Book Notes for Pain Free 1-2-3
In this section:
In most cases, the sensation of pain is generated in nerve fibers in the skin or joints. It is then sent to the spine, and from there to the brain. In the brain, the pain signal is either ignored, modified, or amplified. The pain signal can be disrupted or modified anywhere along this pathway.
There are an immense number of receptors along this route, and researchers are finding more all the time. To list and discuss them all would be a mind-numbing adventure that is not necessary for you to understand to make your pain go away. But, for those who are interested, I will mention a few of the key ones.
The key receptors in the central nervous system (brain) for moderating pain are the NMDA (N-Methyl-D-aspartate) receptors. These receptors can be stimulated by glutamate, which is one reason why some people are so sensitive to the MSG (mono sodium Glutamate) in Chinese or other foods. When these receptors are stimulated, pain is increased. Other chemicals then become involved. These include substance P (a major chemical that transmits pain), alpha agonists (enhancers included in medications such as Clonidine® and Zanaflex®), and antagonists (blockers such as minipress), and GABA (gamma-amino butyric acid), which settles down the pain signal. For all of these to work, we need adequate minerals such as calcium, magnesium, potassium, and sodium, which travel through channels. Modifying these channels can also impact pain. Different medications impact a different mix of receptors. One is more likely to see an effect by trying or combining medicines that work on different parts of the system, than by combining two medicines with the same type of action.
For example, the anti-seizure medicine Neurontin® (which also blocks glutamate) and the calcium channel blocker Procardia® can both be effective for nerve pain. Both suppress NMDA reactivity by different mechanisms, thereby muting the pain signal. Catapres®, which is a calcium channel blocker, stimulates alpha receptors and blocks the release of norepinephrine. In cases where adrenaline is stimulating pain, this can settle down the discomfort. Like most medications, however, it has multiple actions. Catapres also enhances the opioid (narcotic) receptors, decreasing substance P, which also decreases pain. Blocking the calcium channels also relaxes the blood vessels and gets more blood flowing into the tissues, which is another way that pain is decreased. Although both Catapres and Procardia are calcium channel blockers, only the Catapres also stimulates the opioid receptors.
Zanaflex® is an alpha stimulator that also relaxes muscles. In addition, it decreases reflex activity within the spine, reducing the release of glutamate and substance P and thereby decreasing NMDA activity. Lidocaine® and Novocaine® are anesthetics that work topically by blocking sodium channel activity.
These are just a few examples of how different medications can be combined, taking advantage of their different effects. It’s really not necessary to understand or follow any thing in this section, except to remember that it can help to combine medications that work by different mechanisms. It is not a clear-cut issue however, as most medications work through a number of different mechanisms—many of which we may not even be aware of.
Families of NSAIDs:
1. Propionic—includes ibuprofen (Motrin® and Advil®), naproxen (Naprosyn® and Aleve®), Oxaprozin® (Daypro®), and ketoprofen
2. Acetic—includes diclofenac (Voltaren®), indomethacin (Indocin®), Tolmetin®, and Sulindac® (Clinoral®)
3. Salicylic (carboxylic)—includes aspirin and diflunisal (Dolobid®)
4. Anthranilic (enolic)—piroxicam (Feldene®)
5. Pyrrolopyrroles—etodolac and Ketorolac® (Toradol®)
For example, you may not respond to ibuprofen, but may respond well to Voltaren®. The important thing is that if you try ibuprofen, don’t try naproxen next because you’re just adding a chemically similar agent. If you use one type of NSAID and it does not work, change to another family altogether if you’re going to try another NSAID. This applies not just to effectiveness, but also to tolerability.
1. Although Topamax acts as a GABA agent, it has other effects that contribute, sometimes dramatically, to its effectiveness. These include being a sodium channel blocker. Begin with 25 to 50 mg daily and increase it by 25 to 50 mg a week until you get the desired effect. This medication is usually given twice a day at a total daily dose of 50 to 100 mg per day for migraines and 200 to 300 mg a day for nerve pain, although lower doses can be effective. If you get side effects, decrease the dose and perhaps later increase it more slowly until you get the desired effect. The most common side effects are diarrhea (11 percent), loss of appetite (11 percent ), sedation (10 percent ), and nausea (10 percent ). The side effects often go away after 2 to 3 months. Along with pain relief, it also has the benefit of causing weight loss. Besides sedation, its most worrisome, albeit unusual, side effect is that it can make your body very acidic—to the point where it is dangerous. Because of this, it is reasonable to check a blood bicarbonate level every so often (especially if you start developing symptoms such as fatigue) and make sure that the level is over 17.
A number of reports on the use of oral Ketamine can be found in the medical literature. One patient with severe post herpetic neuralgia, who did not respond to conventional treatments, improved dramatically with oral Ketamine, 200 mg, 5 times a day.25 In a placebo-controlled study of eight patients with severe long-standing neuropathic pain who had responded to IV Ketamine, oral Ketamine was also used (1/2 mg per kg body weight each 6 hours). Pain relief began 15 minutes after a dose, lasted for 6 to 8 hours, and was much more effective than placebo.26
1. Dextromethorphan has also been shown to be helpful for post herpetic neuralgia.29 Only a small percent of fibromyalgia patients (less than 18 percent), however, received significant benefit from the dextromethorphan (a 51 percent decrease in pain at an average dose of 50 mg, 3 times a day). For most patients, the side effects—dizziness, mental fog, nausea, and fatigue—at these doses are prohibitive. But if you have persistent pain, Dextromethorphan is worth trying by starting at 50 mg a day and slowly increasing the dose as tolerated.30 Although this medication is over-the-counter, it is usually found mixed with other medications. It can be obtained in pure form from compounding pharmacists.
1. Check Dilantin blood levels to make sure they do not go too high.
Dilantin can also cause birth defects if one gets pregnant while taking it. Otherwise, its main side effects include dizziness, sedation, and nausea. It can also cause unwanted hair growth (sometimes on the ears in females) and overgrowth of gum tissue. The latter side effect can actually be beneficial in those who have receding gums. Dilantin can be given as a topical cream applied to the gums for this purpose.
Begin the Tegretol at 100 mg, 3 times a day and increase the dose to 200 mg 3 times a day after 1 week. If no benefit is seen at 1200 mg a day for 1 month, the patient should be weaned off the medication. Check a baseline blood count before treatment. When you are on the medication, check the blood level and blood count every two weeks while the dose is being increased, then check each month for 6 months, then every 6 months while on the medication. The main side effects include sedation, tremor, and difficulty with speech. A drop in white blood cell count can occur in 10 percent of patients, but this sometimes resolves after 4 months. If blood counts go too low or there is lymph node enlargement, stop the medication. This medication can also cause birth defects if one gets pregnant while taking it.
In one study of cancer patients receiving massive doses of morphine (approximately 844 mg a day), 73 percent had less sedation on Aricept. Patients were started on 5 mg a day, and the average patient needed approximately 9 mg daily. After 3 weeks on the medication, sedation decreased markedly, and pain also decreased somewhat as well.32
In one study of 18 fibromyalgia patients,42 Lidocaine was given at a dose of 5 mg per kilogram of body weight over 30 minutes. This is a much higher dose/speed than I recommend; it is safer to give it slower. Ketamine® and morphine (each at 3/10 mg/kilogram IV administered over a one half-hour time period) and a salt water placebo were also given with each of these 4 treatments a week apart. Fifteen of the 18 patients improved with one or more of these medications. Half of the patients improved with Lidocaine, with pain decreasing by an average of over 60 percent. Similar effects were seen for Ketamine and morphine. Most patients developed a very comfortable sedation. Although patients felt numbness around the lips with Lidocaine and “spacey” with the Ketamine, the treatments were found to be effective and were well tolerated. Pain relief lasted several days in over half the patients. The fact that different patients responded to different medications in this study shows the importance of tailoring treatments to each patient.
Other studies of Lidocaine have shown similar effects. In one study, 10 patients with fibromyalgia were given 250 to 500 mg of Lidocaine each day for 6 days (each dose was given over 6 hours). There was a 50 percent decrease in pain, with most of this benefit persisting when patients were checked 30 days later.43 Another study was conducted with 11 fibromyalgia patients, who were give 240 mg of Lidocaine over a one half-hour time span each week (as noted above I think this is too fast a speed to give this dose) for 4 weeks. Six of the 11 patients had complete resolution of their fibromyalgia, and 8 of the 11 felt that they were better overall. On a zero to 10 scale, pain dropped from 7.2 to 2.0 on average. Despite the high-dose being given fairly quickly, no abnormal heart rhythms were seen. A friend of mine, Jay Goldstein M.D., has used intravenous Lidocaine in hundreds of fibromyalgia patients. He finds that the treatment improves not only the pain but also the fatigue, spastic colon, and cognitive dysfunction. In his experience, the treatments increase in effectiveness with each dose up until about the fifth dose at which point the effect levels out. Some people have no effect until they receive the fourth or fifth dose. He has never seen anyone suffer any serious reactions from the IV Lidocaine.
Despite the intoxicated/dissociative feelings that can routinely occur with Ketamine in higher dosing, it can be powerfully effective in very difficult pain syndromes. In another small study at an Irish Hospice, Ketamine given subcutaneously was very helpful for 10 patients with narcotic resistant chronic cancer and non cancer pain. Seventy percent of these severe pain patients had no pain after Ketamine treatment, and all had some pain relief. Patients were treated for an average of 42 days, and some were able to switch to Ketamine by mouth. The only significant adverse reaction was inflammation at the site of injection, which ranged from mild redness to tissue necrosis. Hydrocortisone cream did help settle down some of the inflammation, but four patients still needed to stop the injections because of this. Most patients noted benefit at a dose of approximately 300 mg subcutaneously daily.45 Any uncomfortable (most often they are not) psychological side effects of Ketamine can be decreased by giving the patient Klonopin® and having them sleep right after the injection.
