Case Studies in an

Integrative Pharmacy Practice II

By

Mark Burger, Pharm.D.

Health First! Pharmacy & Compounding Center

Objectives Give pharmacists some guidance in adding an

integrative pharmacy approach to their current operation;

Give pharmacists some recommendations as to potential sources of information and reference in maintaining a knowledge-base to support an integrative practice;

Demonstrate the application of an integrative practice through the use of case studies;

Discuss some of the financial incentives to adding an integrative model to an existing pharmacy practice.

A perspective …

"The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease."

~ Thomas Edison

"I am always doing that which I cannot do, in order that I may learn how to do it."

~ Pablo Picasso

Some Basics About My Practice

Compounding / Integrative only Large front-end “nutraceuticals only” (> $100K inventory) Highly dedicated and trained staff (everybody must read

and understand A Message To Garcia by Elbert Hubbard

17 pages [see www.wizardofads.com to order ] My wife/partner is our Buyer Small community of ~ 26,000 (County 500,000) Mixed-Use Development: We live above our pharmacy Open 7-Days per week

Some Basics About My Practice

Small consultation room w/o a desk Professional Brands only (~95%) Only about 100 SKUs of traditional OTCs Special orders welcomed and handled

promptly My staff promotes my Consults to most

customers (or we refer them to practitioners we trust … so we DRIVE referrals and the docs reciprocate)

Location

Views of the Town Green

Health First Pharmacy

Some Basics About My Practice

Graduated fee structure (15 min, 20 min, 70 minute consults)

We sell lab test kits (Saliva, Blood Spot, Urinary neurotransmitters, Iodine saturation, WBC nutritional analysis) only w/referral

On average, consultations result in sales of another $200-500 in products

Follow-Ups w/MDs result in consult referrals FROM doctors for other patients

Case 1: When to use adaptogens

“All plants contain adaptogenic/tonic compounds because plants have to contend with a good deal of stress themselves”

~ James Duke, PhD ethnobotanist & scientist Defined by Nicolai Lazarev circa ’47: “allows the body to counter

stress by raising non-specific resistance to stressors thereby allowing the body to ‘adapt’”

Balance endocrine system and modulate immune system Further defined in ’68 by I. Breckham, PhD:

1) non-toxic to recipient;2) non-specific response/resistance to chemical, biological or physical insults;3) a normalizing influence on physiology REGARDLESS OF THE REGARDLESS OF THE DIRECTION OF CHANGEDIRECTION OF CHANGE from the norm caused by the stressor.

Some adaptogens

American ginseng (Sang, seng) Amla(Indian gooseberry) Asian ginseng (Korean or Chinese ginseng) Astragalus (Milk vetch) Cordyceps (Chinese caterpillar fungus) Eleuthero (Siberian ginseng) Holy Basil (Tulsi) Licorice (Glycyrrhiza)

Some adaptogens (cont.)

Lycium (Goji, wolfberry) Maca Reishi (Ganoderma) Rhodiola (Golden root) Schisandra (Chinese magnolia vine) Shatavari (Indian asparagus root) Relora (Magnolia Bark) Phosphatidyl serine (PS)* Pregnenolone*

* Not officially an adaptogen

Remember the “Cold War” Remember when the USA and USSR tried to outdo each other in

the Olympics? Russian scientists knew of the ability of adaptogens to increase

stamina and improve oxygen intake and improve athletic prowess and they gave them, legally, to Russian athletes;

They could enlist thousands of mine workers to participate in studies (no Institutional Review Boards to deal with!): Results-67% reduction in flu cases during epidemic, 30% improvement in productivity, 40% reduction in heart disease, 50% reduction in chemotx doses + 50% reduction in damage to immune system by chemotx given for gastric CA

These results have been duplicated by German and Japanese researchers

Over 1500 studies YET TO BE TRANSLATED INTO ENGLISH!

Do you ever have a patient that DOESN’T have stress?

