Hi Chloe,
I took a close look at your history, meds, labs etc & did a bit of research
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Background & History35 years old Female
DX’esMigraines
Pustular Psioriasis
Fibromyalgia 2006
B12 deficiency
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RX Meds1)
Somac (Pantoprazole) a Protein Pump Inhibitor
www.medsafe.govt.nz/consumers/cmi/s/Somac.htmen.wikipedia.org/wiki/Proton_pump_inhibitor-for GERD
-
how long on this med?-works by reducing gastric acid secretion by up to 99%.
-lack of stomach acid is also called hypochlorhydria (lack of sufficient HCl) your deficient Chloride suggests you have this at present
-Hydrochloric acid is required for the digestion of proteins and for the absorption of nutrients, particularly of vitamin B12 and of Calcium.
-
decreased vitamin B12 absorption may occur with long-term use
-your deficient/low Chloride, Calcium & B12
likely caused by or worsened by this med2)
Elavil (Amitriptyline) a Tricyclic Antidepressant
en.wikipedia.org/wiki/Elavilwww.psychatlanta.com/documents/elavil.pdf-for depression
-extensive list of potential side effects including orthostatic hypotension (often related to low/deficient Sodium levels),
can affect ADH secretion, breast enlargement & galactorrhea (perhaps through increasing Prolactin levels), nausea, urinary frequency, neuropathy, numbness, tingling
3)
Neurontin (Gabapentin) GABA analogue for neuropathic pain
en.wikipedia.org/wiki/Gabapentinwww.pfizer.com/files/products/uspi_neurontin.pdf-for Fibro pain management
-side effects dizziness, drowsiness, and peripheral edema
-have to wait a couple hours after taking antacids (like Somac) before taking Neurontin
4)
BCP (Birth Control Pill)-all BCP interfere with Endocrine function
-
which one are you on?-
have you got any Androgen & Sex Hormone results? Including Estradiol, Progesterone, LH, FSH, Testosterone (Free & Total), SHBG, DHEAS
5)
Methotrexate (Amethopterin) en.wikipedia.org/wiki/Methotrexate-for Pustular Psoriasis 6 years ago (currently in remission) was unable to walk
-stopped Methotrexate because of infection
-no longer taking
-
how long since you stopped taking this med?-acts by inhibiting the metabolism of Folic Acid
-
Have you tested RBC Folate recently..if not urge you to do so!
-inhibition of enzymes involved in purine metabolism, leading to accumulation of adenosine,
adenosine is important as ATP (Adenosine Triphosphate) for intracellular energy transfer
-side effects include exacerbation of depressive illness, anemia, neutropenia, increased risk of bruising, nausea and vomiting, dermatitis and diarrhea, small percentage of patients develop hepatitis, and there is an increased risk of pulmonary fibrosis.