Adapted from the book “From Fatigued to Fantastic!” by Jacob Teitelbaum, M.D. – The books & supplies can be ordered from 800-333-5287 or our web site at www.endfatigue.com.
Below is a listing of the more common treatments used in treating pain and associated problems. If you would like, a more comprehensive form with over 280 options can be seen and printed out at http://www.vitality101.com/. I would use this list as a record of your treatments and have it with you for follow-up/phone visits. Put a line through the number in front of any treatment you stop and note the reason stopped and date. Put the date started in front of the other treatments. Although it can take 6 weeks to see a treatment’s benefits, most of the medications’ side effects will usually occur within the first few days of starting a treatment. Except for treatment #1 through 14 which can all be started in the first 1 to 3 days, add in 1 new treatment each 1 to 3 days. If a side effect occurs, stop the last 2 or 3 treatments for a few days and see if it goes away. If the side effect is acute and worrisome, call your family doctor (or go to the E.R.) immediately. Do not get pregnant on treatment or drive if sedated. It is normal for a woman's periods to be irregular during the first 3 to 4 months of treatment. On average, it takes 3 months to start feeling better. You can begin to slowly taper off most treatments when you feel well for 6 months. Stop things one at a time (e.g. one pill every 1 to 2 weeks) so you can see if you still need it. If needed, however, any or all of these can be used forever (usually not necessary). Some prescriptions can be obtained at a much lower cost from Consumers Discount Drug Company (323-461-3606). We priced 90 Sporanox tablets (100 mg)—they would cost $820 at a local food chain pharmacy vs. $600 at Consumers Discount Drug. Another good source for generic prescription drugs is http://www.costco.com/—click on pharmacy. Do not take any treatments below that you are allergic to or that have caused prohibitive side effects. Prescription items have ’Rx’ after their names. If a recommended (i.e. checked off) treatment has the number in front of it circled then it is a critical treatment. If it has a ** by the number, it is a “most important” treatment, if it has an * it is an important treatment and no * means the treatment is helpful but not critical. If you choose to simplify your program, you can begin with just the circled and **’d followed by the *’d items and then no *’d items that are checked off.
We have listed natural/over-the-counter alternatives for most prescription therapies that can be substituted for and/or added to the prescription ones. We often recommend products made by Enzymatic Therapies or Phyto Pharmica as these have proven potency and purity. Dr. Teitelbaum does not accept money from any company whose products he recommends. He has directed all his royalties for products he makes be donated to charity.
Only the items that are checked off are the ones recommended for you.
___ 1.** Energy Revitalization System - Daily Energy Enfusion Powder – ½-1 scoop a day (as feels best) blended with milk, water or yogurt with 1 capsule of the included Daily Energy B-Complex (also available separately). If diarrhea occurs, mix the powder with milk and/or start with a lower dose and work your way up to the dose that feels best or divide the daily dose into smaller doses and take 2-3 times a day. These products are made by Enzymatic Therapies and are available from our web site at http://www.endfatigue.com/ and most health food stores. There is the equivalent of over 35 tablets worth of supplements in one scoop of the powder.
___ 2. * Complete GEST Enzymes (Enzymatic Therapies)/Similase (PhytoPharmica) – 2 capsules with each meal to help digest your food properly. If you have ulcers or they irritate your stomach begin with GS Similase.
___ 3. Lipoic Acid - 200 mg a day (protects the liver) whenever you’re on Sporanox, Nizoral, or Diflucan (#57). If you have active Hepatitis or Cirrhosis, consider 300 to 2000 mg a day depending on it's severity. In addition, it has been shown to be helpful for diabetic neuropathy and burning mouth syndrome (200 mg 3 times day for 2-5 months) and is likely helpful for many kinds of nerve pain.
___ 4.* Vitamin B-12 - 1 I.M. injection (1 cc = 3000 mcg) 3 to 7 times weekly for 15 doses, then as needed (e.g. 1 to 12 times a month). This needs to be made by a compounding (holistic) pharmacy (e.g. Cape Drugs 800-248-5978).
___ 5.* NAC (N-Acetyl- L-Cysteine) – 500-650 mg a day for 2-3 months. Makes Glutathione.
___ 6.* Chromagen FA (Rx, iron) - one tablet a day. Do not take within 6 hours of thyroid hormone preparations or Cipro (antibiotic), as this can prevent their absorption. Take on an empty stomach (i.e. take between 2 and 6 PM on an empty stomach). It is OK to miss up to 3 doses a week. Stop in 4 to 6 months or when your Ferritin blood test is over 40. If afternoon fatigue is a problem, consider continuing iron supplements until your Ferritin level is over 100. Iron may turn your stool black. If this is a problem, Flora Dix iron is much easier on the stomach and is not constipating (supplies 10 mg of highly absorbable iron per dose of 2 tsp). Available from 800-446-2110.
___ 7.* Eskimo 3 Fish Oil (by Tyler) - ½ to 1 Tablespoon a day – for 3 to 9 months until the dry eyes and mouth resolve, and then as needed. Use this brand as most others are rancid and often contain mercury, lead or other toxins. Dry eyes, mouth, & hair, pain, and excessive hard ear wax suggest a need for this.
For Anxiety - Natural Treatments
___ 8. Inositol - helps depression, anxiety, Bipolar and other psychological stress states. Use just like sugar. Take 3-6 teaspoons a day. Takes 3-6 weeks to work. Buy as bulk powder.
___ 9. Thiamine (Vitamin B1) - 500 mg 1-3x day can help anxiety (within 1-4 weeks on it).
Mitochondrial Energy Treatments
Use these for 4-9 months. Then drop the dose to the lowest dose that maintains the effect (or stop it if no benefit).
___ 10. * Acetyl-L-Carnitine - 500 mg - 1 capsule once or twice a day for 3 months. Then 250 to 500 mg/day or stop it. Although important in CFS/FMS, it is even more important to take this if you also have Mitral Valve Prolapse, MS, and/or elevated blood triglycerides. This helps with weight loss.
___ 11. Coenzyme Q10 - 200 mg - 1x a day. Especially important if taking cholesterol lowering prescriptions (e.g. Mevacor). Take it with vitamin E or a meal that has fat, oil supplements or in an oil based form to improve absorption. Vitaline makes the best form and this is the one I recommend. It also already contains vitamin E to enhance absorption.
___ 12. Magnesium/Potassium Aspartate – two 500 mg capsules 2x a day (need to use a “fully reacted” brand) for 3 to 4 months.
___ 12A.** D-Ribose (Corvalen) - 5 grams (1 scoop) of powder 3x day for 2 weeks, then 2x day. Lower the dose if too energizing.
___ 13. NADH (Enada brand) – 10 mg sublingual tablets – dissolve one under the tongue(or swallowed two 5 mg tablets) each morning. Take it on an empty stomach first thing in the morning (leave it by your bedside in the bottle or foil wrap with a glass of water) at least ½ hour before eating, It takes 2 months to see if it works.
___ 14. Magnesium Glycinate - 75 mg/Malic Acid - 300 mg (Fibrocare) - 2 tablets 3x a day for 8 months, then 2 tablets a day (less if diarrhea is a problem). Start with 1 to 2 a day and slowly work up as able without getting uncomfortable diarrhea. You can take up to 10 a day for constipation. Taking it with food may lessen diarrhea. If pain or fatigue recurs on lowering the dose, increase it. Taken at bedtime, it helps sleep.
You can try these in the order listed or as you prefer based on your history. Adjust dose as needed to get 8-9 hours of solid sleep without waking or hangover. No going to the bathroom if you wake up unless you still have to go 5 minutes later. Mixing low doses of several treatments is more likely to help you sleep without a hangover than a high dose of 1 medication. You can take up to the maximum dose of all checked off treatments simultaneously. Do not drive if you have next day sedation (adjust your treatment to avoid this). If you’re not sleeping 8-9 hours a night without waking on the checked off treatments, do not wait until your next appointment to let us know or contact your physician! Ambien, Klonopin, Xanax and Soma are considered potentially addictive, but in the dose and form that we use this is rarely a problem. If you have next day sedation, try taking the medications (except the Ambien) a few hours before bedtime. The antidepressants (e.g. Prozac/Paxil) can improve sleep a lot after 6 weeks. Taking calcium and magnesium at bedtime can help sleep. In addition you can try the other natural&/or nonprescription products in combination first to see if they give you 8 hours of sleep a night. Add them in this order #16, 19, 20, 29, 21.
___ 15.**Ambien (Rx, zolpidem) - 10 mg- ½ to 1½ at bedtime. If you tend to wake during the night, leave an extra ½ to 1 tablet at bedside and you can take it as needed to help you sleep through the night.
___ 16.**Revitalizing Sleep Formula (by Enzymatic Therapies & PhytoPharmica) – Valerian 200 mg, Passion Flower 90 mg, L-Theanine 50 mg, Hops 30 mg, Piscidia 12 mg and Wild Lettuce 28 mg. Take 2-4 capsules each night 30 to 90 minutes before bedtime. It can also be used during the day for anxiety. If Valerian energizes you (occurs in 5-10% of people) use the other components. It is also excellent for anxiety. Do not take more than 8 capsules a day.
