. Available at: https://www.niams.nih.gov/health-topics/atopic-dermatitis. Accessed January 5, 2018.2. Janeway CA Jr, Travers P, Walport M, et al. Immunobiology: The Immune System in Health and Disease. 5thedition. New York: Garland Science; 2001. Available from:

FİLAGGRİN AND BARRİERFUNCTİON

• Key barrier protein of the epidermis; forms NMF (natural moisturizing factor)

• 37 mutations identified, 14 common (10%Europeans)

• Null mutation extremely strong risk factor (>50%) for severe AD (especially

hand eczema)

• FLG mutation positively associated with atopicmarch

• allergic rhinitis

• asthma

• allergic sensitization

• FLG testing is available1. Marenholz I, Nickel R, Rüschendorf F, Schulz F, Esparza-Gordillo J, Kerscher T, Grüber C, Lau S, Worm M, Keil T, Kurek M, Zaluga E, Wahn U, Lee YA. Filaggrin loss-of-function mutations predispose to phenotypes involved in the

atopic march. J Allergy Clin Immunol. 2006 Oct;118(4):866-71.2. Swindle EJ, Collins JE, Davies DE. Breakdown in epithelial barrier function in patients with asthma:identification of novel therapeutic approaches. J Allergy Clin Immunol. 2009 Jul;124(1):23-34; quiz 35-6. doi:

10.1016/j.jaci.2009.05.037.3. De BenedettoA, Qualia CM, BaroodyFM, Beck LA. Filaggrin expression in oral,nasal, and esophageal mucosa. J Invest Dermatol. 2008 Jun;128(6):1594-7. doi:10.1038/sj.jid.5701208.

• Dilute bleach hand soaks• 1tbs in 2 gallons H20• Antimicrobial, mice: inhibits NFkB, anti-inflammatory

• Ceramide prescription topical

• Ceramide/probiotic wraps at night

• Taper off steroids very slowly (contributing to barrier permeability)

1. Leung TH, Zhang LF, Wang J, Ning S, Knox SJ, Kim SK. Topical hypochlorite ameliorates NF-κB-mediated skin diseases in mice. J Clin Invest. 2013 Dec;123(12):5361-70. doi: 10.1172/JCI70895.2. McLean WH, Hull PR. Breach delivery: increased solute uptake points to a defective skin barrier in atopic dermatitis. J Invest Dermatol. 2007 Jan;127(1):8-10.

Ceramides: most abundant fatty acid in stratum corneum.

Negatively influenced by nullFLG.

ACETAMİNOPHEN ANDASTHMA

• One dose of acetaminophen reduces glutathione

• Glutathione depletion may promote asthma

McBride, J. (2011). The Association of Acetaminophen and Asthma Prevalence and Severity. PEDIATRICS, 128(6), pp.1181-1185.

ARE FİSH OİL SUPPLEMENTS SAFE

İN FİNNED FİSH- ALLERGİC

PATİENTS?

Mark BJ, Beaty AD, Slavin RG.

Source

Section of Allergy and Clinical Immunology, Division of Immunobiology, Department of Internal

Medicine, Saint Louis University School of Medicine, St. Louis, Missouri 63104, USA.

Abstract

Fish oil supplements are popular alternative medicines. Many manufacturers label their products

with the warning "avoid this product if you are allergic to fish." The objective of this study was to

determine if finned fish (FF)-allergic patients could safely tolerate fish oil supplements. Six FF-

sensitive subjects as determined by history and skin testing were selected. They were skin tested

with two different fish oil supplements and given an oral challenge of each supplement 1 hour

apart. Vital signs were measured at baseline and at 20-minute intervals after each challenge.

In one small trial, finned fish-allergic patientshad negative skin tests to two fish oil supplements.

All had negative oral challenges to fish oil supplements.Spirometry was measured at baseline and 1 hour after each challenge. Six of six patients with

positive skin tests to at least one FF had negative skin tests to both fish oil supplements. All six

subjects then had negative oral challenges to both supplements. In this pilot study, FF-sensitive

patients tolerated fish oilsupplements

Mark, B., Beaty, A. and Slavin, R. (2008). Are fish oil supplements safe in finned fish–allergic patients?. Allergy and Asthma Proceedings, 29(5),pp.528-529.

REPLACE:SELECT BOTANİCALS FOR

ALLERGY AND ATOPY• Quercetin: 0.5-3 grams/day divided

• Stinging Nettles Leaf powder: 0.5-3 g/day, divided

• Bromelain: 2-3 grams/day divided (away from food)

• Butterbur (pyrrolizidine-free) extract: standardized to at least 8mg Petasin. BID to QID/day (asthma and/or allergic rhinitis)

• Saline nasal irrigation (neti pot or irrigation system)- may add drop(s) of berberine (powder), or tea tree oil 1-2gtts

• Boswellia (5LOX inhib-asthma): 300mg TID; 1-2g/d

First Second Third

• CBC with manual diff• CMP

• ESR, hs-CRP• Insulin• Vitamins D

• RBC Zn, Mg, Se• IgG food panel• IgE foods,

environmental including molds/fungi (location specific)

• IgA and IgG celiac panel,genes

• Stool testing•Organic acids panel (includes B12, folate, B

complex assessment; D- lactate, oxidativestress)

• Metals• Thyroid panel (with abs)• Adrenal Stress test

• Iron panel

• ANA• DHEA

• Estrogens/progesterone• MTHFR, Homocysteine• *Histamine and tryptase•(*consider whole blood histamine)

