This compounded pharmaceutical is often used to address autoimmune conditions in functional, integrative, and naturopathic medicine. It is one of the top 5 pharmaceuticals that I prescribe (for autoimmunity, chronic pain, mold toxin-induced illness, and more), but it is NOT something I initiate in the first or second visit.
Overview of today’s email:
- What is LDN?
- My experience with prescribing LDN
- Some resources
1. What is LDN?
LDN stands for Low Dose Naltrexone.
A quick PubMed search shows reviews and studies on many chronic conditions including chronic pain, fibromyalgia, rheumatological diseases, post-COVID-19 sequelae, cancer therapy, chronic fatigue syndrome, IBD, and multiple autoimmune conditions.
Dr. Bernard Bihari is responsible for discovering the clinical effects of LDN in humans. It was the mid 1980s, and he had been working with patients experiencing addiction. Naltrexone came out around this time, but at the dose recommended, had a lot of side effects.
He shifted to working with those with HIV/AIDS after he learned of the effects of naltrexone on endorphins, and that patients with HIV/AIDS had significantly lower levels of endorphins.
The increase in endorphins with naltrexone leads to a cascade of potential benefits including but not limited to:
- Relieving pain
- Shifting blood flow to the brain and muscles
- Supporting the immune system
Read more about Dr. Bihari’s interview on the discovery of LDN here.
Other things to know:
- The half life of LDN is around 4 hours
- The effect of LDN - increasing endorphins - lasts up to 24 hours
- Due to first pass effects, bioavailability of oral LDN is around 30%
- 90% of endorphins are produced between 2 and 4am, which is why LDN is recommended to be taken right before bed
2: My experience with prescribing LDN
Contrary to what you may see in online functional medicine forums, I don’t find that LDN is always a game changer.
With the patients for whom I have prescribed this, I’d estimate that 50% of patients may see a noticeable effect (either for symptoms and/or for lowering antibodies).
I suspect that some of this has to do with whether someone has more of a Th2 vs Th1 dominant immune response (check out Cogence Immunology courses if you want a deep dive into this!).
A few clinical tips to potentially increase the efficacy of LDN:
- Add a trial of LDN after addressing inflammatory lifestyle factors, optimizing omega 3 intake, and addressing non-restorative sleep
- After speaking with someone a few years ago who is involved in LDN research, I screen for candida overgrowth/immune reactivity (labs and/or symptoms) before adding LDN (candida imbalances appear to decrease efficacy of LDN)
Clinical tips on dosing and effects:
- Average dose per literature is 4.5mg, but I tell all my patients to stick with whatever dose appears to have a benefit on symptoms (lowest effective dose); max dose I will prescribe is 9mg
- I start most patients on 1 or 1.5mg capsules/tabs, and have them increase the dose every 2 weeks
- Most common (usually temporary) side effects are insomnia or vivid dreams (not necessarily nightmares); take in the morning if this occurs, for 2-4 weeks, before trying to take it again in the evening
- Set expectations with patients: If focusing on symptomatic relief, let them know it can take 4-6 weeks to see results (lab changes take closer to 3 months); if no difference in symptoms or labs, I generally will pause use (cost is around $1 per tab, and most of my patients are cost conscious)
- I do continue LDN in pregnancy (but will not start it during pregnancy); for medico-legal purposes, I document that there are no OBGYN organizations that support its use but that it is successfully used in the NeoFertility Clinic based in Ireland (I generally refer patients to watch this interview with Dr. Phil Boyle)
3: More resources on LDN
Thanks for reading!
Next week's topic = Dietary approaches to autoimmunity.
Meg
P.S. Did you notice a difference in the subject line of today's email?! I added "practical" because that is how I describe my approach (and what the collective mentorship will be focused on!). Join me for one of the brainstorming sessions on the Functional Medicine Collective Mentorship!
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