___ 17. Desyrel (Rx, trazodone) - 50 mg - ½ to 6 at bedtime. Although sedating, it can be used (50-250 mg at a time) for anxiety. Do not take over 450 mg a day (or 150 mg a day if on other antidepressants).
___ 18.* Klonopin (Rx, clonazepam) - ½ mg - begin slowly and work your way up as sedation allows. Take ½ tablet at bedtime increasing up to 6 tablets at bedtime as needed. Can be very effective for sleep, pain and Restless Leg Syndrome. Klonopin may be addictive. Taking one quarter to one half tablets in the morning (not more) can actually decrease brain fog in some patients.
___ 19.* 5 HTP (5 Hydroxytryptophan) - 200 to 400 mg at night. Naturally stimulates Serotonin. Don’t take over 250 mg a day if you are on Prozac, Paxil, Zoloft, Desyrel or Celexa. Can help with pain and weight loss at 300 mg a day for at least 3 months. Or ___ Tryptophan 500 mg caps 1-6 at bedtime.
___ 20 Calcium 500-600 mg and Magnesium 100-200 mg at bedtime helps sleep.
___ 21. Doxylamine (Unisom for Sleep) or Benadryl - 25 mg at night (antihistamines). May also help pain.
___ 22.* Neurontin - 300 mg (see #126) - 1-2 caps at bedtime. Also helps pain and restless legs syndrome.
___ 23* Zanaflex (see #119) - 4 mg ½ -2 at bedtime for sleep (higher for pain). Stop if it causes nightmares.
___ 24. Sonata (Rx) - 10 mg – Take 1-2 capsules during the night if you wake after 3 AM or if you only have trouble falling (vs. staying) asleep. It’s sedation only last 3-4 hours.
___ 24A. Lunesta (Rx) - 2-3 mg at bedtime. If taken with Sporanox, Nizoral, Diflucan or Zithromax a lower dose may be needed.
___ 25.* Soma (Rx, carisprodol) - ½ to 1 at bedtime. This is very good if pain is severe. Soma may be addictive.
___ 26.* Flexeril (Rx, cyclobenzaprine) - 10 mg- ½ to 2 at bedtime. Muscle relaxant—can cause dry mouth.
___ 27.* Doxepin (Rx, Sinequan) – 5-10 mg, 1-3 capsules at bedtime or Doxepin liquid 10 mg/cc. If a lower dose is needed you can start with 1-3 drops at night. A powerful antihistamine. Some people get the greatest benefit with the least next-day sedation with a dose of less than 5 mg a night.
___ 28. Elavil (Rx, amitriptyline) - 10 mg - ½ to 5 tablets at bedtime. May cause weight gain or dry mouth. Good for nerve pain and vulvadynia.
___ 29. Melatonin - ½ mg – 1 mg at bedtime (available at health food stores). If you feel wide awake at bedtime, try 5 mg taken 3 to 5 hours before bedtime. Don’t use a higher dose unless you find it more effective (.5 mg is usually as effective as 5 mg and may be safer).
___30.* Gabitril - 2 mg twice a day (see # 126B) .Increase by a maximum 4 mgs daily each week to a maximum of 24 mg a day( optimal effect is seen at an average dose of 16 mg/day).Even 5 mg at bedtime can markedly improve deep sleep and can sometimes decrease next-day sedation The main side effects are sedation, dizziness and gastric upset.
___ 31. Xanax (Rx, alprazolam) - ½ mg - ½ to 4 tablets at bedtime. This is short-acting and gives a good 3 to 5 hours sleep with less hangover in the morning. Xanax may be addictive.
___ 32. Seroquel (Rx) - 25 mg – 1 at bedtime (an anti-schizophrenic medication).
Several studies show that thyroid therapies can be very helpful in CFIDS/FMS—even if your blood tests are normal. This treatment is, however, very controversial—even though it's usually very safe. All treatments (even aspirin) can cause problems in some people though. The main risks of thyroid treatment are:
1. Triggering caffeine-like anxiety or palpitations. If this happens cut back the dose and increase by ½ to 1 tablet each 6 to 8 weeks (as is comfortable) or slower. Sometimes taking vitamin B1 (thiamine) 500 mg 1-3x day a day will also help after about a week. If you have severe, persistent racing heart, call your family doctor and/or go to the emergency room.
2. Like exercise (i.e. climbing steps), if one is on the edge of having a heart attack or severe ‘racing heart’ (atrial fibrillation), thyroid hormone can trigger it. In the long run though, I suspect thyroid may decrease the risk of heart disease. If you have chest pain, go to the emergency room and/or call your family doctor. It will likely be chest muscle pain (not dangerous) but better safe than sorry. To put it in perspective, I've never seen this happen despite treating many hundreds of patients with thyroid. Increasing your thyroid dose to levels above the upper limit of the normal range may accelerate Osteoporosis (which is already common in CFIDS/FMS). Because of this, you need to check your thyroid (Free T4 - not TSH) levels after 4 to 8 weeks on your optimum dose of thyroid hormone. All this having been said, we find treatments with thyroid hormone to be safer than Aspirin and Motrin. If you have risk factors or Angina, do an exercise stress test to make sure your heart is healthy before beginning thyroid treatment. These risk factors include: 1. Diabetes, 2. Elevated cholesterol, 3. Hypertension, 4. Smoking, 5. Personal or family history of Angina, 6. Gout, 7. Age over 50 years old.
There are several forms of thyroid hormone, and one kind will often work when the other does not. Do not take thyroid within 6 hours of iron or calcium supplements or you won't absorb the thyroid. It can take 3 to 24 months to see the thyroid's fulll benefit.
___ 33. Levoxyl or Synthroid (Rx) - (L-Thyroxine) 50 mcg - (100 mcg = .1mg). See paragraph below and thyroid information above.
___ 34.**Armour Thyroid (Rx) - 30 mg (1/2 grain = 30 mg) (natural thyroid glandular). If #37 (Cortef) is checked, begin the Cortef and/or adrenal support 1-7 days before starting the thyroid. See paragraph below and thyroid information above.
For both of these 2 forms (#33-34), take ½ tablet each morning on an empty stomach for 1 week and then 1 tablet each morning. Increase by ½ to 1 tablet each 1 to 6 weeks (till you're on 3 tablets or the dose that feels best). Check a repeat Free T4 blood level when you're on 3 tablets a day (or your optimum dose) for 4 weeks. If okay, you can continue to raise the dose by ½ to 1 tablet each morning each 6 to 9 weeks to a maximum of 5 a day and then recheck the Free T4 4 weeks later. Adjust it to the dose that feels the best (lower the dose if shaky or if your resting pulse is regularly over 88/minute). Do not go over 5 tablets a day without discussing it with your doctor (although it may take as many as 10 a day to see the optimal effect). When on your optimum dose, you can often get a single tablet at that strength. If your energy wanes too early in the day, you can also take part of your thyroid dose between 11 AM and 3 PM. Some people find that taking part of their thyroid dose at night feels better. You can divide your thyroid dose through the day to see what feels best.
___35. Iodine – Iodoral tablets from Optimox ½-1 a day for 2-4 months if you have daytime body temperatures under 98.3 degrees or breast or ovarian cysts. It contains 12.5 mg iodine (iodine 5 mg & iodide 7.5 mg). May flare Hashimoto’s Thyroiditis and rarely may suppress thyroid function (with long term use).
___ 36.* Cytomel (Pure active T3) (Rx) – 5 and 25 mcg tablets. In Fibromyalgia, resistance to normal thyroid doses may occur and patients often need very high levels of T3 Thyroid to improve. Dr. John Lowe’s research group feels that the average dose needed in FMS is 75-125 mcg each morning—much higher than your body's normal production. Because we are often going above normal levels with T3, the risks/side effects noted above increase. Because of this, if you have risk factors, it is more important to consider an exercise stress test to make sure your heart is healthy (i.e. no underlying Angina) before beginning this protocol. Also, consider a Dexa (Osteoporosis) Scan each 6 to 18 months while on treatment. There may be initial bone loss the first year, then increased bone density. Bone density may decrease at 6 months and then increase after that. This having been said, in our experience this treatment has been quite safe and, in some FMS patients, dramatically effective. Begin with 5 mcg each morning and continue to increase by 5 mcg each 3 days until you feel well, shaky or you’re at 75 mcg a day (whichever comes first) and then increase by 5 mcg a day each 1 to 6 weeks until (whichever comes first):
1. You reach 125 mcg each morning (or 60 mcg if you're over 50 years old unless approved by your physician).
2. You feel healthy.
3. You get shakiness, worsening significant palpitations (occasional "flip flops" are common), anxiety, racing heart, sweating or other uncomfortable side effects. If this happens, lower the dose a bit for 2-4 weeks and then try raising again till you note significant improvement WITHOUT uncomfortable side effects or you tried to raise it 3 times and still became shaky/hyper.
Blood tests for thyroid hormone or TSH are not reliable or useful on this regimen. If you feel no better even on the maximum dose, taper off (decrease by 5 mcg each 3 days until you’re at 15 mcg a day. Take 15 mcg a day for 3 weeks and then drop to 5 mcg a day for 3 weeks—then stop).
After being on treatment for 3 to 6 months, some patients can lower the T3 dose or stop it. Feel free to try dropping the dose. If you feel better initially and then worse (beginning more than 4 weeks after starting a new dose), you probably need to lower the dose. If you lose too much weight, try to eat more (and discuss this with your physician) and lower the dose.
Adrenal Hormones, Glandulars & Support
Helps your body deal with stress and maintains blood pressure.
