Safely Deprescribing Medications for Your Chronic Disease Patients
Lara Zakaria RPh, MS, IMFCP: Dr. Zakaria is a pharmacist and nutritionist who specializes in medication therapy management and medical herbalism. She works with patients on nutritional interventions to lower their medication doses and, as part of a larger care team, works alongside the primary physician to deprescribe medications as necessary. She is also an expert on prescription compatibility, identifying potential drug-to-drug and drug-to-herb/supplement interactions. Dr. Zakaria’s unique approach to traditional pharmacology focuses on drug-induced nutrient depletions and helping patients regain their health through nutrition.
Elizabeth Board, MD, DABA, IFMCP, ABIHM: Dr. Board is a highly trained physician, certified in functional medicine, but also in pain management, medical acupuncture, and anesthesiology. As a board certified anesthesiologist, she has done a remarkable job in deprescribing pain medications due to her success using the functional medicine model for treating pain. She is extremely effective at motivating her patients to make the lifestyle changes that lead to the ability to deprescribe all sorts of medications.
Host Kalea Wattles, ND:
Joining me today are Drs. Lara Zakaria and Elizabeth Board, who are both strong advocates for using food as medicine and leveraging nutritional therapies for the treatment of prevalent chronic conditions. Dr. Zakaria is a licensed pharmacist, nutritionist, and expert in medical herbalism. She works closely with patients on nutrition and supplementation to lower their dosage and ultimately deprescribe what is often a myriad of prescriptions. Also with us today is Dr. Board, a board certified anesthesiologist who uses lifestyle interventions to help treat patients with chronic disease and pain. Dr. Board’s approach focuses on optimizing nutrition and immune function as preventative measures to reduce long-term health complications.
You both have such unique backgrounds when it comes to practicing medicine. I’m really excited to see how this conversation unfolds. Thank you both so much for being here today.
Lara Zakaria, RPh, MS, IMFCP :
Let’s get started with some statistics. This might not be surprising, but I found it to be really eye-opening. The most common types of medications prescribed are ACE inhibitors, PPIs, antidepressants, synthetic hormones, and pain relievers. Research shows us that many of these conditions can be remediated with lifestyle therapies, yet these medications are being prescribed as the only option, to the tune of hundreds of millions of individual prescriptions per year. So this is a very important topic. My first question to you both is in regards to your personal process. We know that about half of the US population takes at least one prescription drug, so how do you identify conditions that really need to be treated with medications versus a situation where, let’s say, a botanical or a nutraceutical or a lifestyle intervention would actually be appropriate? What’s that process like for you? We’ll start with you, Betsy, I’d love to hear your thoughts.
Elizabeth Board, MD, DABA, IFMCP, ABIHM :
So, Kalea, when I first start working with a patient, I want to find out from them what their greatest concerns are. And I try to limit it to about three different things. From that, I can find out from them how severe their symptoms are, and what the timing of those symptoms are. I always like to find out, what have they tried so far? Because we can learn so much from the patient, from what they’ve been through, what has worked, what hasn’t worked. And then, of course, using a functional medicine approach, I can learn a lot about what the best treatment would be. Now, in my first assessment, I might spend an hour and a half with a patient. If I do that deep dive, then that allows me to know—maybe they’re already on some medications that haves depleted them of certain nutrients, and maybe the symptom is coming from the depletion of those nutrients.
In that case, of course, I’m going to go with supplementation or changing the patient’s diet. So it really depends on, first of all, what their major symptoms are, what the timing and severity of those symptoms are. Has it been going on a long time? Have they tried everything? And then if I do move to a medication, I like to think of the medication as a bridge, and the bridge is a temporary treatment while we’re building a foundation for the patient built on good lifestyle factors, good lifestyle changes, and making sure they’re getting all the nourishment that they need so that they may not need that medication as a bridge for very long.
Yeah, that’s great. I think that really speaks to the power of taking a good history, a thorough history, which is what we do so well in the functional medicine world. How about you, Lara? How do you identify when patients are good candidates for implementing some of these lifestyle strategies, botanicals, nutraceuticals?
This is a great question, and I really love that Betsy is really thinking about what has worked in the past and what hasn’t worked in the past, because often, we’re not seeing people when they’re initiating their problem, we’re seeing them—often, they’ve been frustrated, something hasn’t worked out for them, or they might have some distrust in some of the process. So I think getting a good foundation and a baseline of where they’re at and understanding their willingness and their readiness to implement something. Often, one of the first things that I’ll do is just see where they’re at in terms of lifestyle modifications and what their thoughts are on supplements. And from there, depending on their readiness, depending on how committed they are—some people come in and they are so ready to jump right in and some people really do need that crutch or need a bridge.
And then from there, you can make a decision as to which direction might be more appropriate with them. The last thing I want to do is burden somebody with some complex diet or a complex list of supplements that they need to take when they’re not really ready for that yet. So that’s a big part of my initial assessment and just figuring out what their definition is in terms of what the best approach towards health is. And then from there, we could come up with a plan together.
Yeah, that’s great, Lara. I love how you mentioned the stages of change. That’s something that we talk about all the time. And just to follow up on that, let’s say, okay, we decide that someone is a good candidate for maybe tapering off some medications, bringing on some of our nutrition therapy, botanicals. We know that that can be a little bit more labor intensive, it requires a bit more planning, a bit more being really proactive. How do you have conversations with patients to make the case that that is worthwhile when typically it can be a bit easier just to maybe take a medication every day? What’s that discussion look like?