Test their 4-point cortisols (we rarely see a normal diurnal pattern) & DHEA

Anxiety, carb cravings, joint inflammation, BS dysregulation, sleep disturbances, thyroid dysregulation, BP changes, immune dysfxn, reduced DHEA, hair loss

Low-dose, slow-release Cortisol caps can help but sometimes cause jitteriness

Common Stressors Biologic (bacteria, parasites, mold, viral) Chemical (pesticides, herbicides, fungicides,

insecticides, heavy metals, household cleaners, fumes, smoke, tobacco & drugs(!)

Environmental (noise, UV light, allergens, xenoestrogens, EM & radiation)

Physical (High BP, long workouts(!), surgery, trauma, drug use, new baby, infection, etc.)

Psych (depression, anger, fear, anxiety, worry, desire, grief, loss, mental illness, etc.)

Spiritual (soul sickness, loss of worth (job? relationship? Empty Nest Syndrome?)

Some uses (Health First! Top 5)

Holy Basil: 2 PO QAM w/food, repeat @ 2 PM (helps w/inflammation & high blood sugars)

Pregnenolone 10, 30, 50 mg PO or S.L. or put into compounded hormone creams (Rx) [really helps when there are memory problems]

Phosphatidyl serine complex (500 mg PO QD-TID … combine with Phosphatidyl choline) [really good for sleep disturbed patient]

Rhodiola rosea root (100-400 mg PO QAM 30 min. before food … start slow) [good for high anxiety pt.]

Combo [B-6, B-5, Vit C, L-tyrosine, rhodiola, eleuthero, ashwaganda, choline, ginger, licorice, astragalus, schizandra] Dose: 2 PO upon arising, repeat at 2 PM.

Some commercial products

Phyto-ADR by Pure Encapsulations Energy Xtra by Pure Encapsulations Cortisol Control by Complimentary Rx Adreset by Metagenics Daily Stress Formula by Pure Encaps. Cortisol Manager by Integrative Therap. AdreCor by NeuroScience Inc. Boswellic acid (when inflammation is big factor)

e.g. NorLox or Boswellia by Pure Enc.

Case 2: Digestive Disorders

“No matter what you do, if the patient is not absorbing nutrients, you will not be successful at helping them”. ~ M. Burger

8 out of 10 of the people who walk through our doors have digestive issues

People are taught to accept digestive disorders as part of the “passage” through life

OR, they are overmedicated for them

The Problem (as Functional Medicine sees it):

Gastric juices (as well as most bodily fluids) are reduced with age (HCl, pancreatic fluids, etc.)

Without adequate HCl acid there is poor absorption of protein, minerals, B-vitamins, Folic Acid, Drugs(!)

Without adequate HCl there is overgrowth of H. pylori, Campylobacter, Giardia, etc.

Without adequate HCl the LES stays open and the Pyloric valve does not open

Without a pH < 2.0, pepsin does not work If we don’t digest well in Upper GI, Lower GI

problems will plague us (gas, yeast, inflammatory bowel diseases like IBS, Crohn’s, Diverticulitis, etc)

The Problem as others sees it Hyperacidity, Zollinger-Ellison Syndrome,

GastroEsophageal Reflux Disease (GERD) MUST be reduced with H-2 blockers and PPIs to

prevent Barrett’s Esophagitis and Esophageal Cancer

These drugs can be given indefinitely These drugs are now OTC and can be given Ad Lib

w/o medical supervision When they stop working, double dose or add

another drug

From “Why Stomach Acid Is Good For You” by Jonathan Wright, MD

Adding small aliquots of acid (acetic, betaine HCl, etc) to meals will close LES

Pepsin will now be active to digest proteins Calcium, Iron, Zinc, B-vites, FA,

Pharmaceutical agents will be absorbed Small inoculums of bacteria, eaten will NOT

cause pathology There will be no lack of digestion to cause

problems in the lower GI tract

Products you can use to treat digestive disorders (Healing)