___ 37.* * Cortef (Rx) - 5 mg tablets - ½ to 2½ tablet(s) at breakfast, ½ to 1½ tablets at lunch and 0 to ½ tablets at 4 PM. Use the lowest dose that feels the best. Most patients find that 1 to 1½ tablets in the morning and ½ to 1 tablet at noon is optimal. Take it with food if it causes an acid stomach. Do not take over 4 tablets a day without discussing the risks with your physician. Take Calcium if on Cortef. If taken too late in the day, Cortef can keep you up at night. You can double the dose for up to 1 to 3 weeks (to maximum 7 tablets a day), during periods of severe stress (e.g. infections—see or call your doctor for the infection and let him/her know you're raising the dose). If routinely taking over 4 tablets a day (at your doctor’s direction), wear a "Med-Alert bracelet" that says "on chronic Cortisol treatment." After 9-18 months, you can try to wean off the Cortef (decrease by ½ tablet a day each 2 weeks) if you feel OK (or no worse) without it.
OR 38 plus 39
___ 38.**Adrenal Stress End – From Enzymatic Therapies or PhytoPharmica. Take 1-2 capsules each morning (or 1-2 in the morning and 1 at noon). Take less or take with food if it upsets your stomach.
___ 39. Isocort (Adrenal Glandular) – Contains approximately 2½ mg Cortisol (Cortef) per pellet (see #37 above for directions). Order from (800) 743-2256.
___40.* DHEA - ____ mg each morning or twice daily (lower the dose if acne or darkening of facial hair occurs). Some experts recommend that the entire dose be taken in the morning. Keep your DHEA-Sulphate levels between 140-180 mcg/dL for females and 300-500 mcg/dL for males. If you have breast cancer, do not use without your physician's OK. See information sheet for dosing.
___ 41.* Natural Estrogen (Rx) - _____ take Estrace (estradiol) 1mg, 1 to 2 times a day, OR _____ put a Climara 0.05 to 0.1 mg patch on each Sunday, OR take a Biestrogen 2½ mg 1 to 2 times a day. If you have not had a hysterectomy, you must be on progesterone with the estrogen to prevent uterine cancer. If you are on the patch and it seems to stop working the last 1 to 2 days of the week, you can change the patch every 5 days.
Use the Estrogen ____ every day; ____ day 1 through 25 of your cycle (day 1 of your period is day 1 of your cycle). It is normal for your periods to be irregular for 3 to 4 months. If your symptoms (including migraines and anxiety) worsen for the week you are off the Estrogen, we can add a Climara .025 mg patch for that week. If they worsen a few hours before you take the Estrogen by mouth, divide the dose up through the day (e.g. ½ tablet 4 times a day vs. 2 tablets each morning). If you order your Estrogen/Progesterone capsules from Cape Apothecary, Tom will be glad to work with you in adjusting the dose (800-248-5978 or 410-757-3522).
___42.* Biest____mg, plus Progesterone ____mg, plus Testosterone___mg all in 1 capsule. Take one capsule 1-2x day. If you order your Estrogen/Progesterone capsules from Cape Apothecary, They will be glad to work with you in adjusting the dose (800-248-5978 or 410-757-3522).
___ 43. Ortho-novum 1/35 (Rx) - Begin the Sunday after this period. It's effectiveness as birth control begins after you've been on it the first week. If you miss a pill, add alternate contraception that cycle. It's effectiveness as birth control is decreased while on Doxycycline or Amoxicillin/Augmentin family antibiotics. If you feel poorly the week off the pill, you can take it every day till you get your period (or 5 months, whichever comes first). Then stop the pill for 5-7 days and then repeat this cycle.
___ 44.* Natural Progesterone (Rx) - (Prometrium—available in most pharmacies) - 100 mg daily if over 48 years old OR 200 mg a day for the 16th to 25th day of your cycle if under 48 years old. Take it at night.
___45.* Testosterone (Rx) - Females 2 mg tablets or cream, 1 to 2 times a day - make 4 mg/gm of cream (less if acne or darkening of facial hair occurs). Rub the cream into an area of thin skin on the abdomen or inner thigh. The cream is available by prescription from Cape Apothecary (410-757-3522).
___ 46.* Testosterone (Rx) - Males ____ 25 to 50 mg (order 100 mg/gm of cream) 2 to 3 times a day (less if acne occurs). Rub the cream into an area of thin skin on the abdomen, or inner thigh. The cream is available by prescription from Cape Drug and can be mailed to you. Or ____ Androgel ___25 or __50 mg—apply gel 1-2x a day Consider also checking estrogen and DHT levels when you check your testosterone blood levels. If the DHT goes too high it can cause hair loss—which can be prevented by Proscar (Rx) or Saw Palmetto 160 mg 2x day. If estrogen goes too high, this can be blocked by Arimidex (Rx) 1 mg a day. If you are taking thyroid tablets, be aware that adding testosterone can increase your thyroid blood levels. If you get moody, anxious, or racing heart, check a blood level for your thyroid and consider lowering the dose.
See the article "Treating Respiratory Infections Without Antibiotics" in my book, Volume 2, Issue 2 of my newsletter or on our web site at http://www.endfatigue.com/. For HHV-6, CMV & EBV Infections, see Vol. 4, Issue 1 of our newsletter.
__ 47. Colloidal silver (Use Argentyn 23 from our web site). For acute infections or aggressive treatment take 2 tbsp by mouth in the morning, 1 tbsp before lunch, and 1 tbsp 20 minutes before dinner. Silver should be taken on an empty stomach (at least 10 minutes before eating or drinking). If you get a “die-off” reaction (flaring of symptoms) as the infection is killed, lower the dose to 1 tsp a day and increase more slowly. Although the higher dose (a 240 oz bottle is an 8 day course) can be taken safely for at least a year, 1 tsp a day is good maintenance dose (a 240 oz bottle lasts 48 days) after the infection resolves.
___48. Monolaurin - 300 mg capsules. Take 9 capsules once a day on an empty stomach for 1 week, followed by 6 capsules once a day for 20 days. Take Lysine 1500 mg twice a day while on Monolaurin.
For a non-prescription approach, use 49, 51, 52, 53 & 54.
___49.** Avoid sweets - this includes sucrose, glucose, fructose, corn syrup, or any other sweets until the doctor says that it is okay to include them in your diet again. Avoid fruit juices, which are naturally sweet. Having 1-2 fruits a day (the whole fruit as opposed to the juice) is okay. Stevia is a great sugar substitute. Inositol (#8 helps anxiety and depression) & Xylitol (helps osteoporosis) are also excellent and healthy sugar substitutes that look and taste like just like sugar.
___ 50. Stevia is a wonderful herbal sweetener. A great tasting one is “Body Ecology’s” available from 800-478-3842. Use all you want.
___ 51.**Acidophilus Milk Bacteria – Acidophilus ‘Pearls’ form (by Enzymatic Therapy/ Phyto Pharmica). Take 2 twice a day for 5 months. Then consider 1 a day to help maintain a healthy bowel. Do not take within 6 hours of taking an antibiotic (e.g. take it midday, if you take the antibiotic morning and night). The Enzymatic Therapy/PhytoPharmica Acidophilus or Probiotic Pearls form contains ~ 2.8 billion units per pearl—even though box says only 1 billion. I use only this brand, as in many other brands the bacteria are not viable.
___ 52. Primal Defense powder - 1-6 scoops 3x day for 3-5 months along with the acidophilus (contains “soil based organisms” that also fight yeast, but do not stay in the bowel long term like acidophilus).
___ 53* Phytostan (NF Formulations/ITI) is an excellent natural antifungal mix. Take 2 twice a day for 3-5 months.
___ 54. Citricidal - 100 mg (use the tablets) 1-3 times a day.
___55. Mycelex Oral Lozenges (Rx, for Thrush and/or "in the mouth" sores) - Suck on 1 lozenge, 5 times a day for 1 to 4 days (as needed). After sucking on it awhile (e.g. 10 minutes), put pieces of the lozenge up against the sore(s) until you are tired of it being there.
___ 56.* Nystatin (Rx) - 500,000 units - 2 tablets 2-4x a day. Begin with 1 a day and increase by 1 tablet a day until you are up to the total dose. Your symptoms may initially flare as the yeast die off. If this occurs, stop it and take Actos (Rx) 45 mg a day for 10 days. On the 7th day of taking Actos, resume the Nystatin and raise the dose more slowly or stop for awhile if die off is still severe. The Nystatin is usually taken for 5 to 8 months. If nausea occurs take 2 twice a day and/or switch to the Nystatin powder in capsules or mixed in water (available from Kronos Pharmacy 800-723-7455- in 1 million unit capsules which are much cheaper & better tolerated but need to be refrigerated). Repeat Nystatin for 4 to 6 weeks anytime you take an antibiotic or have recurrent bowel symptoms.
___ 57.**Diflucan (Rx)(fluconazole) - 200 mg a day. Or, if not covered by insurance – Nizoral 200 mg a day. Take it for 6 weeks. IMPORTANT: Begin taking the Diflucan 4 weeks after starting the Nystatin. See the paragraph below.