Well, for me, the first step is, what’s the severity of the illness that we’re dealing with? Is it something that’s going to require us to jump in there very quickly and get something on board very quickly? Because at that point, if we’re talking about risk reduction for cardiovascular risk, maybe they are in an active flare of some autoimmune disease, you might just need to get in there and get that under control first. So, first and foremost, assess where they’re at. From there, I love to educate, empower. I want to come in there with as much information as I can to get them on board with what we’re about to do.
So, if I really, for example, believe that this particular person has maybe dyslipidemia, dysglycemia, and I want to put them on a berberine or a bergamot or a fish oil or an ALA, then I’m probably going to sit down with them and say, “Look, this is what we know about the studies for this in the conventional field, and this is what we know from our studies in terms of the supplements and the herbs and how well they work. And yes, it might require more compliance on your end. We might have to talk about a strategy to keep you on time, taking them every day so that you’re not skipping any doses, so that we’re really maximizing their benefit. But here is the benefit at the end if we go this route, here’s the benefit in the end if we go this route, here’s the downsides,” and then leave it really up to them to make a decision.
I find, again, if they’re ready for it, then once you empower them with the information, they’re typically more likely to come on board with you. And then from there, it just becomes lifestyle modification, habit building, retraining, giving them tools and resources so that they can stay compliant and that it becomes a part of their routine.
Yeah. That’s great. Betsy, similar question to you, if you decide that a patient, if your conversation reveals that they are ready for some changes, for some alternatives, do you talk to patients about potential benefits that they could find or experience from deprescribing medications?
Oh, absolutely. I mean, I think if you look at dysglycemia as an example, like Lara brought up, if people are on beta blockers, for example, if there’s a way that we can get them off the beta blocker, that actually may dramatically improve their blood sugar levels. Another one is statins. So, we know that in women, depending on the study that you look at, a good percentage of post-menopausal women will develop diabetes from just being on a statin. There are some statins that tend to cause less diabetes, for example, the water-soluble statins, for example, Pravachol. So sometimes I might just shift someone who’s suffering from hyperglycemia and terrible hemoglobin A1c levels, just shifting them from a Crestor to a pravastatin or Pravachol, I’ve seen dramatic improvements in their blood sugar.
So they’re still using the bridge, they’re still using the crutch, but we’re moving them to something that’s going to have fewer collateral damaging effects on their body. And when they see that, that also generates a sense of trust with the practitioner. And if we can also at the same time, like Lara was talking about, if we have that sense of readiness, if we can get the patient to start choosing what I call low insulin demand diet, or a diet that doesn’t tend to raise insulin levels, those patients will tend to lose a little bit of weight as their insulin levels come down. We want to roll in a little bit of exercise, and sometimes I might start with five minutes of walking twice a day. And I always talk to them about moving every day. I don’t really want patients to do heavy duty exercise and get sore and get injured, especially people that are new exercisers, if you will.
So a little bit of consistent exercise. And a lot of what I do is really just motivate them to do these sort of consistent baby steps. And I think when you’re thinking about changing the outcome, you can apply these sort of multimodal effects. I always think of it like if you’re going to tackle an enemy, if you use the air force, the navy, the marines, and the army, even just using a little bit of those different complimentary effects, you’re going to get a great outcome. So a little bit of exercise, following a low insulin demand diet, adding in some supplements, changing some medications can have an overall huge impact. So that’s one of the things that I do with my patients as well.
I think you brought up a great point there that it doesn’t necessarily mean we’re going to discontinue medications today, we’re going to get you on the cardiometabolic food plan, and that’s going to take the place of your medications, that there’s some overlap. You start the therapeutic nutrition plan, and then based on the outcomes you see from being on that food plan, then we can potentially make adjustments to medication. Is that somewhat how you frame it to patients?
Absolutely. Because, if you think about it, you want that foundation. You want the foundation built strong, so that when you start to decrease—because I don’t typically stop a lot of medications, occasionally I do, but in general, I wean the patients down—that’s when you’re going to be able to take them off completely over time and also encourage patients that, “This isn’t a race. There’s no definitive timeframe on this. What we really want to do is take our time with it so that you don’t have side effects.” Because once your patient starts to have side effects as you’re deprescribing, they’ll start to lose trust and they’ll want to cling to that medication that they’ve had. So I like to go real slow with that.
But even like Lara was saying, building that foundation. And I love how in functional medicine, we have the modifiable personal lifestyle effects. And I like to employ every one of them, because that’s using that analogy again, if we can use a little bit, making sure they’re sleeping, making sure their diet has changed, getting that little bit of exercise in, working on stress reduction, and then also making sure that they have relationships in their home and in their business and around them that are positive and supportive. One of the first things I like to find out when I’m changing a diet with a patient is, who’s eating what at home? It’s very difficult for an individual to change their diet when the husband or the children or the spouse in general are eating very different things.
I love it if I can get a spouse in with a patient and get their support. I can’t tell you how many times… Like, I had an autoimmune patient who had a terrible autoimmune condition and we changed his diet, and he was doing really, really well. And he had a terrible autoimmune condition, which is… it’s bullous pemphigoid, if you ever know what that is, and he was getting better and better, and the beautiful thing is, we had the wife on one of the phone calls, and she goes, “My cholesterol is totally better.” She’s like, “I’ve lost 10 pounds, and I’m getting off my cholesterol medication.” So this is what I call the collateral benefits of functional medicine. And I also consider this healing the community. And the community can start just in our home. It doesn’t have to be the community out there, it can just be the people that we’re closest to. So don’t forget about relationships as part of one of the silver bullets that we have to help us stay healthy long-term.