6)
B12 bimonthly i.m. injections-for B12 deficiency
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SymptomsPoor health for last 6 years
Fibro-pain and also some neuropathy
B12 Neuropathyif no injections for more than 2 weeks
-I get numbness back
-worsening of depression
October’08-began to feel really unwell
-breasts were very sore
-constant nausea
-Frequent nocturnal urination
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Notes-B12 deficiency
have you been tested for Pernicious Anemia?Calcium, Chloride, B12 deficiencies likely related to Somac med-Urate, Urea all deficient on all recent tests
www.rcpamanual.edu.au/sections/pathologytest.asp?s=33&i=631-Sodium intermittently deficient
-Elevated Phosphate – strongly suggest you test
Vit D (25-OHD), PTH (Parathyroid Hormone), Corrected or Ionised Calcium, -Phosphate, LFT-Alanine Transaminase (ALT) undetectable Oct’08
Any LFT results prior to Oct’08?=====================================
Chloe’s Labs
Thyroid TestsFT4 optimal is top 1/3 to ¼ of range
FT3 optimal is top or a bit over range26/10/06 TSH 0.77 (0.1-5.0)
11/12/06 TSH 1.01 (0.1-5.0)
31/01/09 TSH 1.01 (0.1-5.0)
31/01/09 FT3 12.4 (9-19)
*34% in range31/01/09 FT4 4.0 (2.5-6.0)
*43% in rangeAbove Lab Ref Ranges are very conservative!!TSH many Labs now use 3.0 as top of range
Free T3 good range is 9-24 or 10-25
Free T4 good range is up to 7-8
Even on your Labs “low” ranges you are suboptimal meaning
likely you are HypothyroidNeed to test RT3 & Thyroid Antibodies (TPOAbs & TG Abs)Serum Cortisol optimal is top of range
9am 31/1/09 379 nmol/L (150-700)
*suboptimal only 42% in rangeSuggest test Serum ACTH & 8am CortisolAlso strongly suggest
Salivary ASI (4x Cortisol & DHEAS)Serum Iron 13/10/08 18 (9-30)
Need to test Ferritin preferably full Iron Profile
(Ferritin, Iron, transferrin, Transferrin Saturation%)
-Has recent FBC & ESR been done?Lipids13/10/08 Cholestrol (Total) 6.2 (2.6-5-5)
*slightly elevated13/10/08 Triglycerates 0.9 (0.5-2.0)
Where’s rest of Lipid tests HDL, LDL, CRR??? Glucose Random (nonfasting)
13/10/08 3.9 (3.6-7.7)
*seems low?To check Blood Sugars
need fasting Glucose, Fasting Insulin & hbA1CLactic Hydrogenase (100-200)
13/10/08 164
27/11/08 125
27/01/09 131
31/01/09 164
LFT (Liver Function Test)13/10/08 ALT less than 3 (5-45)
*undetectable???13/10/08 ALP 69 (30-100)
13/10/08 AST 29 (10-45)
13/10/08 GGT 21 (10-70)
13/10/08 Bilirubin 7 (less than 20)
Significance of Alanine Transaminase (ALT) undetectable??
Urgently need to retest LFT!!!!Protein (62-83)
13/10/08 72
27/11/08 68
27/01/09 75
31/01/09 70
Albumin (33-47)
13/10/08 39
27/11/08 36
27/01/09 41
31/01/09 39
KFT (Kidney Function Tests)Urea (3.0-8.0)
13/10/08 2.6
*deficient27/11/08 2.8
*deficient27/01/09 2.8
*deficient31/01/09 2.6
*deficientCreatinine (49-90)
13/10/08 63
27/11/08 53
27/01/09 63
31/01/09 58
Sodium (135-145)
optimal 144-14613/10/08 122
*deficient27/11/08 142
*little low27/01/09 129
*deficient31/01/09 135
*bottom of rangePotassium (3.2-4.5)
optimal top of range13/10/08 4.3
*slightly low27/11/08 4.0
*suboptimal27/01/09 4.6
*slightly elevated31/01/09 3.9
*low in rangeStrange Lab range is usually (3.5-5.5)
Which Path Lab do you use?Bicarbonate (22-33)
13/10/08 24
27/11/08 23
27/01/09 23
31/01/09 25
Chloride (100-110)
13/10/08 90
*deficient27/11/08 96
*deficient27/01/09 99
*deficient31/01/09 110
*top of rangeAnion Gap (5-15)
13/10/08 8
27/11/08 9
27/01/09 10
31/01/09 11
eGFR13/10/08 99 ml/min/1.73m2
27/11/08 121 ml/min/1.73m2
27/01/09 99 ml/min/1.73m2
31/01/09 109 ml/min/1.73m2
Calcium (2.15-2.60)
optimal midrange27/11/08 2.10
*deficient27/01/09 2.24
*low31/01/09 2.20
*lowPhosphate (0.7-1.4)
13/10/08 1.25
27/11/08 1.05
27/01/09 1.34
*high in range31/01/09 1.44
*elevatedLow/deficient Calcium & elevated Phosphate strongly suggest need to test the following (at same time)....Vit D (25-OHD), PTH (Parathyroid Hormone), Corrected Calcium, Phosphate, LFT Urate (0.15-0.45)
13/10/08 0.13
*deficient27/11/08 0.14
*deficient27/01/09 0.14
*deficient31/01/09 0.10
*deficient------------------------------------------------------------------------------------
Final CommentsNeed to test Aldosterone & ReninTo exclude low Aldo as cause of Hyponatremia.