___ **Sporanox (Rx) (itraconazole) - 100 mg, take 2 each day (simultaneously) with food.
Begin taking the Diflucan, Nizoral or Sporanox 4 weeks after beginning the Nystatin. If the symptoms have improved and then worsen when you stop the antifungal, refill the prescription for another 6 weeks. (Note: a 6-week supply costs over $500!) If your symptoms flared when you began the Nystatin, begin with ¼ to ½ the above dose for the 1st week. Do not take cholesterol lowering agents related to Mevacor or antacids (e.g. Tagamet) while on Sporanox! Diflucan 200 mg a day may be substituted for Sporanox if you are on antacids. Do not take Mevacor family medications with Diflucan or Nizoral! Take Lipoic Acid (#3) any time you take Sporanox, Nizoral or Diflucan. Also, taking Betaine HCL (stomach acid to help digestion—available at most health food stores) at the same time as the Sporanox, can dramatically increase Sporanox's absorption and effectiveness. Lipoic Acid may decrease the risk of liver inflammation from the Diflucan, Nizoral or Sporanox. If you need to stay on these medications more than 3 months, check liver blood tests (ALT, AST) every 3 months. If you feel well and symptoms (especially bowel symptoms) recur over time, consider retreating yourself with Acidophilus Pearls 2 twice a day, Nystatin and Sporanox (or Diflucan) for 6 weeks as needed. If you have a low income and no prescription Insurance the Diflucan company may supply it for free. Call 800-869-9979 for information (let them know you have immune suppression and fungal overgrowth). If you flare your symptoms on this treatment, take Actos (Rx) 45 mg a day for 10 days. Retry the Diflucan/Sporanox on the 7th day of taking Actos.
___ 58.**Thymic Protein (a.k.a. Proboost and Bio Pro A) – VERY POWERFUL. Dissolve the contents of 1 packet under your tongue - any that is swallowed is destroyed! Take it three times a day for 12 weeks, then 1 a day for 6 weeks. Also take it 3 times a day at first sign of any infection until the infection resolves (it is approximately $1.80 a packet). Available from our office (800-333-5287 or www.vitality101.com). Works in the first 24 hours for acute infections but takes 2-3 months to work for chronic infections.
__ 59.* Colloidal Silver. See #49.
* Treatments for Parasites, Bowel, and Other Infections
If your stool test shows parasites, recheck the stool test 3 to 4 weeks after finishing the treatment below. See the Comprehensive treatment protocol at http://www.vitality101.com/ for info on how to treat specific parasites or antibiotic sensitive infections.
___ 60.* Vermox (Rx) - 100 mg - Chew 1 twice a day for 3 days. 1 week later chew 1 twice a day for 1 day. Good as an “empiric” therapy if you suspect parasites but cannot isolate them.
___ 61.* Neomycin (Rx) - 500 mg 3 times a day for 10 days. Used for small bowel bacterial overgrowth.
___ 62.* Multi-pure Water Filter - Most other filters except reverse osmosis are ineffective. (Available from Bren Jacobson, 410-224-4877.) Decreases the risk of reinfection.
Chronic & Acute Sinusitis
___ 63.* Sinusitis Nose Spray (Rx) – By prescription from Cape Drug (800-248-5978). Contains Sporanox, Xylitol, Bactroban, Beclamethasone and Nystatin. Use 1-2 sprays in each nostril twice a day for 6-12 weeks. If it irritates the nose, use nasal saline spray just before using the prescription. Use with silver spray below.
___ 64.* Nasal silver spray - 5-10 sprays in each nostril three times a day for 7-14 days until the sinusitis resolves (from www.EndFatigue.com.
___ 65. Nasal Irrigation (Rx) – Get 1 liter of normal saline with 100 mg Amphotericin B and a second liter with 80 mg gentamycin. Use 1 ounce of each in each nostril as a nasal rinse twice a day as needed.
Kills Many Infections
__ 66. Colloidal Silver (Use Argentyn 23 from our web site). Take 2 tbsp by mouth in the morning, 1 tbsp before lunch, and 1 tbsp 20 minutes before dinner. Silver should be taken on an empty stomach (at least 10 minutes before eating or drinking). If you get a “die-off” reaction (flaring of symptoms) as the infection is killed, lower the dose to 1 tsp a day and increase more slowly. Although the higher dose can be taken safely for at least a year, 1 tsp. a day is good maintenance dose after the infection resolves.
E. Coli Bladder Infections
___ 67. D-Mannose - 1 teaspoon (2 grams) stirred in water every 2 to 3 hours while awake for 2 to 5 days for acute bladder infections (may use up to 1-2 times a day long term if needed for chronic infections) caused by E.Coli (this causes approximately 90% of bladder infections). If not much better in 24 hours, get a urine culture and consider an antibiotic. Continue taking it for 2-3 days after the last symptom resolves (1 tsp). Taking it an hour before and immediately after intercourse can also prevent bladder infections. D-Mannose is available from BioTech (800-345-1199), our office or our web site Vitamin Shop.
__ 68. Una D’gato TOA free cats claw drops - 5 drops 3x day for 12 months for Lyme disease (From Allergy Research). If symptoms flare, start with a low dose and work up as comfortable.
Food & Other Sensitivities
___ 69.**N.A.E.T. – Wonderful for elimination of sensitivities/allergies (see http://www.naet.com/ for more information). In Annapolis see Laurie Teitelbaum at 410-266-6958.
___ 70. Food Allergy Elimination Diet (instruction sheet is available on www.endfatigue.com).
I.V. Nutritional Support
___ 71.** Myers Cocktail - I.V. nutritional therapies (very helpful). In Annapolis—Rhonda Kidd (443-994-0126) or Kim Weiss at 410-280-1655.
There are several simple things that you can do that can be very helpful:
___ 72. Sweating can remove toxins—especially if you shower immediately after, and can be very helpful for health. Many of the newer saunas are what are called “far infrared”, and a half-hour 3-7 times a week can help detoxification.
___ 73. Some of you may be more comfortable with hot baths. This is one recipe that was given to me by a wonderful practitioner (Anette Mnabhi, DO in Montgomery, IL ):
Recipe for a detox bath—which helps a lot with general muscle aches and pains.
Epsom Salt - 2 cups & Baking Soda - 1 cup & Hydrogen Peroxide - 1/3 cup.
Fill tub with hot water and add above ingredients. Soak for 20-30 minutes. You will sweat in the tub and lose toxins (which causes you to lose some water as well). It is important to drink plenty of water while you soak. You can make fresh lemon juice and mix with water and drink, or plain water, but it is essential to drink while you take the bath. If you have a tendency to get light headed easily, be cautious when getting out of the tub, or have someone nearby the first time you take a detox bath. Take a lukewarm to cool shower after getting out of the tub to rinse off the salts or you may itch. Rest for 30 minutes after the bath.
___ 74. There are two excellent products that can be used intermittently to eliminate toxins. These are the___ “Whole Body Cleanse” and ___“Metal Magnet” by Enzymatic Therapy. Simply follow the labeled instructions.
___ 75. Dexedrine (Rx) (dextroamphetamine) - 5 mg - 1 to 2 tablets in the morning; plus ½ to 1½ tablets at noon; or Concerta 18 mg take 1-2 each morning and/or _____ Provigil (Rx) 200 mg ½- 1 tablet in the morning and at noon, as needed for energy. Dexedrine is an amphetamine family stimulant similar to Ritalin and may be addictive. Take less if you have caffeine-like shakiness. Most patients use 1-3 tablets of Dexedrine in the morning and ½-2 at noon. If appetite suppression and/or weight loss is a problem you can add Periactin (Rx) 4 mg (antihistamine & anti-serotonin) up to 5 tablets a day.
Help pain & brain fog- even if not depressed.
___ 76. Hypericum (St. John’s Wort) - 300 to 625 mg - 3x a day (takes 6 weeks to see the antidepressant effect). Use one standardized to at least 0.3% hypericum. Can take 2/3 of the total daily dose at night to help sleep. Can take up to 2000 mg Hypericum a day if not on other antidepressants (otherwise limit to 1000 mg a day).
___ 77. Effexor (Rx) (venlafaxine) - 37 ½ mg _____ tablets - _____ times a day.
___ 78. Prozac (Rx) (fluoxetine) - 20 mg - _____ capsule(s) each morning. Begin with 10 mg a day the first week if the full dose makes you hyper.
___ 79. Celexa (Rx) - 20 mg ____ tablet(s) a day OR #109.
___ 80. Zoloft (Rx, Sertraline) – 50 mg - _____ tablet(s) each morning or evening.
___ 81. Paxil (Rx) (paroxetine) - 20 mg - _____ tablet(s) each morning.
___ 82. Wellbutrin (Rx) (bupropion) - _____ mg - _____ x a day. Not sedating.
___ 83 Meridia (Sibutramine) - 10 or 15 mg each morning. Causes weight-loss.
___ 84. Serzone (Rx) (nefazodone) - 100 mg - 2x a day for 1 week, then 150 mg 2x a day. Can cause liver injury.
Make sure your testosterone levels are optimal.
___ 85. Antidepressant induced sexual dysfunction can be treated with___ ginkgo biloba 120 mg twice daily, ___ Dexedrine – 25 mg each morning, ___ Symmetral 100 mg twice daily, or switching to Wellbutrin (see # 99).
___ 86. Viagra - 100 mg - take ¼ -1 tab 1 hour before intercourse on an empty stomach for erectile dysfunction (do not use with nitroglycerin or underlying heart disease).
___ 87. Cialis - 20 mg - take one half to one tablet 15 minutes before intercourse for erectile dysfunction (do not use with nitroglycerin or underlying heart disease).
Spastic Colon - IBS
Treat the yeast and parasites and the IBS will usually go away. For symptomatic relief :
___ 88. Peppermint Oil - Enteric/stomach coated (2/10 =0.2cc) capsules, 1 to 2 capsules 3 times a day between meals (not with food) for spastic colon. Peppermint Plus from Enzymatic Therapies. Mentharil from PhytoPharmica.