If I can jump in on that point, Betsy, I love that you’re talking about that collateral benefit. A majority of my patients tend to be women, and they tend to be women who are mothers and wives, and they tend to be the ones that are in charge of the kitchen. They’re the head chef, they’re the food gatherers as well. And so they’re really in charge of what happens and who’s eating what in their home. But I often find, for a lot of them, what they’re choosing to eat may not match up with what their kids want to eat, what their husband wants to eat, what their partner wants to eat, and so, there then becomes this tension within the family and a negative connotation around whatever that prescribed dietary approach is going to be.
So I find it really helpful to actually invite the family on. I usually do a lot of remote consults. 2020 aside, I’ve been doing remote consults for a while, and so I actually try to invite everybody on the Zoom call, because I want to make sure that everybody’s on board. So if we sense that sort of tension, I start to shift it towards the benefits that some of the other folks in the family might get, or some things that they might be able to look forward to. So we start talking about designing meals and snacks and having them pitch in, actually, so that they’re part of the change, part of the process to support mom or partner or whatever her role is, or whatever that leading chef is, their role is in the conversation. And that helps a lot because you’ll then build community rather than create friction around the conversation.
Exactly. I think you’ve just beautifully highlighted when we support those modifiable lifestyle factors, this is nutrition, but it’s also the relationship aspect, or supporting all of those areas at the same time. So I think that that’s brilliant. As we’re talking about nutrition, and people improving their health outcomes and maybe biomarkers just with dietary interventions, one thing that we’ve thought about is, do people then become overprescribed? If they aren’t needing as much of their medication but the dose isn’t being monitored or changing, is there a risk for being overprescribed? I’m wondering if either of you have some examples of any complications you’ve seen from patients that are being overprescribed, how did that impact their health and their quality of life? And then were you able to make some adjustments? So Betsy, let’s start with you, if you have any overprescribing tales to share.
Thanks for asking that question. I’m going to tell a quick beautiful story about a young man who fell asleep working late and hit an overpass and had a horrible head injury, and he was left for dead, really. I mean, it was his mother who would not let him be taken off the ventilator, and she worked with him for years. Long story short, he comes to my office. Now, he can’t even remember three things. He’s alive, but he’s had major brain damage. And I’m thinking, “What am I going to do with this patient?” But they gave me a list of all the medications that he was on. Now, he’s on medications that I remember from my years doing internal medicine in the hospital, these are the typical medications that we send someone out on when they’re being discharged. They’re never meant to stay on all those medications. And it was the mother’s instinct.
And let me tell you, listening to the instincts of the individual or the primary caregiver is really important for us as practitioners. And so, what we did is, we slowly weaned him off of the medications. I’m going to tell you, it was a little concerning, and I did do some consulting with that, but we were able to get him down to, I think, only one medication. And this is a young man who could not remember three things, and in a very short period of time, I kid you not, he could sing for me, he could remember all three things. Eventually, mom was showing me pictures of him swimming, and they were teaching him to walk again. I mean, it was a miraculous recovery. I do want to point out again how important the gut microbiome in this case was. One of the things that we’re taught in functional medicine is that when someone has a head injury, there’s a lot of chance that they have a disruption of the gut microbiome.
And so, we did do a gut test, and not surprising, he had dramatic dysbiosis. So we did work on that, and I do think that that did play a major role. So it’s going back to what Lara was talking about, if we can set the foundation, if we can make sure… it goes back to the old serenity prayer, changing the things that we can change. As practitioners, we want to look for those things that are within our realm of control, and change those for the better, because there’re so many things that we cannot change, like a horrible head injury. We can’t go back and change the fact that he had this devastating injury, but we can heal the gut, and we can build a foundation, and we can gently pull him off medications until he is literally whole again.
One other quick story is one of the first first-line therapy patients that we used, who was very compliant. Lost weight, got in great shape. And I remember he came into our office and he was working with one of our lifestyle educators, and I was called in to check his pressure. His pressure was so low, we were like, “You have to stop your blood pressure medicine.” And what a joyous thing to do, to be able to be so healthy that you no longer needed to be on blood pressure medicine.
Yeah, I love these success stories. How about you, Lara, any tales of an overprescribing situation that was turned around?
Yeah, absolutely. I actually recently had an initial consultation with somebody that was hospitalized a few months ago. Older gentlemen, had a long list of medications, and some suboptimal supplementation happening, some not so great multivitamins and not so great forms of certain nutrients. And as we were going through the med lists, he had realized that he needed some assistance in terms of the lifestyle piece. And as we were going through the prescriptions, realized he didn’t actually know why he was taking most of what he was taking. And to Betsy’s point, a lot of it had been prescribed while he was in the hospital, got discharged, and now he forgot that they were just there. They just kept getting refilled without really paying attention as to whether or not he actually needed them.