GES-5 (licorice, alginic acid, slippery elm) Pyloricil (mastic gum, bismuth citrate,

berberine, ginger root) Gastric Repair Complex (DGL, mastic gum,

L-glutamine, aloe vera 200:1) Zinlori 75 (zinc carnosine) DGL Plus (DGL, aloe vera, slippery elm,

marshmallow root, vitamin C)

Products you can use to treat digestive disorders (Gastric Atrophy)

B.P.P. (betaine HCl, pepsin, pancreatin) Thorne

Metagest (betaine HCl, pepsin) Metagenics

DuoZyme (betaine HCl, glutamic acid, papain, pepsin, pancreatin, ox bile, lipase,protease, amylase Karuna

Betaine HCl Integrative Therapeutics, Inc.

Vinegar Capsules

Products you can use to treat digestive disorders (Duodenal)

IntestiMax (herbs, l-glutamine, N-acetyl-d-glucosamine, oryzanol)

IBS Max (many herbs, seeds, MSM) Similase GFCF* (DPPzyme IV blend, L.

acidophilus, FOS, arabingogalactans) L-glutamine (3000-8000 mg QD) G.I. Fortify (psyllium, flax, l-glutamine,

DGL, marshmallow, plantain, slippery elm, triphala)

*digests hidden gluten & casein

Products you can use to treat digestive disorders (Colon)

Curcumin (Turmeric Force by New Chapter) + Bioperine [PE] Intestinal Bowel Solution (2 bottle kit: AM/PM) [Adv. Natural] Peppermint Oil [many sources] [Compound?] Aloe Vera [George’s, Lily of the Desert] Omega-3 Fish Oils (high in EPA) Probiotics (Ultimate FloraMax, Primal Defense, Multi-Probiotic,

Probiotic-5, Florastor, Ultra Flora Plus DF) Prebiotics (FOS, inulin, flax, fiber-in-general) Fiber (SuperSeed, FiberMax, Barlean’s Forti-Flax, Chia seeds,

Fiber Plus, Triple FiberMax) Triphala Extract [Complimentary Prescriptions] Smooth Food

Digestive Disorders Review

You can’t use what you don’t absorb Stomach acid required! When you fix digestion, you fix a multitude of

problems: Lack of B-vites causes depression Lack of folate cans lead to cancer Thyroid & other meds can be absorbed Yeast overgrowth Improvement in immunity

Case 3: Sugar Handling

Type II diabetes is epidemic. You can treat everyone for this.

Hyper- and Hypo-glycemia: 2 sides of same coin

Affects hormone balance Affects blood pressure Affects cholesterol Causes inflammation (arthritis, Alz Dis,

glaucoma, macular degeneration, etc., etc.)

Type II Diabetes: Metformin (not necessarily) Required

Patients MUST eat breakfast with 20-30 Gms of protein

Protein shakes can help them remain compliant There are protein drinks that are made for the

Glycemically Challenged patients There are nutraceuticals and herbs that are very

helpful for treating Type II diabetes We have had patients reduce their insulin and/or

metformin needs with nutraceuticals

Some Protein Drinks for DM

UltraGlycemX 360 Plus by Metagenics Glycemic Balance by Jarrow Formulas Glycemic Foundation by Orig. Medicine CLA Slim by Jarrow Formulas Ultra Lean Body Composition by BioGenesis Metabol X by BioGenesis PureWeigh PreMeal Beverage by P.E.

Other Protein Drinks (weight loss & athletes too)

Protein Energizer by Rainbow Light (rice protein) Acai Berry Blast Protein Energizer (acai + rice protein) Brown Rice Protein Concentrate by Jarrow UltraMeal by Metagenics (best tasting) NanoPro PRP (w/colostrum peptides) by BioPharma Bio-Inflammatory Plus by BioGenesis (arthritis, etc) Ultra-InflamX 360 Plus by Metagenics (arthritis, etc) Pro-Basics by Pure Encapsulations Ruth’s Hemp Protein + E3 Live + Maca (menopause) Perfect Meal by Garden of Life

