GI Assessment and Treatment

Dr. Paul S. Anderson ConsultDrA Webinar © PS Anderson and www.ConsultDrA.com 2020

ALL of these webinars will have AANP CE Accreditation. • The certificate at the end (last slide) will have the total and Pharm hours. • The AANP Accreditation has applied for ALL US States to date. • All webinars for the past 12 months have active AANP CE (for example this is 02-2020 so 03-2019 through this webinar are all active). • Past webinars will be re-accredited based on their viewership due to the high cost of re-accreditation of all the webinars. WE WILL DENOTE THIS ON THE WEBSITE AS WE RE-ACCREDIT WEBINARS.

(c) PS Anderson - www.ConsultDrA.com 2020 2 Conflict of interest: • None –I have no financial connection to ANY lab, product or company mentioned –Specific products (IF mentioned) are examples of items I use commonly in practice • © Images will be credited. If no credit given, they are (a) mine or (b) in the public domain

(c) PS Anderson - www.ConsultDrA.com 2020 3 Next Webinars All are Tuesday PM – 5:30 – 7:00 PM Pacific Time NOTE – All are third Tuesday of the month unless noted “*”

08-04-2020: IM/SQ Injection Update *08-17-2020 Mon: Toxins, Immune Function and Cancer 09-15-2020: 10-20-2020

19. Autoimmunity-2: Management 1. EBV diagnosis and Treatment 36. Organic Acid Testing 57. Benzodiazepine Rx and 2. Histamine – CNS 20. Chronic Infections – Testing, Management assessment and re-assessment 37. Migraine 3. Cortisol 38. PCOS 58. Anti-ID Rx Pharmacology 21. Lyme Illness – A top down approach 4. Iodine & T3 39. Fluoroquinolone Toxicity 5. Biofilms (#1) 22. Chronic Infection Bundle 40. GI Absorption and Rx 59. Eclectic and Low Dose Botanicals 6. Desiccated Thyroid 23. Oral Chelation 41. Dysautonomia and EDS 60. Natural Medicines for Chronic 7. Autoimmunity 24. Pain Medication Weaning 42. Low Dose Immunotherapy Infections 8. Histamine – Peripheral 43. Detox of Unusual Metals 25. Assessment of Chronic Cases 9. Mitochondria 44. NAD 61. Metabolic Toxins 10. ReDox and Inflammation 26. Nutrigenomic basics 45. Lab testing for B6, B12 and Folates 62. Adrenal Assessment and 11. IV and Injection Q&A 27. IV Therapy Q&A and Latest Updates 46. Acute Use of Thyroid and Adrenal-Rx Therapeutics: Clinical Diagnosis 12. Sulfation Pathways 28. ADHD Medications and Weaning 47. Assessing the Complex Patient and Management 13. Antidepressant Rx and Taper 48. Optimizing 21st Century 14. Pediatric Rx and dose 29. Seizure Medications and Weaning ND/Integrative Medicine 63. Red Flags and Critical Diagnoses adjustment 30. Low Dose Naltrexone – 49. Nasal & Respiratory Therapies 64. COVID-19 Updates 15. Renal Rx and Dose pharmacology, uses and cases 50. USP-FDA 2019 Update adjustments 31. Medical Cannabinoids 51. Bipolar Medications 65. Managing Comorbidities in 16. Biofilms #2 52. HBOT-2 Cancer and Neuro Chronic Illness 17. Cardiac Rx dosing and tapering 32. Neurological Inflammatory Therapies 53. Neuro-AI Part-1 18. Steroids and Respiratory Med’s 33. Food Allergy and Sensitivity 66. Repurposed Drugs in Oncology 54. Neuro AI Part-2 34. Hyperbaric Oxygen Therapies 55. Interrelationships in Chr-Dz 67. Immunology: Clinician Update 35. Kidney and Liver Functions – Effect 56. Neuro Manifest. Chron. Illness on Rx and Labs 68. Controversies in Oncology 69. Natural Immunologic Agents

(c) PS Anderson - www.ConsultDrA.com 2020 5 A quick note: If you are “reading the slides” only you’ll miss a lot as most of what I attempt to transmit is done verbally (the slides are a prop to keep me on

track and(c) PS toAnderson -tell www.ConsultDrA.com stories 2020 that 6 illustrate my points (I mean, please do read the slides as sometimes there are things on there that I don’t say – but know that the audio is more than 50% of the presentation.)