And so starts the process of trying to decide how to now start to deprescribe. And as we know, the more medications we got somebody on, the more we have a risk of adverse reactions, the more likely we have drug interactions, the more little nervous we get maybe about adding on some additional herbs or supplements, et cetera. So, we want to be a little bit more careful about potential interactions and shifts in detoxification, as well as shifts in the microbiome and gut integrity, right? And so, all these factors then have to get weighed and definitely takes a lot more brain power. And so, ideally, you want to try to start to reduce that medication burden. And I think that’s across the board, there’s nothing functional about that, that’s just good old-fashioned common sense.
So I would say, in those cases, I think that is where the functional medicine pharmacist is going to be your best friend. I’m going to get on the soap box here for a second, because those are going to be your allies in trying to not only make sure that we’re managing those medications properly when they are on board, but they’re also going to be able to help, as I like to call it, put the training wheels on as you start to deprescribe. Start thinking about those drug-induced nutrient depletion, start thinking about how to support the gut safely, start thinking about detoxification, and really getting in there and starting to slowly figure out what’s essential, prioritize those steps, and then start to take those steps slowly, gradually, and safely.
So at the end of the day, we started… I saw him relatively recently, so we haven’t been working together that long, but we started to work on a protocol to get his gut cleaned up so that we can first get him off his PPI. And I feel like if I can get him off that PPI, that’s going to start putting a lot of things in place, because that’s a major component in terms of his ability to absorb his nutrients. Your gut’s not functioning, it’s not absorbing, you’re not going to be able to absorb well. I saw this on Instagram the other day, so forgive me, I don’t remember who said it, so I’m totally stealing this right now, but you’re not just what you eat, you are what your gut absorbs.
So, to me, that’s often that PPI is the lowest hanging fruit in terms of being able to get folks not only feeling better off of it, their GI function is going to improve. Often, that’s going to improve their bowel movement, it’s going to improve their dysbiosis and their microbiome health, and it’s going to help them improve their ability to absorb their nutrients more fully. So we started with that, we did a little bit of a nutrition supplement overhaul, cleaned up some of the nutrients, got him on optimized doses based on his drug-induced nutrient depletions and based on his need and for his particular conditions, and slowly started to initiate that protocol, or that taper, very gradually and very slowly.
So this is the first week that he has been off of the PPI. So far, so good. So fingers crossed. We don’t have too many relapses, but we know with PPIs, often there is sometimes a little bit of a lag, and sometimes you do have to get off them, on them. But we’re using H2 antagonist as needed, we’re having him use the PPI PRN, but fingers crossed, so far, so good.
Yeah. That’s great. I think you’ve shown us here that really one of the ways that we can avoid or reduce our chances of overprescribing is to do medication therapy management with a functional pharmacist, right? I think that probably a lot of physicians don’t have existing relationships with the pharmacist who help support patients through this process. Lara, can you talk to us a little bit about how you like to build those relationships? Do you like to get referrals from docs who need some support with managing the medications and the supplements and the botanicals that patients want to be on? Just, I’d love to hear a little bit about the process of what medication therapy management looks like.
Yeah, absolutely. So first, let’s just define it. Medication therapy management is a actually conventional well-established program that is pharmacy-led, that leverages the pharmacist’s expertise in reducing medication error, optimizing therapy, ensuring that guidelines are met—and then the functional piece of it is being able to then layer in some of the nutritional pieces, including drug-induced nutrient depletion, and finding any existing gaps, monitoring for potential depletions or adverse reactions. So that is a basic framework that many pharmacists have already been trained in doing. And that’s part of what we already do, and it’s part of the framework of pharmacy practice, to begin with.
What we’ve been seeing is this surge of interest within the pharmacy world, pharmacists who are interested in layering in functional medicine. And so, part of that training has been, okay, how do we use those encounters and that same training to then layer in some of these pieces that are really important when it comes to functional medicine? What I really appreciate is, I think there has been a growing conversation, at least amongst the physicians and the prescribers I’ve talked to, in having somebody who can really own that piece. Because if you’re steering the ship, it’s really hard to look at every single one of these nuances and be an expert in the pharmacology and the detoxification piece, and then the step-down therapy, that’s often not part of the training that you have.
Just like I really am a big advocate also for referring out for nutrition management as well, or health coaching for that lifestyle modification and the dietary piece. So I would love to see, and I would love to see if folks are interested in this, creating some sort of community where we can have pharmacists paired with physicians, and you’ve got a specific kind of practice, maybe you’re focused on hormones, or maybe you’re focused on autoimmune disease, or cardiometabolic. And then maybe there’s a pharmacist that’s an expert in that area, that really hones in and can help you manage those medications. I think this is becoming more and more important as we’re seeing a rise in the geriatric population that’s coming over into functional medicine, and with that comes complexities in their pharmaco-management. And I think this could be a really interesting way to really build a partnership and a collaboration that not only makes it easier and more… just time management easier for both parties, but also gets the best outcome for our patients.
Yeah, that’s excellent. I know that when I’m prescribing hormones, I have a compounding pharmacist who I work closely with, and I’m calling her all of the time, and she’s really an invaluable part of my decision-making, such a great resource. And so I think that I love the ideas that you mentioned. Betsy, you gave a big nod when we talked about the benefit of working with pharmacists to make sure that our patients’ medications are safe and well controlled. Can you tell us a little bit about how you interface with pharmacy professionals in your practice?
