Medicine has become much too narrow-minded in many of its protocols. Medicine is a science. But it is also an art and in many incidences in the clinical setting I see that physicians do not utilize this creative force to rethink and reimagine how we can better help our patients. This is particularly the case in the modality of using substances as medicine. Somewhere along the way, the pill culture mindset became ingrained in the U.S. Each patient gets the same dosage range of medications with no deviation from the norm. The doses of medications are determined by lots of careful scientific studies to produce efficacy and safety for the largest amount of the population that is being studied.
In daily practice, physicians who understand that medicine is also a practice in creative thinking see that medication management might need to look a little different than what is standard. One of my favorite mentors was a progressive MD who treated patients with mystery illnesses and cancer (yet another mystery illness in the modern medical care system). I studied with him in my last year of medical school and he would write his prescriptions for patients one way but then tell them something different. “Do not take it the way I have written it”, he would say, “Take your medicine the way I have it in your notes.” He would then hand them the paper prescription on which was written the standard of care recipe-book prescription that they could take to the pharmacy and he would give them the way he wanted them to take it in their patient summary.
I have learned that in order to really help my patients benefit I have to improvise and go with not what the medical literature always tells me about how to dose a certain medication, but with how my patients present, where their symptoms are, and how sensitive they may be to medication. The flaw in following a recipe book for medications is that it does not take into account much about the individual makeup of the patient. Patients can have genetic SNPs (deviations) that may affect how they can detoxify a medication. This can affect how quickly or slowly their individual genetic makeup can metabolize a medication. Some medications may need a higher dose to be therapeutic for them, or it can mean that they cannot detoxify it very well at all it and their body may treat it as a poison.
Medication dose ranges also do not take into account our accumulated lifetime toxic burden of environmental contaminants and infections, which can greatly affect our processing of any external inputs to our system (medications, stress, new diets). So if we are already on toxic overload (which many of you are who come to see me), then even if we give you medications that may be good for you, your body will not be able to tolerate them at the typical dose prescribed. This is unfortunately where I have seen many patients give up on medications that may be helpful AND where I have seen many providers give up on the patients where they prescribed a medication that is highly indicated for their condition but which the patient cannot tolerate. They have what we call a paradoxical reaction and providers do not always understand how to move beyond that to help their patient.
Many of my patients already know that they cannot ever take the same amount of medication their doctor prescribes and they automatically take ½ or ¼ of the medication dose given to start with, even if not instructed by their provider. Many of my patients have also had enough issues with adverse effects of medications that they do not feel comfortable taking the first dose of anything without having someone there to help monitor them or assist them if they have an anaphylactic response or if they get a worsening of symptoms - someone who can provide them care for a time while they recover from introducing a new substance to their body.
Often times I have patients come to me on really amazing protocols from other providers, but because they did not know some of the guidelines (which I will describe below) their treatments failed. I do not always do anything radically different from other providers who treat patients with mystery illness. But I think learning how to approach medications with a certain fluidity to match the patient’s reactions is often times the key to starting and maintaining a successful treatment protocol.
I have some rules of thumb that I have my patients follow. If you have already been working with me this might be a refresher, and for those of you who are not currently working with me, this might be information that you can apply to the current treatment protocol you have with your other providers to help make it more successful.
Medication Dosing Strategies:
The Poison is in the Dose. Try a new medication with a fraction of the dose to make sure your body can tolerate it. Then you can work the dose up to what your provider may want you to take. If you are very sensitive you might not need to get up to the dose your provider prescribes. For certain medications, it is important to work up to the appropriate dose, such as with blood pressure-lowering medications, anti-depressant, and anti-epileptic medications to help control your body symptoms. For some medications, my more sensitive patients have realized that they do not need to take the full dose to get the same effect. Early on in my practice, I recall that many of my patients only needed to take a drop of an herbal tincture to have the same effect whereas other patients would need the standard dose of two teaspoons four times a day.
I have also had patients begin medications and have a huge response such as vomiting or pain and cramping. These are medications for which these adverse effects are atypical, so when this happens I ask that they try taking a fraction of the dose only once, then wait a few days to see if they still have the same response. Sometimes getting onto a medication needs to be less a plunge into the deep end but more of a slow careful slide into a hot tub. I think sometimes our immune nervous system interface needs an introduction first to a substance, and then it can slowly become accustomed to it before we can increase the dose to receive a therapeutic effect.
The Rule of Threes: At times, introducing a new medication to our systems will not always provoke an immediate negative response. I have noticed that many patients can take a new substance for two or three days and then they get a negative response. This almost always happens right at that 72-hour mark. So when I prescribe a new medication I will have a more sensitive patient take one dose, then wait 72 hours, then take another dose, wait 48 hours, then take another dose again and wait 24 hours. Then they can begin to take the medication every day and if the medication is something they need to take more than once a day they can begin to work towards that. This method has worked often when someone has responded poorly to a medication prior and I am recommending it again.
I also have patients introduce one medication at a time in this same manner. I ask that they wait at least three days (or more) after they start one medication before they start a second one, especially if they are very sensitive. I want to make sure they do not have a poor reaction to something. I also want to be clear about which medication their body doesn’t take kindly to. Otherwise, we need to begin the whole process again.
Excipient Troubles: An excipient is a substance that is blended in with the active ingredient of a medication. There are virtually no medications, nutritional, or herbal products on the market today without an excipient in them unless you are able to purchase something in a bulk powdered or liquid form. Capsules may have silica or another desiccating (drying) compound added to help prevent the powder from caking together. They can also have artificial colorings and other chemicals that many patients respond poorly to. A patient can be reacting to something that is mixed in with the medication rather than to the medication itself.
The medication database that I refer my patients to in order to look up prescription medication excipients is the following:
https://dailymed.nlm.nih.gov/dailymed/
We do not have anything in the nutraceutical world that is as comprehensive as this database so you just have to look at each individual bottle you are taking to see what the “other” or “inactive” ingredients are. I have had many patients realize that even in the supplement industry there are many excipients being used that they simply cannot tolerate.
Excipients or “fillers” are also used in compounding pharmacies, as they need to fill the capsules completely before they are allowed to sell them to a patient. The nice thing about compounding is that they often times have different options of fillers available for patients to choose from. Many of my patients react poorly to one of the most common fillers used in compounding pharmacies, which is called microcrystalline cellulose. This is derived from plants and thought of as an “inert” or “non-reactive” substance. I have had enough of my patients react to it now that I always request other fillers to be used or try to find a way to compound without the use of fillers. Although it is only a tiny amount of filler that is placed in a capsule with your medication, this can make a huge difference for many patients. When you already have a toxic burden or if you have any issues with detoxification then this can really add up quickly and you can have a poor reaction.
I hope that if you are reading this and know that you react to lots of medications and supplements that this may provide you with some tools to rethink how you approach beginning to take medications that might be helpful for you.
Disclaimer: This blog post is in no way meant to replace the educated guidance of a physician. Please consult with your provider before making any dosing changes to your medications. My intentions with these guidelines are to help patients who might find that they are unable to taking lifesaving medications effectively to help them heal. Dosing for many medications does need to be at a certain level in order to be effective and I recommend that you work with your provider to make sure that you are able to get to the dose necessary in order to have the medication work effectively. Some examples of medications where a dose needs to be at a certain level to be effective are birth control pills, anti-seizure medications, hypertension medications, blood thinning medications and psychiatric medications.