The gastrointestinal tract is often considered to be of paramount importance in long term health and disease prevention. “Treat the gut first” is common advice given and for good reason. In this CE Dr. Anderson will contrast normal GI function with how that function breaks down and the disorders associated with it. Natural and Pharmacological therapeutics will be discussed.

I. Key Concepts in GI Function

II. GI Testing

III. GI Pharmacology

IV. Concepts in Correcting Imbalances

V. Therapeutics

Mucosa and Smooth muscle (operated by autonomic and local signals) with differing functions throughout the GI tract 1. Digestion 2. Absorption 3. Metabolism 4. Immunity

(c) PS Anderson - www.ConsultDrA.com 2020 11 GI TRACT : INNERVATION (And – why is this important?) • EXTRINSIC INNERVATION – Parasympathetic NS • Excitatory • Carried by Vagus and Pelvic Splanchnic nerves – Sympathetic NS • Inhibitory • Carried by prevertebral ganglia (T-8 – L-2) • INTRINSIC INNERVATION – AKA: Enteric Nervous System (Local reflexes) – Two Plexi: • Myenteric (Auerbach’s) Plexus: MOTILITY • Submucosal (Meissner’s) Plexus: SECRETION & BLOOD FLOW.

• Stomach: – Histamine: [Stimulates Gastric H+] – G cells = Gastrin: [Stim. H+ and Gastr.Mucosa] • (+) Amino Acids; St. Distention; Vagal (parasymp). • (-) Gastric Acid; Secretin; GIP • Duodenum / Jejunum: – I cells = CCK: [Stim GB contraction and Oddi Relaxation; Panc Enz and Bicarb. secretion – Inhibits Gastric Emptying]. • (+) Amino Acids, Fatty Acids – S cells = Secretin: [Stim Panc. And GB Bicarb. Secretion – Inhibits Gastric Emptying]. • (+) H+ and Fatty Acids in the Duodenum – GIP: [Stim Insulin Secretion – Inhibits Gastric Acid Secretion]. • (+) Oral Glucose, Amino Acids and Fatty Acids

• Food allergy: – See webinar noted below. Consider the MOA being tested always. • Don’t forget stool metals assessment: – What does this tell us? • Why O&P suck – What if O&P does find something??? • Nothing is perfect: – Combine micro / PCR / Culture etc. for best yield.

• IgA ideas

–IgA elevation only?

• Implications of resistant H. pylori and ASO

Cimetidine H-2 Blocade: Blockshistamine PUD, GERD Small chemical so can Causes P450 [Tagamet] from activating cAMP pathway IN cross the BBB, think of system to PARIETAL CELLS (and antihistamine side effects accelerate THEN elsewhere). Also decreased libido, decelerate; impotence and Contraindicated with gynecomastia kidney or liver failure

Ranitidine H-2 Blocade: Less CNS and sexual Less inhibition of [Zantac] effects than Cimetidine P450 system Etc…

Omeprazole Block proton pump to inhibit PUD, Headache, diarrhea, Interact with (Prilosec) H+, K+ and ATPase and GERD abdominal pain, drugs that blocks the formation of nausea, require low Lansoprazole gastric acid vomiting, gastric pH for

(Prevacid) constipation, absorption flatulence, Rabeprazole URI, (Aciphex) rash

Pantoprazole (Protonix)

Esomeprazole (Nexium)

• [3-2-2011] The U.S. Food and Drug Administration (FDA) is informing the public that prescription proton pump inhibitor (PPI) drugs may cause low serum magnesium levels (hypomagnesemia) if taken for prolonged periods of time (in most cases, longer than one year). – In approximately one-quarter of the cases reviewed, magnesium supplementation alone did not improve low serum magnesium levels and the PPI had to be discontinued. • [02-08-2012] The U.S. Food and Drug Administration (FDA) is informing the public that the use of stomach acid drugs known as proton pump inhibitors (PPIs) may be associated with an increased risk of Clostridium difficile– associated diarrhea (CDAD). A diagnosis of CDAD should be considered for patients taking PPIs who develop diarrhea that does not improve.

(c) PS Anderson - www.ConsultDrA.com 2020 20 https://medicine.uiowa.edu/iowaprotocols/proton-pump-inhibitor- side-effects-ppi-considerations

[04-27-2019] Proton Pump Inhibitor Side Effects PPI Considerations… 2016 Schoenfeld and Grady classified adverse effects: • Kidney Disease • Hypomagnesemia • Infections / Cardivascular Events • Fractures • And to this scheme additional sections on malignant change, B12 absorption, and dementia are added. *** The link above has an excellent database.