___ 89. Simethicone (Mylicon) - 40 to 80 mg, chew one tablet 3 times a day as needed for abdominal gas pains.
___ 90. Iberogast (digestive system herbal) - Take 20 drops 3 times a day in warm water with meals. Very helpful for indigestion (takes 4 to 8 weeks to work). From Phyto Pharmica.
In addition to weight bearing and estrogen replacement, DHEA and testosterone replacement can also be very beneficial in the treatment of osteoporosis. In addition to calcium, numerous nutrients (e.g. magnesium, boron, etc) are critical for building bone strength. Except for calcium, strontium, and vitamin K, most of these are contained in the Energy Revitalization System (see #1 above) which contains over 50 nutrients. Take this plus calcium and:
____91. Strontium - 680 mg/day. Take on an empty stomach and at a different time of day than the calcium as calcium can block strontium’s absorption. Early data also suggests the strontium may be helpful in the treatment of Osteoarthritis as well.
___ 92. Fosamax - 70 mg once a week on an empty stomach taken with a full glass of water. It is best to take it immediately on waking and then stay upright for 30 minutes so gravity helps it get past the stomach quickly (because it can irritate the stomach). For those of you on the 35 mg a week prevention dose, be aware that the 35 and 70 mg tablets cost exactly the same amount—so you can save half the cost by getting a 70 mg tablet and breaking it in half!
___ 93. Use Xylitol powder instead of sugar (increases bone density and tastes and looks like sugar).
Can adjust these as needed to have one soft bowel movement a day. Increasing your water, fiber (e.g. 1 bowl of whole grain cereal in the morning) and magnesium intake is also helpful.
___ 94. Miralax Laxative (Rx) – 1 heaping tablespoon a day in 8 oz. water (comes in 14 oz. and 26 oz bottles).
___ 95. Prunes and/or Prune Juice.
___ 96. Zelnorm - 6 mg twice a day for spastic colon associated with constipation.
___ 97. Sorbitol 70% – 1-3 teaspoons 3 times a day as needed.
For migraine prevention, Magnesium (see #1 plus take an extra 200 mg at bedtime) is very important. I would add vitamin B2 and butterbur (or feverfew if the butterbur is too expensive). It can take three months to see the effect of these preventive measures! If your migraines are predominately around your period or associated with taking estrogen, they can often be eliminated by adjusting estrogen dosing. Many medications which are elsewhere on this form can also be helpful for the prevention of migraines when taken regularly. These include Neurontin, Topamax, Elavil, and Doxepin. Inderal XL can also be helpful but may aggravate fatigue, asthma, or depression. Food allergies should also be addressed. Other medications can also be helpful.
___98.** Food allergies are also very important to consider in the production of migraines. To tell if foods are playing a role, it is helpful to do a food elimination diet. Although a very limited diet is needed for five days (eat only pear and lamb, and drink only bottled spring or distilled water), this kind of strict elimination diet for five days will make it easier to tell if true food allergies are present and triggering your migraines when you reintroduce the foods into your diet. In one study, by avoiding the ten most common food triggers, there was a dramatic reduction in the number of headaches per month, with 85% becoming headache free. The most common reactive foods were wheat in 78% of patients, orange in 65%, eggs in 45%, tea and coffee and 40% each, chocolate and milk and 37% each, beef in 35% and corn, cane sugar, and yeast in 33% each when the patients were challenged with these foods . If you have severe and frequent migraines, it is worth exploring this. You may find that instead of avoiding these foods for the rest of your life, you can eliminate the sensitivities/allergies using an acupressure technique called NAET (see http://www.naet.com/).
___ 99.* Vitamin B2 (riboflavin) – 400 mg each morning to prevent migraines.
___ 100.* Petadolex (butterbur) – 50 mg 3 times a day for 1 month and then twice a day to prevent migraines. Can take 2 every 3 hours up to 6 capsules for acute migraines. Use only Enzymatic Therapy or ITI brands—others often have impurities and do not contain the amount of Butterbur the label claims. This can be highly effective.
___ 101. Feverfew – 250 mg 1 to 3 times a day to prevent migraines.
___ 102. Zonegran - 100 mg - an anti-seizure medication. Begin with 100 mg a day for two weeks and then increase to two tablets a day. The maximum dose is 400 mg daily, although most of the benefit occurs at the first 200 mg. Because there have been rare occurrences of a life threatening rash (most rashes caused by the medication are not however), stop the medication immediately if you get a rash.
For Acute Migraines
___ 103.* Petadolex (butterbur) – 50 mg - 2 every 3 hours up to 6 capsules for acute migraines.
___104.* Imitrex - For the treatment of acute migraines, medications in the Imitrex family still remain the first choice. Imitrex comes and 25, 50, and 100 milligram tablets, and up to 100 mg may be taken at a time. The 100 mg dose is a reasonable one to start with. If pain persists at two hours, another dose of up to 100 mg can be taken. In addition, it is also available by nasal spray, using a dose of up to 20 mg initially, followed by one more spray of up to 20 mg 2 hours later if needed. Another alternative is a 6 mg subcutaneous injection which can also be repeated one-hour later if needed. It is reasonable to try these different forms to see what works best for your migraines. You may also want to try a newer cousin called Amerge. Use 2.5 milligrams initially. This dose may be repeated four hours later if needed.
___ 105. Axert (Almotriptan) - 6.5 or 12.5 mg - Can repeat after 2 hours. A cousin to Imitrex but less expensive.
___ 106. Magnesium - 1-2 grams intravenously over 15-30 minutes will usually knock out acute migraine attacks.
___ 107. Midrin - Two capsules are taken immediately followed by one capsule every hour until the headache is relieved (to a maximum of five capsules within a 12 hour period). It can also be helpful for tension headaches in a dose of two capsules four times a day as needed.
___108. Metoclopramide - 10 mg plus lysine acetylsalicylate (compounded) 1620 mg or aspirin 900-1200 mg (chewed). Metoclopramide returns the absorption of aspirin to normal during migraine attacks and also combats nausea and vomiting. In 2 placebo-controlled studies, this combination (using lysine acetylsalicylate) was more effective then 100 mg of Imitrex by mouth and was better tolerated.
___ 109. Indomethacin (a “super-aspirin”), prochlorperazine (for nausea), and caffeine in suppository form (also compounded) eliminates an acute migraine in 49% of patients
___ 110. ACTIQ (Fentanyl lollipops) - 200-1600 mcg. This powerful narcotic should only be used for breakthrough pain that is not relieved by other medications (i.e. used instead of going to the emergency room). Fentanyl lollipops should be sucked on, not chewed or swallowed. In between being sucked on, it should be left between the cheek and lower gum. Time it so that it takes approximately 15 minutes to be absorbed into your cheek. In doing it this way, it is most effective. It begins working within 5 to 10 minutes with pain relief lasting approximately three hours. Its effectiveness is similar to 2-16 mg of intravenous morphine. The most commonly used doses are 400 & 800 mcg. Because these medications are only approved by the FDA for use in patients who are on chronic narcotics, it is reasonable to have you (if you are not on chronic narcotic pain medications) take the first dose in a doctor’s office to make sure that it does not cause excessive sedation. Like other narcotics, this medication can be highly addictive. Because of this, it should only be used as a rescue medication when other medications have failed. Once you have tried the 200 and 400 mcg doses and know that they are not too sedating, begin with a 400 mcg dose over 15 minutes. If adequate pain relief is not achieved 10 minutes later (i.e. 25 minutes after beginning the first lollipop), use another 200 or 400 mcg unit each 25 minutes until adequate pain control is achieved or you reach 1200 mcg. The average dose needed is 800 mcg.
___ 111. Phenergan rectal suppositories (for nausea) - 25 mg - one every 4 hours as needed for nausea (up to 5 a day).
___ 112. Diamox (a diuretic) - 125-500 milligrams once or twice daily may decrease severe pressure headaches. Carbonated beverages will taste funny while you’re on this medication.
(Antidepressants often help pain). THE NATURAL TREATMENTS CAN BE SUBSTITUTED FOR OR ADDED TO THE PRESCRIPTION PAIN MEDICATIONS. If side effects occur, they often can be avoided by starting with a low dose and raising it each 3-7 days as your body gets used to the medication. It may take 2-6 weeks for a treatment to start working.
Natural Pain Therapies
___ 113. Rolfing, Trager, Myofascial Release, Chiropractic, other body work & manipulation modalities, and/or Acupuncture. In Annapolis Maryland, Bren Jacobson (410-224-4877) does superb Rolfing.
___ 114. Dr. Teitelbaum’s Pain Formula - Contains Willow Bark, Boswellia, and Cherry. Take 2 tabs 3x day. It takes 2-6 weeks to see the full effect. At that time, you can often lower the dose to 1 tab 3x day or 2 twice a day.
___ 115. NAET - Treat food and other sensitivities and pain often resolves. See http://www.naet.com/ and the book “Say Goodbye to Pain” available on the site. Other related techniques such as JMT can be very helpful for rheumatoid and other arthritis problems.
___ 116. Niacin (not niacinamide or “flush free" niacin). Take 100-500 mg (100 mg is usually enough to cause the desired flush) of niacin 3-4 times a day on an empty stomach as needed to cause a “flushing” feeling, which occurs within ~ 10-20 minutes. This can significantly help pain by flushing nutrients into and toxins out of painful areas, and is very inexpensive. Try to keep the dose at 1000 mg a day or less if this is enough to cause flushing, as higher doses can rarely cause liver inflammation or unmask diabetes. This treatment also helps to lower cholesterol and decrease brain fog
___ 118. Lipoic Acid - 200 mg 3 times a day for neuropathic pain. Benefit usually begins to be seen by 2-3 months. It has been shown to be helpful for diabetic neuropathy and burning mouth syndrome (200 mg 3 times day for 5 months).