• *Zonulin•*Diamine oxidase (DAO)

•*24 hour urine N-

methyl histamine

• *24 hour urine Leukotriene

E4 (LTE4)•*24 hour urine 2,3-dinor 11 beta-prostaglandin F2alpha

•*consider for mast cell disorderswork-up.Bestto collect specimen within 4 hour window of symptomology

• Genetic testing:• Filaggrin• Immune/inflammatio

n SNPs/panel orindividual

• General

detoxification

panel

Other

• Fatty acids• Vit A, beta carotene• Cytokine testing

• Lactulose:mannitol• IG class, subclass testing

• Dermal or nasal swab• Dermal biopsy or scrap• Skin Prick or patch testing• Organotoxin testing

(BPA, pthalates, parabens, etc)

• Mycotoxins

CASE MANAGEMENT OF AUTOİMMUNEDİSEASE

ROBERT ROUNTREE, MD

Immune Advanced Practice ModuleAtlanta, GAFebruary 2018

Meds & supplements

• Colchicine: 0.6 mg bid/tid• Duloxetine: 40 mg: definitely helps

stabilize mood, decreases anxiety

• Licorice root +/- Cortef, 5-10 mg prn in am: definitely helps energy

• DHEA, 75 mg + pregnenolone 30 mg:helps overall symptoms

• Coenzyme Q10: 50 mg

• Fish oil: 3 grams qd

• Vitamin D3: 5000 IU

• Probiotic: 100 CFUs qd

• L-glutamine: 5 grams qd• Oral bovine immunoglobulin

concentrate: 5 grams

• Lumbricus extract (with Atractyloides, Poria, Grass-Leaf Sweetflag root), 3 caps bid: “definitely helps with GI symptoms)

FMF

PLoS Med, 2006,Vol 3(8): 1242-1248

• GLA: 900 mg daily• EPA-DHA: 1500 mg• Quercitin: 1 gm tid

• Ginger extract: 2 caps daily• L-glutamine to 10 grams qd• Multivitamin/mineral

• Flax seed: 1/4 cup (ground)

• Lactobacillus rhamnosus GG: 2 caps qd

• Bovine colostrum: 6 caps daily

• DHEA: 25 mg

• Squalane oil (shark liver source): topical

CASE#4:

CHRONIC DERMATITIS & ARTHRALGIAS CLINICAL COURSE

Rx: Strict gluten-free diet, expanded to avoid corn, soy, dairy, yeast

CASE#4:

CHRONIC DERMATITIS & ARTHRALGIAS CLINICAL COURSE

• Continued aching in DIP's, which was not impacted by the dietary changes. No morning stiffness, but the pain & swelling became more chronic. Quercitin & ginger extracts seemed to alleviate the pain but never eliminated it completely. The physical changes were subtle at first, but eventually she did develop mild palpable hypertrophy of the DIP's, primarily of the 4th digits.

• By July, 1999, her skin "almost normal," however, became aware thatexposure to chemicals, such as perfume, would make her feel itchy allover, especially face.

• Fish oil: 2 tsp qd = 2000 mg EPA + 1500mg DHA

• Vitamin D drops: 4000 IU qd (summer); 6000 IU qd (winter)

• Vitamin K2 (MK4 liquid): 20 mg qd

• Calcium: microcrystalline hydroxyapatite & citrate: 1200 mg

• Magnesium: 400 mg

• Glucosamine sulfate: 750 bid

• Organic silica (choline-stabilized orthosilicic acid): 10 mg qd

• Green tea powdered concentrate: 2packets qd (=10 cups)

• DHEA: 25 mg

• Sulforaphane glucosinolate: 100 mg qd

• Probiotic: 100 billion CFUs (mixture Lactobacilli & Bifidobacteria)

CASE#4:

CHRONIC DERMATITIS & ARTHRALGIAS 12 YEAR FOLLOW UP (2010)

On-going regimen:

AUTOİMMUNEDİSEASE:PROMISING TREATMENT OPTIONS

• Vitamin D: titrated to blood level of 60-90 ng/mL

• Essential Fatty acids (EPA/DHA; GLA): 2-6 grams qd

• DHEA high dose = 100-200 mg qd

• Fecal microbiota transplants [IBD, MS]

• Phytochemicals:• Sulforaphane (as glucoraphanin): 100-200 mg

qd of 10% extract

• DIM: 150 mg bid

• Resveratrol: 50-200 mg qd

• fermented wheat germ extract: 1 sachet qd

• Cordyceps sinensis extract: 1 gm bid to tid [SLE nephritis]

• Naltrexone – low dose (4.5 mg) hs [Crohn’s, thyroiditis]

• Tranilast (mast cell inhibitor): 300 mg bid to tid [MS, RA, IBD]

• Triptolide (Thunderduke Vine-- léi gōng téng): 200-400 mg qd of a 20:1 peeled root extract [RA, SLE]

Wang X, Zu Y, Huang L, Yu J, Zhao H, Wen C, Chen Z, Xu Z. Treatment of rheumatoid arthritis with combination of methotrexate and Tripterygium wilfordii: A meta-analysis. Life Sci. 2017 Feb 15;171:45-50. doi: 10.1016

Scientific American Volume 312, Issue 3. Scientific American. 2015. Available at: http://www.scientificamerican.com/magazine/sa/2015/03-01/. Accessed January 15, 2018.

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