(c) PS Anderson - www.ConsultDrA.com 2020 21 They do fine ON acid blockers (or even the triple GI healing formula) and Sx return when off them?

• Every case I have seen there is another reason for the “fire”: – H. pylori or other infection – Food allergy or sensitivity – Gastric or maybe other cancer – Occasionally sneaky hypothyroid states… • Your work up and treatment combined with the patient compliance is the only thing that can change this.

Metoclopramide Stimulates motility of GERD, pre-op Diarrhea, Extrapyramidal [Reglan] upper GI tract to gastric emptying, restlessness, side effects increase rate of nausea / anxiety, fatigue, gastric emptying, vomiting with seizures, works on the CNS chemotherapy headache, treatments drowsiness

NO Absorption Decreases other Sucralfate GI Demulcent used to drug GI Powerful [Carafate] coat tissues so they absorption – use demulcent activity. can heal. away from meds. Dose between meals and before bed acutely.

“Belladonna Anticholinergics CNS depression. Alkaloids” (Parasympatholytic) Constipation, dry mouth, N/V, drowsiness, headache Hyoscyamine Diarrhea / [Levsin] Belladonna alkaloid Spasms (hyoscyamus) Dicyclomine IBS / Spasms Anticholinergic

Scopolamine Act upon Muscarinic Motion Available in Receptors, more potent Sickness transdermal at eyes, less potent on prevention application heart, lungs and GI Increases digoxin levels

Opium Tincture Inhibits GI motility by Diarrhea Constipation, Many side effects [Paragoric] binding opiate receptors abdominal pain or and drug-drug and muscarinic distention, nausea interactions Diphenoxlylate & receptors Atropine [Lomotil]

Loperamide Acts directly on Diarrhea Constipation, dry Hepatotoxic at [Imodium] intestinal muscles to mouth, abdominal high doses inhibit peristalsis and pain, distention, skin prolong transit time rash

Prochlorperazine Anti-DOPA Antiemetic Extrapyramidal Side Effects! [Compazine] Chlorpromazine [Thorazine]

Ondansetron 5-HT-3 Antiemetic CNS effect (can be similar to an [Zofran] Antagonist H1 drug) Dola- Increase AST / ALT (Rare Alo- unless you draw labs after a does or the patient is on the Granisetron drug constantly.

(c) PS Anderson - www.ConsultDrA.com 2020 27 Stool MOA Uses Adverse Effects Other Softeners Docusate Reduced surface Constipation Electrolyte TOXIC with [Colace] tension of the oil- imbalance with concomitant water interface of excessive use, mineral oil stool to soften it. decreases use. coumadin effect

Saline Draws water into Constipation, Abdominal Short term [Milk of lumen pre-op cramps, nausea, treatment Magnesia] vomiting, only diarrhea

Bulk Forming MOA Uses Adverse Effects Other Agents

Psyllium Swells in water to form Constipation Flatulence, may Slower acting [Metamucil] gel or viscous solution, cause impaction 1-3 days softening the stool Guar Gum [BeneFiber]

Castor oil Stimulate intestinal mucosa Constipation Nausea, vomiting, by irritating mucosal lining cramps, anorexia Senna

Cascara

Prunes

Bisacodyl Increases water and Constipation Diarrhea Do not mix with milk or antacids because it [Ducolax] electrolytes to increase can prematurely dilute motility the enteric coating of the tablet

Sodium- Osmotic stimulant enema GI Pain, Dehydration Phosphate Enema

HCL Restore gastric acidity Hypochlorhydria OD will damage esophageal and stomach epithelium

Digestive Improve food digestion Pancreatic Enzymes insufficiency, Pancrease… maldigestion, inflammation

Bile Salts Bile Acid that probably Cholelithiasis Nausea, diarrhea, Ursodiol suppresses hepatic Surgical acute cholecystitis, cholesterol release into alternative colic the biliary tract, slowly solublizing NON Ca++ Bile Stones.

• Consider the organ(s) involved – Recall they are not always the ‘only’ ones • Consider aggravating factors – Allergy – Autoimmunity – Medications – Toxins – Biofilms • If removing infections / dysbiotic organisms always have some GI support supplements as well • Once therapy is complete assure good diet and supplemental biotic support

• Digestive system therapies fall into categories of effect. These categories are generally acute use and then products for long term or recurrent symptom / disease use. • Generally support for the lining of the GI tract and biotic balance should be done daily throughout therapy and can be achieved by nightly dosing of a demulcent and probiotic.