___ 119. Glucosamine Sulfate - 500 mg, 3 times a day (for arthritis). Takes 6 weeks to see if it will help. When the maximum benefit is seen, you can decrease to the lowest dose that maintains the effect.
___ 120. MSM 3 grams a day for arthritis.
___ 121. Fish oil (see # 8) can markedly decrease inflammation and pain. Dry eyes and mouth suggest you need it.
___ 122.*Megazyme (Enzymatic Therapies) or Biozyme (PhytoPharmica) – Like a super Wobenzyme. Take 2-4 capsules 3 times a day between meals. May dissolve clots in the blood vessels. Can be helpful for pain and other symptoms (takes days to weeks to work). Especially helpful with inflammatory pain.
___ 123. Purple Pectin for (especially arthritis) Pain: Purchase Certo in the canning section of your local grocery. It is the thickening agent used to make jams and jellies. Certo contains pectin, a natural ingredient found in plants. Take 1-3 tablespoons of Certo in 8 ounces of grape juice 1-2 times a day (1 to 2 tbsp a day is enough for most people, but you can try more). If it’s going to help, you’ll likely know in 7-14 days. As the pain disappears, the dose can be reduced to 1 teaspoon in grape juice once or twice a day as needed. Many people have found this simple, safe and cheap treatment to be very effective!
___ 124. Heel Lift - ______ inches for _____ foot. (For uneven hip heights.)
___ 125. John Sarno, MD’s – Approach for localized pain. The mind can decrease blood flow to muscles to distract us from uncomfortable emotional feelings. When you feel pain, tell your mind you will use the pain as a signal to look for and feel uncomfortable feelings for 10-15 minutes—then do so. The pain will often leave within 6 weeks. Also read my book “Three Steps to Happiness – Healing through Joy!” available in our office as this will help you to let go of feelings that may be buried and causing pain.
___ 126. Rhus Tox (homeopathic treatment) - dissolve under the tongue as directed on the bottle as needed for muscle pain.
___ 127. Magnets - Start with spot magnets, insoles and seat. If they help in 2 months, consider a mattress pad. Available from Bren Jacobsen (410-224-4877) or Amy Podd (410-757-7295).
___ 128. Copper/Magnet Bracelet – Use nail polish remover to remove any coating on the inside of the bracelet so the copper is in direct contact with your skin.
___ 129. Prostate pain. Quercetin - 500 mg twice a day decreases symptoms in both prostadynia and prostatitis.
___ 130. Flexyx – Flexyx can be very effective. It is a brainwave biofeedback system (see http://www.flexyx.com/).
___ 131. Cetyl Myristoleate – 385 mg capsules – 3 capsules 2 times a day for 10 days. You can raise the dose to a maximum of 17 gm a day. For pain—benefits often persist after the 10 days of treatment.
__ 132. Lithium (Rx) - 300 mg ____ times a day. If tremor occurs, take 2 teaspoons of Expeller Pressed Safflower Oil from a health food store (uncooked, e.g. as salad dressing) daily or lower the dose. Check a Lithium level month after beginning medication. Then check a Lithium and thyroid blood test (Free T4) each 6 to 12 months. This natural mineral also has antiviral properties.
Pharmacologic Pain Treatments
If you are not clear about the source/type of your pain, there are many reasonable sequences in which to try the medications. One reasonable order to try them in is the one listed below. It can take 2-6 weeks to see the full effect of the medication. When there are several medications with the same number (e.g. 139 A, 139B, 139C), if the first medication helped but was not tolerated because of side effects, go to the next medication of the same number. If it simply did not help significantly, go to the next number. If you get partial benefit from a medication, continue it and add the next medication as needed to get pain-free. A reasonable order to try pain meds is #136, 135, 133, 134, 137, 139, 142, 141, 140A, 147A, 150A, 148A, 143, 151, 155, 157, 154, narcotics.
__ 133. Tylenol (acetaminophen) For many people, this can be a safe and effective pain medication. Simply be aware that chronic use at too high of a dose can cause liver and sometimes kidney problems. Do not take over 4000 mg a day, and for chronic use it is best to stay under 2000 - 3000 mg daily. If you are taking over 1500 mg of acetaminophen a day on a regular basis, get an extra 500-650 mg of NAC from your health food store (or www.vitality101.com) and take it each day along with the vitamin powder. Otherwise, you will deplete a key antioxidant(which is why Tylenol can damage the liver).
___ 134.*Ultram (Rx, Tramadol) - 50 mg 1 to 2 tablets up to 4 times a day as needed for pain. Side effects are less with 4 or less tablets a day. May cause nausea/vomiting. Caution: May very rarely cause seizures or raise serotonin too high when combined with antidepressants.
___ 135.* Arizona Pain Formula Cream (Rx) - Rub a pea size amount onto painful areas 3 times a day as needed (from Cape Apothecary at 410-757-3522). You can use this on up to 3 or 4 "silver dollar" sized areas at a time.
___ 136.* Lidocaine Patches (Lidoderm Rx) – Can be cut into pieces to put over different areas. Leave the patch on for 12-18 hours then off the rest of the day. It can help localized pain (i.e. it helps pain that is right under the patch). Up to 4 patches can be used at a time each day. It can take 2-3 weeks to see if it works.
___ 137. Daypro (Rx) - 600 mg - 2 each morning as needed. Aspirin family medications can cause stomach bleeding. Take with an antacid or food if it upsets your stomach. If gastritis persists, stop the medicine or lower the dose. If you have a black stool (and are not taking iron tablets or Pepto Bismol), this may represent a life threatening stomach bleed (the stool will often have a very foul smell). If this occurs, go to the Emergency Room immediately.
___ 138. Voltaren (Rx) - _____ mg _____ times a day as needed. Aspirin family medications can cause stomach bleeding. Take with an antacid or food if it upsets your stomach. If gastritis persists, stop the medicine or lower the dose. If you have a black stool (and are not taking iron tablets or Pepto Bismol), this may represent a life threatening stomach bleed (the stool will often have a very foul smell). If this occurs, go to the emergency room immediately.
___ 139A. *Celebrex (Rx, Celecoxib) - 100 to 200 mg 1 to 2 times a day for pain. Do not take if you're allergic to sulfa or Aspirin (e.g. hives). Do not use over the 200 mg a day while on Sporanox or Diflucan. FlexAgility (#112B) is a natural form and is safer.
___ 139B. Vioxx (Rx, Refecoxib) - 25 mg, ½ to 1 tablet daily. Do not use if you are aspirin allergic (e.g. hives).
___ 139C. Bextra (Rx, Valdecoxib) – 10-20 mg once a day. Take twice a day for menstrual pain.
___ 140A.* Neurontin (Rx, Gabapentin) - ____mg ____ times a day (to a maximum of 3600 mg a day). Cut back and increase by 100 mg a day each 4-5 days if it causes any uncomfortable or unusual neurologic symptoms or excessive sedation. Begin with 100-300 mg at night, slowly increase to 300-900 mg 3 times a day as is comfortable. In some, pain relief is immediate, in others, it can take a minimum of 1200 mg a day. You can go up to 3600 mg a day.
___140B. Gabitril – 2-4 mg twice a day and increase by a maximum 4 milligrams daily, each 3-7 days to a maximum of 24 mg a day. Helps both pain and deep sleep. The main side effects are sedation, dizziness and gastric upset.
__140C. Lyrica (Pregabalin) 100 mg 2-3x day. After 2-4 weeks can increase to a maximum of 200 mg 3x day. Helpful for pain, increasing deep sleep, and restless legs syndrome. The main side effects are dizziness and drowsiness, which tend to decrease over time.
___ 141. Flexeril (Rx, cyclobenzaprine) - 10 mg - ½ to 2 at bedtime. Muscle relaxant—can cause dry mouth.
___ 142.* Skelaxin (Rx, metaxolone) - 400 mg 1-2 tablets 4 times a day as needed for pain. This is usually non-sedating.
___ 143. Baclofen (Rx) - 10 to 20 mg 1 to 3 times a day (sedating).
___ 144. Norflex Tablets (Rx) - 1 tablet twice a day.
___ 145. Dantrium (Rx) – 25 mg - For muscle spasm take 1 a day for 1 week. Then one 3 times a day for 1 week, then 2 tablets 3 times a day for 1 week then 100 mg 3 times a day. Adjust to the lowest dose that feels the best. Stop or lower dose if severe diarrhea occurs. Check liver blood tests (#143) at 6, 12 and 24 weeks and then each 1 to 6 months to make sure there is no liver inflammation.
___146. Robaxin (Rx, methocarbimol) - 750 mg - 1 to 2 capsules 3 to 4 times a day as needed for pain (sedating).
Antidepressants can be very helpful in alleviating pain even you are not depressed! Do not presume that your pain specialist thinks that you have a psychological problem if you're offered an antidepressant. Tricyclic antidepressants (e.g. Elavil/amitriptyline, doxepin, etc.) can be dramatically beneficial (even at very low doses) for neuropathic pain. They also improve the sleep problems caused by the pain. SSRI antidepressants such as Prozac, Effexor, and Celexa can also be highly effective for pain. These medications raise serotonin, which lower levels of a major pain messenger (substance P).