Consider
Syndrome of Inappropriate Anti-Diuretic Hormone release (SIADH)en.wikipedia.org/wiki/SIADHHypouricaemia (deficient Urate) is seen in patients with a low purine intake, in SIADH, with hypouricaemic drugs (eg, allopurinol) and in the rare condition of xanthinuria.
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Possibly you are suffering side effects of Elavil (Amitriptyline)
emedicine.medscape.com/article/924829-diagnosis------------------------------------------------------------------------------------
SSRI’s (and Tricyclics) in SIADHwww.pharmacy.duq.edu/pdfs/pic_question/07/SSRI-Induced%20SIADH.pdf------------------------------------------------------------------------------------
Tricyclic Antidepressants (includes Elavil) General Statementwww.ashp.org/mngrphs/ahfs/a382935.htmAnticholinergic EffectsThe most common adverse effects of tricyclic antidepressants are those which result from anticholinergic activity. These include dry mucous membranes (occasionally associated with sublingual adenitis), blurred vision resulting from mydriasis and cycloplegia, increased intraocular pressure, hyperthermia, constipation, adynamic ileus, urinary retention, delayed micturition, and dilation of the urinary tract.
The drugs have been reported to reduce the tone of the esophagogastric sphincter and to induce hiatal hernia in susceptible individuals or to exacerbate the condition in patients with preexisting hiatal hernias.
Tricyclic antidepressants should be withdrawn if symptoms of esophageal reflux develop (GERD) if antidepressant therapy is essential, a cautious trial of a cholinergic agent such as bethanechol used concomitantly with the antidepressant may be warranted. Anticholinergic effects appear to occur most frequently in geriatric patients, but constipation is frequent in children receiving tricyclic antidepressants for functional enuresis
Endocrine and Genitourinary EffectsEndocrine and genitourinary effects that have occurred in patients receiving tricyclic antidepressants include increased or decreased libido, impotence, testicular swelling, painful ejaculation, anorgasmia,
breast engorgement and galactorrhea in females, gynecomastia in males, and elevation or
lowering of blood glucose concentrations.
The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) also has been reported.Paradoxically,
urinary frequency and nocturia have been reported------------------------------------------------------------------------------------
So I think you & your Doc need to really examine your current meds closely.
Somac I think is interfering with Stomach Acid & probably causing/contributing to Chloride deficiency, low Calcium & low/deficient B12 levels.
Elavil should NOT be taken if you have GERD (as per above), can cause orthostatic Hypotension (probably through interfering with Sodium, Aldo, Renin levels), can cause problems with ADH levels, frequent & nocturnal urination, even neuropathy, breast engorgement (hence tenderness & pain)
GERD how do you know you have HIGH stomach acid? Are you sure you dont have LOW Stomach acid? many people make the assumption that high Acid causes Heartburn & pain. In fact BOTH do & low Acid is much more common than most realise. Somac really does a number on Acid without good levels you risk severe malabsorption & nutrient deficiencies.
For low Stomach Acid a good digestive enzyme product with HCl is the answer. Note if you are Hypothyroid (and it looks like you are) low Stomach Acid is very common with that.
Have you a BP monitor at home? Do you measure BP & HR at rest (sitting or lying for 15 mins at least no eating or meds for 1 hour prior) then immediately stand & measure again? BP should RISE not fall when standing. If it falls HR often goes high to try & compensate. If BP doesnt rise consistently then Sodium/Potassium levels & balance are off. Aldosterone & Renin should be tested as they control these.
Let me know what you think?