• Modulation of immune-inflammatory factors is also critical throughout. • Clearing of dysbiotic or pathogenic organisms is a high priority early in therapy. • After active therapies a final push to calm, heal and repopulate the GI tract must be made. • And finally the patient must be counseled to watch for signs of slipping back into old symptoms.

• Once diagnosis (or presumptive diagnosis) is made then assisting in the immediate control of uncomfortable symptoms is necessary. • After this acute care step then assessing the depth of need and order to treat must come in to play. • Focus on: – Symptom control – Primary pathologies assessed and therapy began

• Allergy • Autoimmunity • Medications • Toxins • Biofilms • Etc…

Long term GI support relies heavily on need for treatment, length and type of prior disorder or disease and removal of underlying aggravating factors if possible. Generally people will require less and less GI supportive therapy as the GI tract fully heals. Consider: • Did the acute therapy re-set the system or is more needed? • Are food intolerances – allergens removed from the diet? • Is the diet adequate and well balanced? • Are any dysbiotic or pathogenic flora still in the GI tract? • Is there a chronic condition (autoimmune, post GI surgery status etc.) which may not go away we need to factor in?

First: Remember to replace what the organ produces BUT don’t forget the other things that the part removed signals. (See next slide for a reminder).

• Stomach: Always best with smaller meals and a triple support (Enzyme-Acid-Bile) supplement taken AS THEY EAT. • Ileum: Obvious concerns with B12 and possibly Iron. Also since bile slats won’t reabsorb, they will require binder (fiber). • Colon: Depends on amount removed. Definitely will need binders.

(c) PS Anderson - www.ConsultDrA.com 2020 40 Digestive Aids MOA Uses Ideas on dosing: HCL Restore gastric acidity Hypochlorhydria - Always take DURUING the Digestive Improve food digestion Pancreatic meal. Enzymes insufficiency, - Exception is enzymes for Pancrease… maldigestion, systemic absorption which are inflammation ‘ic’ Bile Salts Bile Acid that probably Cholelithiasis - Dose is relative to patient Ursodiol suppresses hepatic Surgical need AND size / macronutrient cholesterol release into alternative composition of meal. the biliary tract, slowly - Often if enzymes aren’t solublizing NON Ca++ “working” the person needs HCl Bile Stones. and Bile. - The old school dosing of Betaine HCl was keep taking more with each meal until you feel “warm”… - Caution with HCl and potential gastritis or ulcer. REALLY

(c) PS Anderson - www.ConsultDrA.com 2020 41 “I just don’t believe in digestive supports like enzymes…” But won’t the digestive supports just make them dependent and stop their body from working properly?

• If they have all their organs you can taper off the support.

• Often a good bridge is to add in bitters with each meal (ideally before and maybe during).

• And some will be able to be removed faster than others but that is individual. (HCl vs Bile vs Enzymes).

• Like many things, a slow taper is better.

• These can be given at bedtime during an “anti-infective” therapy

• Ideal mix is:

– Demulcent Herbs (Ulmus, Althaea, DGL…)

– GI Cell Support (Glutamine, Carnosine…)

– Probiotics

• L-Glutamine

• L-Glutamine Powder (3 grams/tsp)

– Dose: 2-4 grams TID-BID

• Also see the combination products (next slide)

This is a common supplement available. There are many like it – for CME purposes I will not share companies or names – but if you look at your favorite manufacturers you’ll find a like product.

Amount per Serving • L-Glutamine 3500 mg • Deglycyrrhizinized Licorice Root 500 mg 10:1 Extract • Aloe Leaf Extract† 50 mg (Aloe barbadensis)

Dose: 1 scoop up to TID (before or between meals) and HS

(c) PS Anderson - www.ConsultDrA.com 2020 47 Digestive Enzymes: Consider the formula and if additions (HCl, Bile) are required or not. • Enzymes Only: – Proteins – Carbohydrates • Enzymes plus HCl: – Opens proteins up for enzymes

– Activation of stage two enzymes from stomach • Bile Acids: – Lipid soluble absorption

• Bile from bovine source, freeze-dried. Suitable to supplement the liver's production of bile for digestion. • Ingredients: – Organic lyophilized beef glandular

