Dr. Amy Nett: Great questions. I think one thing that I would ask is like what are the RF levels? Is her rheumatoid factor really high? Are you able to track antibodies? A couple of years ago I definitely heard of LDN being used as a prokinetic agent. I’ve been seeing a little less enthusiasm for LDN as a prokinetic. I’m not sure how great it is, actually, for motility. Whether or not it’s working as a motility agent, yes, you would probably be tracking bowel movements, so does it increase regularity?
In terms of whether it’s helping the autoimmunity, I would probably track antibody levels or symptoms. So, you’re saying antibodies are high, not RF factor, though. So what antibodies does she have that are elevated? The other thing is does she have—you’re saying she doesn’t have pain. You’re kind of talking me out of using low-dose naltrexone because—how old is she? That’s the other question. In patients who are on the slightly younger side, and I would probably—I think as we get older, our idea of “younger” changes, but I would say someone 50s, maybe even into early 60s, I don’t know if you want to sort of commit them to low-dose naltrexone if she is doing well because you’ve just made a lot of improvements just in getting her off the opioid. I might give her a little more time.
What else are you doing in terms of anti-inflammatories? Do you have curcumin? Are you doing glutathione? Like what else is going in there in terms of managing the immune system? So, she’s 51 and culled CCP antibodies. So, 51 is kind of on the younger side to sort of commit her to a lifelong medication in the sense of when do you actually stop low-dose naltrexone? It’s not as entirely clear. If the CCP antibodies are high, you could certainly use those to track, but it’s not clear that she’s having any symptoms.
Are there any adverse effects? You mentioned the sleep issue. Normally, in some patients sleep will be disturbed because we say take low-dose naltrexone right before going to bed. Low-dose naltrexone upregulates or increases our endorphins, so if there is a sleep disruption, that probably means you’re at the correct dose. So if you’re at 1.5, that’s probably an okay dose, and you don’t necessarily want to go up on that dose. Then what you would do is you would move the low-dose naltrexone to a morning dose for about a week until the patient adjusted. Then you can move it back to before bedtime. That’s generally not a long-term adverse effect. Some people might have some digestive distress. I’ve heard that in a few patients, pretty rarely, but overall, it is pretty safe. The biggest disadvantage is cost and just chronically taking a medication with a question as to the utility. I would probably have a discussion with this patient, and I would want to get her input on it.
I would probably say, based on what you’ve told me, I don’t see a strong indication for low-dose naltrexone at this point. I don’t know if there is an advantage to bringing down autoantibodies for the sake of bringing down autoantibodies. If antibodies are elevated, that indicates that the immune system is out of balance. LDN may modulate the immune response, but if it’s not improving symptoms, or in this case if there aren’t really symptoms to improve, I don’t know if there is enough value to just bringing down those antibodies for the sake for that alone. I would be inclined to say, hey, you know, you’ve just made these huge changes. This is amazing. Your HPA axis is going to be recovering because we know that opioids suppress cortisol production. They affect our HPA axis. So I would be inclined to either say if you feel like, you know, you’re not quite where you want to be, we can use low-dose naltrexone as a bridge while your body is recovering and we’re getting you back on track. Try it for six months to a year, if it’s tolerated well. Then trying taking it out. Or you could say your body is still adjusting. You’re still recovering from this. Let’s see what you look like in three months, six months. If we don’t have you where we want you to be in about three to six months, then let’s bring in low-dose naltrexone. Again, I don’t know that it’s the best motility agent. Opioids, of course, are going to affect motility, right? That could have been what is causing the constipation. So, again, it might just take a little while for her body to recover. Maybe you could do something even like Iberogast if needed. If she’s going to the bathroom, hopefully at least once daily, make sure she is on magnesium glycinate too to help with the motility issue. I don’t know. I think you could go either way. My inclination would be she’s made huge improvements already. Just see how she keeps going. I wouldn’t necessarily bring it in yet. I don’t think there is a huge downside to bringing it in, but I don’t see a huge indication for it either, so not straightforward. I would have a discussion with her, get her input, and keep us posted. That’s awesome that she got off those.