I do, I do similar to what you do, Kalea. I have a compounding pharmacist where, when I have an idea, he’s so accessible, I can literally text him, and then I’ll have an idea about something. We teach each other, and I’ll say, “Have you heard about so-and-so?” And then he’ll let me know. “Can you compound this for me? I want to start with little tiny baby doses.” I’ll bring the patient up. So we do some of that work together. And then, also, I’m very much into pharmacogenetics. And I’m not a pharmacologist, and I tell my patients I’m not, but by working with some of the—one of the companies I work with is Genomind, so I work with a psychopharmacologist with them, and they’ve taught me a lot.
And it is amazing when you do these genetic tests. We just did one yesterday with a patient, and it was almost like a magic trick because the medications that she had trouble with in the past, we could have predicted based on her pharmacogenetics. And it blew her mind and blew her family’s mind. And again, by doing these kinds of things for patients that have been to see multiple doctors and they’ve had disappointing and sometimes bad experiences, to be able to put in that layer of trust is just very powerful. And to give people hope again. I mean, even just to give people hope again that there’s a chance. So we were so excited. In fact, she was on a beta blocker, and she wanted to possibly try a new beta blocker, and the two that she was taking and having problems were the two that, according to her CYP genes, were the worst ones for her.
And the one she had not tried looked like it was going to be a green light. So she’s excited to go try that. And the other thing, actually Lara brought it up, is that, as practitioners and as a physician, and I did my pain fellowship at a very, very good institution, Stanford University. We were teaching people… just some of the most brilliant people were there, and I think that as physicians, we are not pharmacologists, but we owe it to our patients to understand that every drug that we give to a patient has the potential for side effects. But not just the side effects that we are taught in medical school, but nutritional depletions. And we need to know that because in today’s society, and I harp on this a lot, we were never designed to be exposed to the number of chemicals that we’re exposed to, where it puts a big burden on our liver, and a big burden on our mitochondria.
And so what we thought was enough B vitamin, for example, maybe in the ’40s and ’50s, is not enough today. We are working our liver enzymes, our cytochrome systems, much harder, our citric acid cycle much harder, and we need to give—we need to replete our bodies with what it needs. And I always like to tell this little story, and it occurred to me one time, about pain, as a pain physician. When you stop and you think about the fact that somehow, the people that came to this country many, many years ago, and they had to cross from the east coast to the west coast, and they didn’t have Oxycontin, and they didn’t even have Advil.
And many of them then were Puritans. So they weren’t even going to drink any liquor, but some of them probably did take some liquor. But they did all of that without pain meds, without medications. Most of them didn’t have access to things like laudanum, they just had to do it. And that means that they were getting something from their environment. And I’m not just talking about nutrition, I’m talking about spiritual help, I’m talking about relationship help. They got something from without, that combined with what was within, that allowed them to get through painful situations. And sometimes with my chronic pain patients, I want to empower them. And I know Lara brought that term up, when you educate, you empower. It’s so important.
But let them know, “You have it within you to get through this, and I’m going to help you find out what might be missing and add it back. And what might be there that’s disrupting the mitochondria, and let’s get rid of that. And then you should be able to go through your life without having to be on a lot of medications.” I mean, we were not ever designed to have to take meds. Think about it, we were not. Human beings have been around, we think, 250-300,000 years. Medications are new. But we’ve always been designed to interface with our environment, with our natural world. And we cannot live without our natural world. So getting back to food as medicine is important. And I’m not knocking medications, I think that we need to continue to do everything we can to find all the perfect medications that we can out there to help us with our acute problems. I mean, it’s very, very critical.
But when modern medicine uses acute care medicine to treat a chronic condition, it’s going to create some chronic problems. And what we want to do, and certainly in functional medicine, we will use acute care medicine every time we need to. But we want to look at the long-term goals. And the long-term goals are to find chronic solutions, which can be tolerated without collateral damage, and maybe even some collateral benefit. But things that we can do long-term. And we’ve talked about those with the modifiable personal lifestyle factors. That’s a lot of information, but I always want to get that plug in. Think about acute care medicine right now, but think down the road, if the problem is diabetes, if it’s hypercholesterolemia, if it’s chronic pain, “How can I set up my patient for a long-term treatment strategy that’s not going to give them long-term negative repercussions like kidney damage or liver damage?”
I love that. And I love that phrase, if I can repeat it, and I will credit you for it. But reducing chronic… what did you call it? Mitigating the collateral damage and increasing the collateral benefit. I love that phrase. That is exactly it. And I love that you’re talking about the mitochondria and the stress on detoxification because of our external environment. I think that’s such an underappreciated, underrated piece when it comes to, we think about it when it comes to environmental toxins, it’s also potential pathological organisms, chronic infections, but even our food quality, to your point, we’re in a place and time where we are stressing our mitochondria and our detoxification because of this added exposure.
Our food supply is also depleted. We know that over the last 80, 100 years, we’ve seen a 75% decrease in the nutrient density of our food. So the broccoli of today is not as nutrient-dense as the broccoli of my great grandmother was. So you have to eat more food in order to even get the nutrients that you would otherwise have thrived on only a hundred years ago. And then you throw on top of that the increased burden of medication, and now all of a sudden, you’ve added just that last straw that breaks the camel’s back and needs that much more attention. So I’m always thinking when I’m thinking about new drug-induced nutrient depletion, what are all those other factors that that drug is riding on?