Dose: 1-3 taken with food in the middle of the meal each time they eat

Consider the reason for needing the product, and relative benefits of each: • Direct “topical” GI anti-inflammatory

• Enteroendocrine balancing

• Decreasing GI Histamine release

• GI Cell support and regeneration (c) PS Anderson - www.ConsultDrA.com 2020 50 TURMERIC Direct GI anti-inflammatory

A combination product – in GI therapy it can be very synergistic to have both Curcumin (for absorption) and Turmeric (for ‘topical’ benefits in the GI tract.) • organic termeric rhizome 230mg+ – (Curcuma longa Linn.) • organic turmeric rhizome powder 370mg+ – (1% Curcuminoids - 3.7mg+) ** Also may be used in enema formulations Dose: 2-4 taken TID with food  In most IBD I will use both a turmeric and a curcumin formulation.

(c) PS Anderson - www.ConsultDrA.com 2020 51 QUERCETIN + NETTLES Direct GI Anti-inflammatory Amount per Serving • Quercetin 600 mg • Nettles Leaf (Urtica dioica)(leaves) 600 mg • [standardized to contain 1% silicic acid]

Dose:2-4 taken TID with food

Nutrition Facts • Serving Size 3 Drops • Serving Per Container About 320 • Amount Per Serving • Iodine (as Iodine, Potassium Iodide) 150 mcg • Other Ingredients: Purified Water.

Dose: 5 – 25 drops QD-BID

• l-Glutamine nutritionally supports the strength of the mucosal lining and the proper functioning of the gastrointestinal tract and supports the development of muscle mass.

• Each Level Teaspoon Contains – l-glutamine (free-form) 3 g.

Dose: 2-4 grams TID-QID

Often best rotated as the GI tract can be home to so much diversity: • Biofilm agents • Direct anti-infectives – Fungi – Viri

– Parasites – Bacteria – Etc…

• The GI tract is where Biofilms start. • General biofilm disruption can be often effected by the use of 500-600mg NAC BID-TID or ALA 300-400 mg BID-TID. • If the person has a phase-2 Biofilm the Rx below will help (compounded): *DMPS 25mg/ Alpha Lipoic Acid 100mg/ Bismuth Subnitrate 200mg per Capsule – Ideally no substitutions – DMSA 100 mg can sub for DMPS – Bismuth Subcitrate can sub for Subnitrate (will make product weaker)

• A 90 minute online CME on advanced Biofilm Rx and management is available: https://www.consultdranderson.com/product/biofilms-update/

Liquid Iodine - With Iodine & Potassium Iodide

• Nutrition Facts - Serving Size 3 Drops Amount Per Serving Iodine (as Iodine, Potassium Iodide) 150 mcg Other Ingredients: Purified Water.

Dose: 5 – 25 drops QD-BID

AuthorsInoue H, et al. The suppressive mechanism of histamine release from rat peritoneal mast cells of iodine-enriched eggs. Int J Tissue React. 2001;23(3):73-9. PMID 11517853

• Amount per 3 capsules Berberine Sulfate 300 mg Grapefruit (Citrus paradisi) Seed Extract 300 mg Gentian (Gentiana lutea) Root Extract 225 mg Black Walnut (Juglans nigra) Hull Extract 150 mg Garlic (Allium sativum) Bulb Extract standardized to contain 1% allicin (odor-reduced) 150 mg Goldenseal (Hydrastis canadensis) Root Extract standardized to contain 5% total alkaloids including berberine, hydrastine, and canadine 150 mg Jamaica Quassia (Picrasma excelsa) Bark Extract 150 mg Sweet Wormwood (Artemisia annua) Aerial Part 150 mg

Dose: 2-4 BID-TID with food

• Each capsule contains:

Artemisinin 100 mg or Wormwood 300-400 mg

• Dose: 2-4 BID-TID with food – Cycle 4 days on and 3 days off (If using long

term watch CBC and iron).

Supplement Facts • Serving Size 1 Capsule - Servings Per Container 60 Amount Per Serving

• Oregano leaf supercritical extract *(32 mg Carvacrol and Thymol) 230 mg

• 2-4 BID-TID with food

(c) PS Anderson - www.ConsultDrA.com 2020 60 You will all have many favorite Nat- Meds • So my list is short. • Others I like are Olive Leaf, Oregon Grape, Garlic etc. • The “---bactin” (AR/BR) supplements are great as are many other proprietary formulations. • ROTATION is usually the best in a long-term case.