Additives to Protein Drinks

Greens (VitaMineral Green, Green Vibrance) Reds (Spectra Reds by DaVinci Labs) Purples (Earth’s Promise by Enz Therapy) Berry Green by New Chapter Hemp seeds, Flax seeds, Fiber (Ruth’s) Omega-3 oil, Flax oil, MCT Oil, Coconut Oil L-glutamine powder (PE), Creatine (Jarrow) Maca and Earth by HealthForce Nutritionals

Supplements for Blood Sugar Dysregulation

Chromium 500 mcgm caps 1-2 caps w/meals Biotin 600-2000 mcgm w/meals Fenugreek, Cinnamon, Bitter melon extract, Magnesium(!) Alpha Lipoic Acid 100-300 mg. PO TID (a MUST!) Vanadium 0.5-1.5 mgm PO w/each meal Insinase by Metagenics Glysen by Apex (Gymnema sylvestre, Green Teas Extract,

Chromium, etc.) MetaGlycemX by Metagenics Glyco-Kinetic Complex by Integ. Therap Clinical Nutrients for Glucose Regulation by Integ. Therapeutics Gluco-Balance by Biotics (an MVI that addresses insulin

resistance)

Case 4: Metabolic Cardiology

There is an epidemic increase in CHFCHF is an energy problemStatin use MAY be the reason for the

increase in CHF occurrenceHypertension is always treated with

drugs when this may be unnecessaryLet’s look at cardiac bio-energetics …

Mitochondria, ATP, Magnesium, Free Fatty Acids, TAN

TAN pool (total adenine nucleotide pool) or How much ATP is available

[ATP] + ½ [ADP] / [ATP]+[ADP]+[AMP] ~ 1 in normal heart TAN Pool in ischemic hearts ~ 0.180 !! Mitochondrial DNA (mDNA) has no protection from

oxidative stress (Interesting note: only from Mom) Enter Co Enzyme Q-10 (a potent anti-oxidant) Statins reduce Co Q-10 blood levels Free Fatty Acids (FFAs) must pass through the

mitochondrial membrane to act as fuel All enzymes requiring ATP to function ALSO need

Magnesium as a co-factor

The Formula for many cardiac disorders (arrhythmias)

Magnesium is nature’s calcium channel blocker

Mg and the amino acid taurine can work synergistically in treating arrhythmias

Magnesium is necessary for ATP utility Many people are magnesium-deficient Many forms of magnesium are hard to absorb

(MagOx, etc.) Magnesium can CURE mild hypertension

The Formula for many cardiac disorders (CHF)

D-ribose 5 Gm. PO TID before meals can restore the TAN Pool (Corvalen, Corvalen-M)

Co Enzyme Q-10 (ubiquinOL, the reduced, active form of unbiquinONE) 100-200 mg BID with food can energize the failing heart

L-carnitine 2000 to 3000 mg. per day in 3 divided doses on empty stomach will enhance FFA transfer into mitochondria (AminoCarnitines™ by Sigma Tau)

Magnesium 200 mg. BID to TID aids in energetics as well as anti-arrhythmia actions (Mag Taurate by Cardiovasc. Res.)

Hawthorn Berry 120-900 mg PO TID (softens vasculature) Curcuminoids (turmeric) 500 mg daily (w/Bioperine) DHEA, Testosterone, Pine Pollen (a phytoandrogen)

Case 5: Cognitive Disorders“I think, therefore I am”

~Descartes

Inflammation is the big player here too Sound structural components (fats,

cholesterol) Blood flow Vitamins important Neurotransmitter precursors important Methyl-donors important (folate, betaine)

The Herbal Approach to Neuron Health

Ginkgo 120 mg PO QD Bilberry 400 mg. PO QD Hawthorn berry (again) 600-900 mg QD L-acetyl carnitine (again) 0.5-1 Gm TID DHEA 25-50 mg. PO QD (or topical) Sage, rosemary, nettles & garlic in diet daily Huperzine A 50-100 mcgm BID (cholinesterase

inhib, memorigenic, antiamnesic, neuroprotector, neural tonic)