___147A. Elavil (Rx, amitriptyline) - 10 mg - ½ to 5 tablets at bedtime. May cause weight gain or dry mouth. Good for nerve pain and vulvadynia.
___ 147B.* Desipramine (norpramin—use 25-150 mg at bedtime) or ___nortriptyline (Pamelor—10 - 25 mg at bedtime) cause less sedation and other side effects than Elavil, and may be as effective. If sedation is still a problem, consider switching to doxepin 10-40 milligrams at bedtime.
___ 147C.* Doxepin (Rx, Sinequan) – 5-10 mg, 1-3 capsules at bedtime or Doxepin liquid 10 mg/cc. If a lower dose is needed you can start with 1-3 drops at night. A powerful antihistamine. Some people get the greatest benefit with the least next-day sedation with a dose of less than 5 mg a night.
___ 148A. Effexor (Rx) (venlafaxine) - 37 ½ mg _____ tablets - _____ times a day.
___ 148B. Prozac (Rx) (fluoxetine) - 20 mg - _____ capsule(s) each morning. Begin with 10 mg a day the first week if the full dose makes you hyper.
___ 148C. Celexa (Rx) - 20 mg ____ tablet(s) a day
___149. Cymbalta (duloxetine) - 60 mg 1- 2x day - a norepinephrine and serotonin reuptake inhibitor. It has fewer side effects and does not cause weight gain. It has been shown to be very helpful in treating FMS pain
Alpha 2 Adrenergic Agonists
___ 150A.* Zanaflex (Rx, tizanidine) - 4mg – Take with food – ½ to 2 tablets 1-2 times a day as needed for spasm and/or pain (sedating). Begin with 2-4mg at night. If side effects occur raise dose more slowly. Stop if it causes nightmares.
___ 150B. Catapres TTS 1 Patch (Rx) – Wear 1-3 at a time and change patch weekly. Related to Zanaflex but cheaper and lowers blood pressure more. Helps pain and raises growth hormone.
NMDA Receptor Antagonists
___ 151.* Klonopin (Rx, clonazepam) - ½ mg - begin slowly and work your way up as sedation allows. Begin with ½ tablet at bedtime increasing to 1-2 mg 3x day as needed. Can be very effective for sleep, pain and anxiety (it is in the valium family). Klonopin may be addictive. Taking one quarter to one half tablets in the morning (not more) can actually decrease brain fog in some pain patients.
___ 152. Dextromethorphan (Rx, DM) – 25 mg – 2 times a day if on narcotics (e.g. codeine/Vicodin) makes the narcotic more effective and less likely to lose effectiveness. From Cape Drugs 800-248-5978.
___ 153 Amantadine - 100 mg 1-3 tablets each morning may help nerve pain and also is an antiviral. The most common side effects include visual blurring, dizziness, and nausea.
___ 154. Keppra is another new anti-seizure medication that we are just starting to explore which has been effective when other treatments have not helped. The dose is 250 to 1500 mg twice daily. Can help “burning pain”.
___ 155. Topamax (topiramate). Begin with 25-50 milligrams daily, and increase it by 25-50 milligrams a week until you get the desired effect. This medication is usually given twice a day at a total daily dose of 50-100 milligrams/day for migraines and 200 – 300 milligrams a day for nerve pain, although lower doses can be effective. This is a medication that I have seen work wonderfully in patients who failed numerous other treatments and sometimes starts working within a few days. If you get side effects, decrease the dose and perhaps later increase it more slowly until you get the desired effect. The most common side effects are diarrhea, loss of appetite, sedation, and nausea. The nausea will often go away after one has been on the Topamax for three months. It also has the benefit of causing weight loss as well as pain relief. Besides sedation, its most worrisome albeit unusual side effect is that it can make your body very acidic—to the point where it is dangerous. Because of this, it is reasonable to check a blood bicarbonate level every so often (especially if you start developing symptoms such as fatigue) to make sure that it is over 17.
___ 156 Benadryl – 25+ milligrams 3-4 times daily can often markedly decrease pain (worth trying).
___ 157. Lamictal (Rx, Lamotrigine) – 25 mg – 1 at bedtime for 1 week. Can then increase to 1 three times a day for 1 week. You can go as high as 100 mg 4 times a day. Although rare, it can cause a rash that, if you stay on the medication, can be fatal. Although most rashes would not be this, to be on the safe side – STOP LAMICTAL AT FIRST SIGN OF ANY RASH!
___ 158. Trileptal (Rx) – 150 mg twice a day. Can go as high as 600 mg 2 times a day.
___159. Zonegran - 100 mg - An anti-seizure medication. Begin with 100 mg a day for two weeks and then increase to two tablets a day. The maximum dose is 400 mg daily, although most of the benefit occurs at the first 200 mg. Because there have been rare occurrences of a life threatening rash (most rashes caused by the medication are not however), stop the medication immediately if you get a rash.
___ 160. Permex (Rx, Pramipexole) – ¼ mg – begin with 1 a night and increase by 1 tablet weekly as needed to maximum of 6 mg. In one study it resulted in a 50% reduction in pain after 2 months at an average dose of 1.5 mg at bedtime. If stomach pain occurs, Nexium or similar medications are used during the first month. If restless leg syndrome worsens, Klonopin is also added at bedtime. Both of these side effects generally go away as the dose is increased.
___ 161. Humibid (Rx, guaifenisin) – 600 mg _____ tablets _____ times a day (see instruction sheet). No aspirin or herbals can be taken while on Guaifenisin. GuaiLife—a shorter acting form may be more effective. See http://www.fludan.com/ for more information.
___ 162. Risperdal (Risperidone) – ¼ mg to 1 ½ mg a day (not more). Begin with ¼ mg and increase by ¼ mg each 6 weeks. Going above optimal dose will cancel out the effect. Takes 2 weeks to work. Blocks Serotonin (not dopamine at this low dose). Helps pain, anxiety and sleep.
___ 163. Aricept (Donepezil) – 5 mg in the AM (or 2 ½ mg AM and noon) to a maximum of 20 mg a day. Central acetylcholinesterase inhibitor—decreases both pain and opiate induced fatigue by 50% in cancer patients. Effects begin within 1 week. Rotate with #108C (Galanthamine) if tolerance occurs.
___ 164. Marinol – 5 mg capsules 1-2 twice a day. As this is a THC extract it may cause sedation and increased appetite.
For Opiate side effects
___ 165. Constipation is common - see constipation section. In addition, opiates can lower testosterone and this should be checked for and treated if loss of libido occurs. They can also cause B2 vitamin deficiencies, so be sure to take the B-complex (see treatment # 1). Provigil (#75) or Aricept (#163) can also decrease opiate induced fatigue.
___ 166. Lidocaine Intravenously (I.V) (Rx) - _____mg (_____mg 1st dose) I.V. each 3 to 20 days as needed. Give 75 mg IV over 10-15 minutes, followed by up to 120 mg per hour (total dose 200-400 mg). Take with I.V. Myers – see #152. For the first dose, give 60 mg over ½ hour first and only continue if blood pressure is stable.
For Interstitial Cystitis
___ 167. Elmiron - 100 mg 3x day is reasonable to try. It may take 3 months to work. Take with water at least 1 hour before or 2 hours after eating.
___ 168. MSM (Methyl Sulfonyl Methane) at a dose of 6-18 grams a day can mimic the effect of DMSO and may be helpful as well.
___ 169. Some practitioners have found that patients with interstitial cystitis often have chronic very alkaline urine. This can be aggravated by excessive coffee and cola intake. PH strip paper can be obtained cheaply at most pharmacies and one can test multiple urine samples at home to see if the pH is regularly over 7.0. Also take the enzyme product URT (enzyme product No. 24) 4 capsules five times a day between meals. During flares add the enzyme product called "kidney" two capsules every 20 minutes as needed. In two to four weeks the symptoms may subside and the products can then be taken just as needed. (Available from our office at 410-573-5389.)
___ 170. L-arginine - 500 mg 3 times a day for 3 months.
___ 171. Saw palmetto - 160 mg twice a day for six weeks Vulvadynia – Treat with Elavil (or Doxepin) and Neurontin (oral or topical). Suboptimal testosterone can also cause Vulvadynia.
Heartburn, Indigestion or Reflux
For detailed information on getting off acid blockers, see article on our web site at http://www.endfatigue.com/ and click the “Useful Articles” link under "Diagnosis & Treatment". Using chronic acid blockers (e.g. Prilosec) is a poor long-term solution for these problems, as it worsens digestion and your defense against bowel infections. Use the treatment(s) checked off below. After 1 month you can stop your prescription acid blocker and switch to Tagamet (cimetidine over-the-counter), up to 400 mg 3 times a day as needed, then taper off the Tagamet as able. Use #2 – Complete Gest Digestive Enzymes as well and sip warm liquids with meals instead of cold water (digestive enzymes work poorly at cold temperatures). Taking a minute to relax before eating and chewing your food will also help digestion. Coffee (including decaf), colas, Aspirin and/or alcohol can markedly worsen indigestion and reflux.
___ 172. Mastic Gum – 500 mg 2 capsules twice a day for 2 months – then as needed.
___ 173. Heartburn Free – by Enzymatic Therapies. 1 every other day for 20 days (may initially aggravate reflux).
___ 174. DGL Licorice/Rhizinate – 380 mg (not the sugar free one). Chew 2 tablets 20 minutes before meals, from Enzymatic Therapies/PhytoPharmica.
___ 175. Saventaro Cat’s Claw – 1 twice a day (see #66).