Treating Parasites In Children https://ndnr.com/pediatrics/treating-parasites-in- children/

Stephen Wangen, ND

• These can be given at bedtime during an “anti-infective” therapy

• Ideal mix is:

– Demulcent Herbs (Ulmus, Althaea, DGL…)

– GI Cell Support (Glutamine, Carnosine…)

– Probiotics

• Basically agents are used to either speed up or slow down motility in the GI tract.

• Speeding motility: – Bulk – stretch receptor activation – Osmotic agents – hydrate stool – Cathartics – chemical stimulation of motility

• Slowing the motility: The goal is to have motility agents be temporary. In some – Decrease inflammation chronic conditions or other situations some may be needed periodically or chronically. – Decrease free fluid – Chemical inhibition

• Magnesium Oxide 500 mg Capsules

– Brings water into the GI tract and stool

– Increased stool hydration = ease of movement

Dose: 1 to 6 per day

• Psyllium Husk 525 mg Capsules

– Bulking agent

– Activates stretch receptors in the GI tract

– Improves movement

Dose: 2-6 QD to TID WITH 12 oz water

Serving Size: 3 capsules - Amount per Serving: Magnesium (as citrate, malate) 200 mg Yellow Gentian root ~ Gentiana lutea 500 mg Turkey rhubarb root ~ Rheum palmatum 250 mg Triphala powder 250 mg Haritake Fruit ~ Terminalia chebula Amla Fruit ~ Emblica officinalis Bibhitake fruit ~ Terminalia belerica Dandelion root ~ Taraxacum officinale 100 mg Protease 37,500 HUT Amylase 7,500 SKB Lipase 250 FIP Cellulase 125 CU Invertase 50 Sumner Lactase 250 ALU Bromelain 50 GDU Dose: 1-2 BID - TID

Serving Size: 1 capsule

Amount per Serving: - vitamin C (as ascorbyl palmitate) 5 mg - cinnamon (Cinnamomum cassia) (dried bark) (10-15:1) 125 mg (standardized to contain 3% trimeric and tetrameric type-A polymers)

Dose: 1-4 per meal

• Psyllium Husk 525 mg Capsules

– Bulking agent

– Activates stretch receptors in the GI tract

– Improves movement

Dose: 2-6 QD to TID with just enough liquid to swallow

Toxicity: Generally parasympatholytic effect is primary Sx to watch for and notify patient. Unlikely as a tincture to cause more than that. Minimum dose: Generally 10 gtt t.i.d. to get pharmacologic (parasympatholytic) effect. Indications: • Congestion • Insomnia • Smooth muscle irritability (Diarrhea, colic etc.) • Cystitis Child: 10 gtt in 4 oz fluid; 1 tsp per hour Adult 3-5 gtt per dose t.i.d. – q.i.d. (Acyte diarrhea 5 mL PO TID-QID) Can be given per-rectum

TOXICITY : Sedation, possible cardiac depression. Treat overdose with charcoal, emetics, cardiac tonics, and fluids, as needed.

INDICATIONS : Non narcotic sedative, Hypnotic. Tolerated well by children. Acts to bring equilibrium to the nervous system. Consider as synergist in Neuropathies, Muscular hyperactivity, possibly in Strabismus.

DOSE : 1 to 10 gtts, as tolerated, up to tid. Max per dose is 3-5 mL without GI upset

• The human GI microbiome has billions of organisms with a great diversity. • Each strain of organism confers its own benefits on the digestive system and the immunity of the body. • Each section of the GI tract is home to a variety of organisms which can be shared with other sections or unique to that part of the GI tract. • As GI therapy the probiotics should be used (if clinically applicable) in a rotation to increase the diversity available.

Human Microflora: Serving Size: 1 Capsule - Amount per Serving Probiotic Consortium 10 billion CFU Lactobacillus acidophilus (CUL-60) Lactobacillus acidophilus (CUL-21) Bifidobacterium bifidum (CUL-20)

Bifidobacterium animalis subsp. lactis (formerly Bifidobacterium lactis) Fructooligosaccharides (FOS) 100 mg