The Supplement Approach to Neuron Health

Phosphatidyl choline (from lecithin) Inositol powder 4 Gm PO TID empty stomach Malic Acid 650 mg TID GABA 250 mg. TID Phosphatidyl Serine 30-50 mg. PO TID Co Q-10 (ubiquinOL) 200 mg PO TID w/food Alpha Lipoic Acid 100 mg. PO TID N-acetyl Cysteine (NAC) 500 mg. PO TID Vinpocetine 30 mg. TID B-vitamins, Folic Acid, Trimethylglycine (methyl-

donors)

The Supplement Approach to Neuron Health (cont.)

Omega-3 fatty acids 2-3 Gms QD (esp. DHA) Resveratrol 100 mg. TID (w/quercetin for better

absorption) [as trans-resveratrol] L-Carnosine (not carniTINE) 500 mg. PO TID on

empty stomach* Yerba Mate Tea (Guayake) ad lib*

* THESE REDUCE A.G.Es (Advanced Glycation End-

products)

Acai berry, Blueberries, Pomegranate juice, etc.

In Conclusion

Your integrative practice can have SIGNIFICANT impact on even serious diseases of aging

If you go after INFLAMMATION, you will cure a raft of ills and prolong the patient’s life

If you practice this way, with confidence, the word-of-mouth will be tremendous

Few practitioners are really solving core problems. Nutrition is never a band-aid!

In Conclusion

Product selection is critical (clients aid you) Make your staff “shadow” you and use your

phraseology Staff must defer to you whenever there is mention of

a drug or a disease or doctor’s orders Try some of these approaches so you have First-

Hand experience … it will speak “volumes” to pts. Guarantee your products Put out a lot of literature and reference books

In Conclusion

Say to clients: “Let us know how that worked for you.” and mean it.

This starts a dialogue that is win-win Don’t be afraid to recommend what you feel will

help: People WANT to be well and will go to the ends of the Earth, sometimes, to feel better;

Get/Share testimonials (for you AND clients) Market and Advertise this aspect of your practice Expand as you learn. Read everything!

Reference Books, Newsletter, Etc.

References for an Integrative Pharmacy Practice“An ounce of intuition is worth a pound of tuition. ~ Unknown“The only real valuable thing is intuition”. ~ Albert Einstein (1879-1955) German-Swiss-U.S. scientist.

Natural Medicines Comprehensive Database, Pharmacists Letter The Sinatra Solution: Metabolic Cardiology by Stephen T. Sinatra, MD, FACC The Veterinarians’ Guide to Natural Remedies for Dogs by Martin Zucker The Veterinarians’ Guide to Natural Remedies for Cats by Martin Zucker Smart Medicine For Your Eyes by Dr. Jeffrey Anshel, DO Heal with Amino Acids and Nutrients by Billie Jay Sahley, Ph.D & K.M. Birkner, CRNA The Magnesium Miracle by Carolyn Dean, MD, ND The Magnesium Factor by Mildred S. Seelig, MD, MPH & Andrea Rosanoff, Ph.D. Wilson’s Thyroid Syndrome: A Reversible Thyroid Problem by E. Denis Wilson, MD Adrenal Fatigue by J. Wilson, Ph.D. Alternative Medicine: The Definitive Guide, 2nd Ed. by Burton Goldberg Townsend Letter for Doctors and Patients (monthly subscription) Alternative Medicine Review by Thorne Research (monthly) www.WholeHealthAmerica.com (newsletter) www.DesignsForHealth.com (sign up for their “Friday Fun Facts” e-mail weekly Vitamin Research News: Complementary Prescriptions Edition (newsletter monthly) Hormone Balance for Men: What Your Doctor May Not Tell You About Prostate Health and Natural

Hormone Supplementation by John R. Lee, MD

Reference Books, Newsletter, Etc.