We know what it does in a confined setting, what that drug could possibly deplete, but when you add then the potential exposures, you add then the increased burden on the detoxes and the increased physiological need, the increased physiological need due to disease, the reduced ability of the GI to absorb, the dysbiosis that then is also contributing then to depletions of nutrients or suboptimal nutrients, you throw that all together, that then becomes so much more amplified. And I would love to see more studies in that, in vivo, in those cases that really help us identify where we should be drawing our attention, but in the meanwhile, maybe we can start relying on the tried and true nutrition evaluations and really listening to the symptoms and really evaluating based on what we’re hearing and what are the symptoms that we’re seeing, and some of the basic as well as some of the functional laboratory testing to really start to amplify those pathways.
Yeah. That’s so good.
That’s perfect. I love how you both talked about drug-induced nutrient deficiencies because this is a big part of our conversation, and I think it’s where a great deal of uncertainty lies. We don’t learn this in school. I think probably many people feel like they don’t know the resources. So I’d love to hear from both of you, in terms of harm reduction, sometimes I think that deprescribing isn’t the only therapeutic goal, it’s also repleting some of these nutrients. And that’s the therapeutic goal. So I’d love to hear your advice about how we identify which nutrients need to be repleted. Is it the nutrition-oriented physical exam? Are there some resources that you use to check? Is it you’re ordering micronutrient analysis? I’d love to just hear your take on how you even identify which nutrients need to be supported. Betsy, we’ll start with you, if you could tell us your strategy.
So part of it starts with the knowledge of knowing what we know from the research. There’re several different papers about, they looked at different drugs and what most common depletions show up. And there are lots of books and places where you can find those. Sometimes I like to cross-reference them, “This is what this paper shows, this is what this paper shows.” And there’s going to be a lot of individual variability because we know every enzyme has a certain genetic code. And we know from MTHFR and COMT and CBS, all these different enzymes, that if you’re heterozygous or homozygous, you may either upregulate or downregulate that enzyme pathway. So I do want to point out that you and I, Kalea, could take the same drug—I could become deeply depleted, and you might not. So I do want to recognize that.
And I think that’s why, if you do look at papers, you’re going to see a significant amount of variants. Alright, it doesn’t mean we need to throw it out, we still want to be aware that people could be depleted, for example, if they take a statin with CoQ10, or if they’re taking an ACE inhibitor, zinc is one of the nutrients that’s going to be depleted. And like Lara has brought up many times, when somebody is on a PPI, there are a lot of nutrients, because it so grossly affects absorption. We’re going to think about most of our minerals, we’re going to think about our vitamins, really, all of our fat-soluble nutrients, because that will and can impact the absorption of fats of not just vitamin D, but we need to think about vitamin E and vitamin A and vitamin K.
In fact, speaking of vitamin K, we now know vitamin K is incredibly important, particularly to go along with our vitamin D so we don’t get that hypercalcemia. And so, with vitamin K, we have to make sure we have a good gut microbiome. But I’m bringing up all these points to say that we need to look at what the common deficiencies are with a certain medication. With that knowledge, then I want to do a nutrition-oriented exam, which really makes me focus in on things like the tongue, and the nails, and the hair. These are all growth. They’re really like lines in the tree rings, right? They’re telling us how our body grows, and what nutrients could be deficient. Looking at the skin itself, looking even in the ears, to see… Sometimes people have more wax in their ears when they have omega deficiencies and things like this. So looking at that nutritional deficiency exam.
And then I do like to do some benchmarking. So if I have a really high level of free fatty acids, perhaps they’re not able to get the free fatty acids into the citric acid cycle, so they’re hanging out in the serum, and they could have a carnitine deficiency, or what I call the little Bs, the unsung heroes of the B world. And nobody gives them any respect. All we care about is B9 and B12. But the little Bs are the worker Bs, they do a lot of the work within the citric acid cycle. And with our patients that want to lose weight, when we’re asking patients to turn their fat into energy, we have to get that fat into the citric acid cycle. And that means we need carnitine, we need that carnitine shuttle, and we need those Bs. So I like to look at free fatty acid levels. And when I replete those nutrients, what happens to the free fatty acid levels? They tend to drop.
We want to look at things like pyruvate, because pyruvate deficiencies or pyruvate problems, along with lactic acid, could indicate things like zinc deficiency or a hypoxemia. So there’s a lot of things in just regular blood work, and alkaline phosphatase. So, I never knew this in medical school, I had some patients show up with low alk phos. I was like, “What the heck is that?” I only knew that a high alk phos was an issue. Well, when you have low alk phos, there are lots of nutrient deficiencies associated with that, not to mention just even hypothyroidism. So, digging deeper and looking at some just basic, even some of your basic blood work, to look for nutritional deficiencies are ways that we can target our patients. Then we could also move into, if a patient’s interested enough, to do some nutritional testing.
There’s a couple different companies that I have used, but I try to explain to patients, “There’s functional nutritional testing, where you’re looking at metabolites.” And I just draw it out for them. “This particular B vitamin is supposed to take this nutrient and turn it into this nutrient. If I have a ton of this, and none of this, then that means you need more of that nutrient.” And they understand that. That’s a functional test. But on the other hand, I could also marry that with just the nutritional level of the vitamin in the bloodstream. I tend to weigh a little heavier on the functional test, because that’s what really matters. But it’s beautiful when you can marry both of them, because you can use that for benchmarking, for what we call in functional medicine tracking, so that we can show the patient that they’re absorbing their nutrients and that they’re making progress.