Dose: 2 to 4 per day

Multi-probiotic: Serving Size: 2 Vegetarian Capsules - (yielding 40 billion CFU) Short Chain Fructooligosaccharide (NutraFlora® scFOS®), Bifidobacterium bifidum, Bifidobacterium breve, Bifidobacterium lactis (infantis), Bifidobacterium lactis HN019, Bifidobacterium longum, Lactobacillus acidophilus, Lactobacillus brevis, Lactobacillus bulgaricus, Lactobacillus casei, Lactobacillus gasseri, Lactobacillus paracasei, Lactobacillus plantarum, Lactobacillus rhamnosus, Lactobacillus salivarius, Lactococcus lactis, Streptococcus thermophiles

Dose: 1 to 4 per day

Saccharomyces boulardii • Serving Size: One Capsule • Each Capsule Contains: – Saccharomyces boulardii 250 mg

S. boulardii is used for the purpose of introducing beneficial active cultures into the large and small intestine, as well as conferring protection against pathogenic microorganisms in the host. - Amir Qamar, et.al. Saccharomyces boulardii Stimulates Intestinal Immunoglobulin A Immune Response to Clostridium difficile Toxin A in Mice. Infect Immun. 2001 Apr; 69(4): 2762–2765. doi: 10.1128/IAI.69.4.2762-2765.2001. PMCID: PMC98222 - Zanello G, et.al. Saccharomyces boulardii effects on gastrointestinal diseases Curr. Issues Mol. Biol. 11: 47-58.

• In the case of immune suppression (biologic medications, long term HIGH

dose steroids, chemotherapy etc.) the goal of probiotic supplementation

should be to protect the GI trach biome while not introducing non-human

strains.

• In these cases I clinically use the “Human Microflora” strains exclusively until

the immune system is working more normally.

[Steam, soup or juice] •Spinach •Kale •Parsley •Beet Greens •Cabbage (very important for GI tract healing) [Eat as is] •Sesame Butter (Tahini) •Sesame seeds •Pumpkin seeds •Dried apricot •Dried tomato •Raisins •High Acidophilus Yogurt [Pre-biotic foods to help GI healing] •Onions, bananas, garlic, honey, leeks, artichokes

• Always treat Biofilms. If using Phase-1 agent then switch to Phase-2 • ADDITIONALLY do a trial of DMSA or DMPS to “starve” the organism of minerals / metals it may be using for metabolism. REMEMBER ORAL DMSA- DMPS ARE POORLY ABSORBES SO THEY ARE GREAT GUT CHELATORS. – I generally use DMSA 250-500 mg or DMPS 100-200 mg QHS and away from minerals 2-3 days on per week and the rest off. – IV will not help this application. • Also consider bugs you have not found and use broader anti-infective meds.

Butyrate enemas are used as a complimentary therapy to treat various gut- related problems, such as ulcerative colitis.1,2 The enema works locally and is more effective when the disease affects the lower region of the digestive tract (distal colitis).3 Butyrate appears naturally as a short-chain fatty acid (SCFA). Butyrate is mainly produced when intestinal microbes ferment dietary fibers but can also be made when they ferment dietary proteins. Butyrate is an energy source for colonic epithelial cells, and has anti-diarrheal, anti-inflammatory, and anti-cancer effects, which suggests it plays a role in a wide array of cellular functions linked to colonic health.1 Some research has proposed that ulcerative colitis may be due in part to energy deficiency of the colonic mucosa, a consequence of impaired SCFA production, uptake and/or utilization.3 As such, butyrate may help with reversal of this energy deficiency.

• CCNM Biological Drugs CE https://www.ccnm.edu/alumni/continuing- education/biologic-medications-pharmacology-patient-management • Webinars we have completed: – #58 THE “OTHER” BOTANICALS (“LOW DOSE,” “TOXIC,” “ECLECTIC,” ETC.) – #59 NATURAL MEDICINES FOR CHRONIC INFECTIOUS CASES – #57 PRESCRIPTION AND MANAGEMENT OF ANTI-INFECTIVE MEDICATIONS FOR CHRONIC INFECTIOUS DISEASE – 03-2018: NUTRIENT ABSORPTION AND GI HEALTH – 09-2017: FOOD ALLERGY AND SENSITIVITY SYNDROMES – Biofilms

(c) PS Anderson - www.ConsultDrA.com 2020 79 Butyrate Enema in Ulcerative Colitis [2] • 10 patients with distal ulcerative colitis unresponsive to or intolerant of standard therapy for at least 8 weeks were assigned in a random order (single- blind) treatment for 2 weeks with sodium butyrate (100 mmol/L) or 2 weeks of placebo. • Two rectal enemas administered 100 ml per day and patients remained supine for 30 minutes. Three patients extended treatment for 4 weeks. • Prior to study, all 10 patients experienced constant diarrhea for at least 3 weeks. After treatment, defecations per day reduced significantly from 4.5 ± 0.5 to 2.1 ± 0.4 (p < 0.01).