A Message To Garcia by Elbert Hubbard [ see www.wizardofads.com to order ] Cracking the Metabolic Code by James B. LaValle, RPh., CCN, ND Essentials of Psychopharmacology: Neuroscientific Basis & Practical Applications by Stephen M. Stahl, MD, PhD Essential Psychopharmacology: The Prescriber’s Guide by Stephen M. Stahl, MD, PhD The Rag and Bone Shop of the Heart: A Poetry Anthology by Robert Bly, et al The 24-Hour Pharmacist by Suzy Cohen, R.Ph. “America’s Most Trusted Pharmacist” The Schwarzbein Principle by Diana Schwarzbein, MD (former advisor to Suzanne Somers) The Diet Cure by Julia Ross, MA The Mood Cure by Julia Ross, MA Why Zebras Don’t Get Ulcers by Robt. M. Sapolsky (“One of the best science writers of our time”. –

Oliver Sacks) The Trouble With Testosterone by Robert M. Sapolsky Probiotics: Nature’s Internal Healers by Natasha Trenev The Yeast Connection by William G. Crook, MD Why Stomach Acid Is Good For You by Jonathan Wright, MD The Schwarzbein Principle II: The Transition by Diana Schwarzbein, MD An Alternative Medicine Definitive Guide to Cancer by W. John Diamond, MD & W. LeeCowden, MD with

Burton Goldberg Thyroid Power: 10 Steps To Total Health by Richard L. Shames, MD & Karilee Halo-Shames, RN, Ph.D.

Reference Books, Newsletter, Etc.

Feeling Fat, Fuzzy, or Frazzled? by Rich Shames, MD and Karilee Halo Shames, RN, Ph.D. Vital Man: Natural Health Care for Men at Midlife by Stephen Harrod Buhner Sacred and Herbal Healing Beers: The Secrets of Ancient Fermentation by S. H. Buhner The Ecological Importance of Plant Medicines to Life on Earth by S. H. Buhner Eat Right 4 (for) Your Type by Dr. Peter J. D’Adamo Live Right 4 (for) Your Type by Dr. Peter J. D’Adamo Encyclopedia of Nutritional Supplements by Michael T. Murray, ND Prescriptions for Natural Healing, 4th Ed. By Phyllis A. Balch, CNC Prescriptions for Herbal Healing by Phyllis A. Balch, CNC Smart Medicine for Healthier Living by J. Zand, LAc, OMD, Allan N. Spreen, MD, CNC and James B. LaValle, RPh., ND Encyclopedia of Natural Medicine, Revised 2nd Ed. By Michael Murray, ND & Joseph Pizzorno, ND Finding Our Way: Leadership For and Uncertain Time by Margaret J. Wheatley Leadership and the New Science by Margaret J. Wheatley In Defense of Food by Michael Pollan The Omnivore’s Dilemma by Michael Pollan Herbal Solutions for Healthy Living by Richard Scalzo, herbalist & Michael Cronin, ND Guns, Germs, and Steel: The Fates of Human Societies by Jared Diamond Alternatives: For the Health-Concious Individual by Dr. David G. Williams (newsletter) Heart, Health & Nutrition: A Cardiologist’s Guide to Total Wellness by Stephen Sinatra, MD (newsletter) Beyond Chemotherapy: New Cancer Killers, Safe as Mother’s Milk by Health Sciences Institute – Special Research Alert The Iodine Project: An Update (see Townsend Letter, 245:100-101, 2003) – Get a free copy fromOptimox the makers of Iodoral (888)

401-0967 All About DIM by Michael Zeligs, MD & A. Scott Connelly (see www.dimfaq.com) Journal Watch by NEJM (monthly abstract that surveys the medical literature – hard copy and e-mail alerts CHE (Collaborative on Health and the Environment) www.healthandenvironment.org/ www.DenverNaturopathic.com (e-newsletter) Emerson Ecologics Women’s Health E-mail Update (e-newletter, monthly) www.naturalstandards.com www.pharmwell.com www.vitasearch.com http://www.wddty.com/07521651368937314994/proof-reports.html The Intention Experiment by Lynne McTaggart What Doctors Don’t Tell You by Lynne McTaggart

The End