So those are just some of the ways, I do it with labs, with the physical exam, and obviously, with history. Now, we can layer in symptoms. So patients that have a lot of the symptoms of hypomagnesemia, which could be constipation, irritability, chronic pain, difficulty sleeping, spasms, asthma, high blood pressure, all the things that we need magnesium for, we add some magnesium. Many times, I don’t even test, I just go and add the magnesium. Those things get better. It’s not quite as important for me to benchmark that, because the risk of giving someone magnesium is so low. So sometimes when we’re applying nutritional supplementation, I always like to look at risk benefit.
So something that’s very, very low risk might not be as important for me to benchmark. Something that has a little higher risk, or if I have the patient that’s a little more suspicious and not willing to take supplements, then I sometimes have to do the benchmarking, if that makes sense.
Lara, how about you? For those of us who don’t have advanced training in drug-nutrient interactions and depletions, any further advice about how we figure these things out?
Yeah, absolutely. So, I’ve got two nutrients that are a go-to, do not pass go, do not collect 100, $200, you are getting these on board, and that’s going to be the D3, K2 combo and magnesium. And then the magnesium, I choose a form, and sometimes even a couple forms, depending on symptoms. So I tend to go magnesium citrate when there’s constipation, magnesium threonate if there is some neurological symptoms, and magnesium glycinate if there tends to be anxiety or sleep issues associated. And then I will piggyback. I’ll say, “Okay, you’re going to do this in the evening, this in the morning,” depending if there’s a combo of symptoms. That is guaranteed, you’re not walking out without me making a recommendation on those two things. Pretty standard.
From there, there’s so much that you could do with basic metabolic testing, with a basic CBC, with an iron panel. That can give you a whole ton of information. There’s a lot of panels that you can get through Quest that are going to give you a lot of that information. Basic RBC testing for minerals can give you a lot of just foundational information. You can look at heavy metals pretty easily as well and assess for detoxification need. So there’s a lot that you can do. I think at the end of the day, we don’t lean enough on the nutrition physical exam. And if there is one golden nugget, it’s that. Because there is so much that you can do by just listening and evaluating the person in front of you, asking questions. If, like me, you’re in a virtual setting, you can ask them questions about it.
You can have them send pictures to you, close-ups. There’s a lot that we can do, thanks to technology. So, even if they’re not sitting physically in front of you, you can still get those pieces of information, and that can go a long way. And I’ll tell you, patients will love it. They love knowing that you can look at their tongue, or that you can evaluate their cracked lips, or their nails, and that you can get so much information out of that. That feels so valuable to them. It also, I think, makes them feel seen and validated and heard, and I think that goes a long way also to building trust and establishing that relationship, and understanding why they’re taking that supplement.
Because if you told them, “Hey, you’ve got some B vitamin deficiencies, that’s why your nails look like that. They’re not growing because you need X, Y, Z nutrient.” And then, when they take that, they’re like, “Okay, I’m taking it because of my nails.” And there is something really powerful about that that really helps to establish compliance.
That was beautifully said. I love the idea of instilling this concept in patients that, “Your body has an innate wisdom, and it’s telling us what it needs. We just have to pay attention to these signs and these signals, and the information is there.” So that’s beautiful.
I think anyone listening to this episode, they’re going to be excited about, “Okay, maybe I can bring on some of these tools and perhaps do some deprescribing.” But for many, including myself, it’s a bit intimidating, the process. So I would love to hear from you both, as we wrap up, what are some takeaways that clinicians can bring forth with them when they are ready to do some deprescribing?
And the things that I’m thinking about specifically, selfishly for myself, I’m thinking about things like charting. How do you appropriately chart that you’re deprescribing just to make sure that everything is well documented? And then how do you follow up with the patient who is perhaps tapering some medication? Are you following up more frequently? Are you encouraging portal messages? Are you having an allied professional within your practice reach out to them to make sure that they’re safe and well managed? I’d love to hear your process. I think many of us want to know the logistics of what this really looks like in the clinic. So, Betsy, if you’d walk us through what that might look like with the patient, we’d all be very appreciative.
Yeah. I mean, with this question, I was trying to think of, if I could come up with a mnemonic, that would be so helpful, wouldn’t it? I’ll have to work on that. But the idea for me, too, is, first of all, with the medication, what is the why? Why are we deprescribing? Is it because the drug is not efficacious or it’s not needed anymore, like in the concern with a patient whose blood pressure is not normal? So looking at the efficacy, looking at the side effect profile. And I think we have to document, as clinicians and practitioners, what is the reasoning for why we’re deprescribing? And that’s very important. And then we have to make sure that the timing is right, and Lara brought this up from the very beginning, is this a right time to deprescribe?
I mean, if we’re going to be deprescribing drugs that help us with sugar and hypercholesterolemia, doing it right before the dietary nightmare triad of Halloween, Thanksgiving, Christmas, that might not be the best time. On the other hand, there might be patients that are fully invested, and that might be a good time. So checking with the patient. And I’ve often done that. “Let’s go ahead and keep you on some of these medications, or maybe just cut it down a little bit until you get to a place where you’re really invested and its timing is correct.” So timing is important, and having a good why. Is it efficacy? Or is it side effects?