• Fecal blood observed in 9 of 10 patients in control phase; after butyrate only 1 of 10. Reductions in endoscopic appearance score 6.5 ± 0.4 to 3.8 ± 0.8 (p < 0.01) and histologic degree of inflammation 2.4 ± 0.3 to 1.5 ± 0.3 (p < 0.02) also occurred. • Three patients with slight improvement continued for 2 more weeks with further regression of inflammation. • Adverse effects: enemas retained for 30 minutes and in some cases up to several hours and no side effects reported.

1. Hamer HM, Jonkers D, Venema K, Vanhoutvin S, Troost FJ, Brummer RJ. Review article: The role of butyrate on colonic function. Aliment Pharmacol Ther 2008. Jan 15;27(2):104-19 2. Scheppach W, Sommer H, Kirchner T, Paganelli GM, Bartram P, Christl S, Richter F, Dusel G, Kasper H. Effect of butyrate enemas on the colonic mucosa in distal ulcerative coilitis. Gastroenterology. 1992 Jul;103(1):51-56. 3. Lawrance IC. Topical agents for idiopathic distal colitis and proctitis. J Gastroenterol Hepatol. 2011 Jan;26(1):36-43.

(c) PS Anderson - www.ConsultDrA.com 2020 83 Next Webinars All are Tuesday PM – 5:30 – 7:00 PM Pacific Time NOTE – All are third Tuesday of the month unless noted “*”

08-04-2020: IM/SQ Injection Update *08-17-2020 Mon: Toxins, Immune Function and Cancer 09-15-2020: 10-20-2020

New “MasterClass” Series at DrA-Academy.com Emergency Medicine for the Medical Office 4.5 Total AANP CME of which 2.0 are Pharmacology --- And More Series to Come (Medical Laser, HBOT, etc.)

TAB – DrA’s IV Monographs: WWW.ConsultDrA.com Tell your friends we have lots of free content…

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NEW WEBSITE RE-BOOT IS HAPPENING!!

DATE CHANGE August 21, 22 & 23(Friday through Sunday)

Advanced Applications in Chronic Digestive Disorders

(c) PS Anderson - www.ConsultDrA.com 2020 88 Daily Focus Areas: aampscottsdale.com FRIDAY: GI Assessment and Treatment in the Chronically Ill Patient • From signs and symptoms to testing and diagnosis – Latest Updates and Best Practices • Infectious Diseases • Autoimmune Diseases • Other Inflammatory Syndromes • Cancers SATURDAY: SIBO – SIFO and Dysbiotic Overgrowth Syndromes • Making sense of SIBO-SIFO: How do I reliably assess and treat a patient? • When to think of “Overgrowth” in a chronic case • Diet Changes and Therapies • Prescription and Natural Therapy Strategies • End the day feeling updated and confident in managing overgrowth syndromes SUNDAY: Allergy – Sensitivity – GI Repair • MCAS – POTS: Latest concepts in assessment and treatment • Food Allergy and Sensitivity: What’s the latest science and their clinical implications • GI Repair: Best practices during and after intensive GI therapies

MOLD, ALLERGY, RESPIRATORY DISEASE AND THEIR SYSTEMIC EFFECTS: THE IMMUNOLOGY AND TREATMENT OF MYCOTOXIN AND IMMUNO-REGULATORY ILLNESS.

TOPICAL AREAS: • MOLD & MYCOTOXIN / BIOTOXIN ILLNESS • CIRS • MAST CELL DISORDERS • ALLERGY: RESPIRATORY & Systemic • INFECTIOUS COMPLICATIONS • OTHER RELATED CLINICAL SYNDROMES

• Paul Anderson • Mary Beth Ackerley MD, MD(H), ABIHM • Jill Crista, ND • Kellyn Milani, ND • Lauren Tessier, ND

This is to attest that: Dr. ______

Attended the webinar “GI Assessment and Treatment” given online live or via recording on or after 07-21-2020 (If viewed as a recording a competency exam was taken and is on file for jurisdictions such as WA State or BC, Canada) Duration: 1.5 clock hours Pharmacology 1.0 hours This event discussed “GI Assessment and Treatment” - AANP CE Credit. Faculty: Dr. Paul S. Anderson