And then talking about what the speed is, how fast are we going to deprescribe? Are we going to go really slow? Are we going to take our time? In educating the patient, what are common things that they could expect as you are deprescribing? And I think about some of the antidepressants, for example, and how they can have visual changes, and they can feel a little dizzy or weird. If we can let the patients know what to expect, when it happens to them, it doesn’t frighten them, it doesn’t make them regress, and it also, again, helps that investment in their trust in us. So looking at what are the side effects of deprescribing? How fast are we going to do that? And do we have a contingency plan? What is the contingency plan when things don’t go the way we thought? Can they reach out to us, like you said?
And you really nailed it, Kalea, because the whole point is, during this time, we have to have really easy ease of interaction with our patients. But you will save yourself a lot of phone calls if you just let people know what to expect. What is an emergency? What’s not an emergency? And what can be done? So we do some real, what I would say, very intricate, detailed information about what to expect. And I think those were the… And one other thing is, from a support… is making sure that there’s people around. So if you have an elderly gentleman that you want to take off a medication that could cause dizziness, for example, and they live alone, that might not be good, that might be better to wait until they have maybe a family member who’s going to be around during that time. So just having someone else around the house. These are just practical things that I consider.
How about you, Lara? Any words of wisdom about how we can appropriately and safely go through the deprescription process?
Absolutely. Absolutely. First of all, I believe in putting the training wheels on first. So the first step is not going to be cut the dose, change the dose, change the medication even, the first step is just going to be, what are we going to add on in conjunction to what we’re already doing? So, if it’s metformin, for example, what are some of the nutraceutical, dietary, and lifestyle modifications that we can add on? Sometimes it’s just like getting them to breathe, sometimes it’s getting them to drink some water, maybe it’s to eat a vegetable. Sometimes this first step is just such a simple, simple first step. We’re not even thinking about removing the medication at this point.
As they start to gain confidence, as they start to gain trust in the process, as they learn to trust themselves, because we forget a lot of times, people don’t trust themselves to be able to get off that medication. They see that medication as their crutch. So, just like somebody learning how to ride a bike, you’re not going to just put them out there on that bike and just say, “Hey, good luck.” You need to put the training wheels on, let them build some confidence around them, let them build some muscle memory around it, and then, when they’re ready, you can start talking about what that next step is, about changing the dosage. When you are ready to take that dosage down, the next step is going to be monitoring them.
I love how you framed it in terms of communication. There are so many different tools to do that. One, there are apps, for example, that help you stay in contact with your patient. There are continuous glucose monitors, where you can actually monitor changes in their blood sugar. Or, if you’re tapering them off their blood pressure medication, you can monitor fluctuations in their blood pressure. Make sure that you have somebody in your collaborative team, maybe a pharmacist, wink-wink, hint-hint, that can really be part of that monitoring piece. Because remember, that’s what we are trained to do. We’re trained to monitor for fluctuations and variations, not just when you’re adding medication, but when you’re trying to taper it off as well.
So make sure that you’ve built a team approach, as well as created some strategy to stay in communication. And I appreciate everybody is super busy, so email may not be the best way for you, text message might be too intrusive. Come up with a strategy that works for you, that allows you to stay in touch and able to make quick decisions when needed. Last but not least, make sure that it’s super clear, as Betsy already said, what to expect. There might be variations of fluctuations, give them something to do in case of emergency. Their blood sugar might dysregulate, they might feel a little hypoglycemic. Teach them what to eat so that they can offset that. Teach them to monitor their blood pressure regularly. It’s one of the most important things, and I’m constantly flabbergasted how often patients aren’t taught how to measure their own blood pressure, even when they’re on… and they’re stable on blood pressure medication, they should always have a blood pressure monitor at home.
Anybody who’s got any sort of dysglycemia should have a blood sugar monitor at home. They’re fairly inexpensive, most patients’ insurances will cover them, make sure that they have those tools so that they can self-monitor, and then make sure that they’re keeping either electronic logs or written logs that they can then share. And frequent communication, frequent interaction, making sure they feel good. But I think the big piece is, if you could set them up for success with both the education and the tools, hopefully, then it’s much easier to keep them on track. Because, again, you don’t want them to suddenly feel wheezy or feel not good, and then they’re just going to lose faith, lose trust. And I’m not even worried about their faith in you, because I’m sure that you’re going to do a great job keeping them motivated, I’m worried about them losing faith in themselves and their ability to stay compliant. That’s the part that always concerns me.
Because folks, when they’re sick and they’re not feeling well, they tend to take that on as a sign that they’ve done something wrong. And that always impedes their progress. So we want to make sure that they feel empowered, that they know what to do, and that they have a lifeline when they need it.
Yeah. As you were speaking, I’m picturing in my mind something that’s so common, which is an asthma action plan. We have our green, and our yellow, and it’s red. And similarly, maybe we could provide something like that to patients, that when we’re tapering medications, it’s, “If you feel this symptom, do this thing and wait this long,” and to set the expectation. And so, I think that that’s a really beautiful example.
Well, you guys, this episode has been jam-packed with pro tips, really invaluable advice, and guidance. Medication management is an important diagnostic consideration and a therapeutic intervention, and you both have given us incredible insights and clinical pearls so that we can support patients who might be good candidates for managing their chronic conditions with personalized lifestyle medicine, therapeutic nutrition.
It’s also so exciting to see how we can continue to build collaborative care teams that are centered around creating long-term resiliency and health for our patients. So thank you both so much for being here and sharing your expertise with us today.
Thank you so much for the opportunity.
That’s great. To join the conversation on this topic, visit IFM’s pages on Facebook and Instagram. For more information about functional medicine, visit ifm.org.