Fxmedce Intro To FM Dind

Introduction to Functional Medicine
and Medication-Related Nutrient

Depletions
Lauren Castle, PharmD, MS
Founder, Functional Medicine Pharmacists Alliance (FMPhA)
Learning Objectives
• Define Functional Medicine (FM) and list the 6 core principles and 7
clinical imbalances
• Compare and contrast conventional medicine, integrative medicine,
and FM
• Utilize FM tools including the Timeline, the Matrix, and GO-TO-IT
• Describe the pharmacist's role in addressing drug-induced nutrient
depletions
Define Functional Medicine
(FM) and list the 6 core
principles and 7 clinical
imbalances
Modern Day FM
Jeffrey Bland, PhD, FACN, Mark Hyman, MD

CNS • IFM Chairman
• Father of FM • Director of the Cleveland
• IFM Founder, 1991 Clinic Center for FM, 2014
Breaking Research from CCCFM
A New Approach
Chronic Disease
& Morbidity
Health
& Economy
Definition
• Functional Medicine is a systems-biology-based model that
empowers patients and practitioners to work together to achieve the
highest expression of health by addressing the underlying causes of
disease.
• Functional Medicine uses a unique operating system and
personalized therapeutic interventions to support individuals in
achieving optimal wellness.
Jones, DS. Textbook of Functional Medicine. Institute for Functional
Medicine. Federal Way, WA: Institute for Functional Medicine; 2010.
Compare and contrast
conventional medicine,
integrative medicine, and FM
Current model: Acute Care
• Rapidly identify and treat emergent problems
• Works well in emergency/hospital settings
• Relies on deductive reasoning and “reductionism”
• Historically developed for Infectious disease
• The “Silver bullet”: antibiotics
• “Name it and blame it”
• “A drug for each bug” FM: We must find
• “A pill for each ill” the root cause of
this broken bone!
Pharmaceutical Evolution
Physiologic Receptor
Antibiotics
Antagonists Modulators
Influences on Chronic Disease

Functional vs. Conventional
http://www.ibsgroup.org/other/articles/Understanding_functional_medicine.pdf
Functional vs. Conventional
http://www.ibsgroup.org/other/articles/Understanding_functional_medicine.pdf
Conventional
Complementary
All Functional Medicine

is Integrative, Alternative
but not all Integrative

Medicine is Functional
Integrative Medicine: healing-oriented, body/mind/spirit, lifestyle approach that combined

Conventional and CAM therapies
X
Functional Medicine: emphasizes underlying cause of dysfunction, organizes assessment
& treatment using FM tools
Seven Core Imbalances
Assimilation: • digestion, absorption, microbiota/GI, respiration
Defense and repair: • immune, inflammation, infection/microbiota
Energy: • energy regulation, mitochondrial function
Biotransformation & elimination: • toxicity, detoxification
Transport: • cardiovascular and lymphatic systems
Communication: • endocrine, neurotransmitters, immune messengers
Structural integrity: • subcellular membranes to musculoskeletal integrity

Six Principles of FM
Biochemical
Individuality
Promotion of
Organ Reserve Patient-Centered
Dynamic Balance
Health as a of Mind, Body, &
Positive Vitality Spirit
Web-like
Interconnections

5R/4R Protocol
Remove Pathogens, food sensitivities, PPI
Replace Vitamins, minerals, enzymes, gastric acid, fatty acids, antioxidants
Reinoculate Probiotics, prebiotics, synbiotics
Repair L-glutamine, anti-inflammatory therapy
Rebalance Stress and lifestyle issues

5 Causes of Environmental Illness
1. Toxins
• biologic, elemental, synthetic
2. Allergens
• food, mold, dust, animal products, pollens, chemicals
3. Microbes
• bacteria, yeast, viruses, parasites, worms
4. Stress
• physical or psychological
5. Poor diet
• standard American diet, or SAD

Four P’s of FM
Personalized Predictive
• Genetic and environmental • Tailored health strategy
variations drive and define based on personalized map
individual treatment of health risks with
traditional and novel
biomarkers
Preventative Participatory
• Proactive vs. reactive • Empowers and engages the
approaches that shift focus patient
from illness to wellness,
from disease treatment to
functional enhancement

“Three Legs of the Stool” Approach

Two questions
Fill an unmet Get rid of

need? something?
• Nutrients • Toxins
• Air • Allergens
• Water • Microbes
• Sleep • Poor diet
• Connection • Stress

The FM Tree

Utilize FM tools including
the Timeline, the Matrix, and
GO-TO-IT
The Timeline
• Use the Timeline to put together an extensive lifetime picture where
clinical patterns emerge:
• Ages, events, symptoms, diagnoses
• ATMs: antecedents, triggers, mediators
• Significant contributory lifestyle factors

Factors, biochemical or psychosocial, that contribute to pathological
changes and dysfunctional responses (cytokines, hormones,
neurotransmitters, free radicals, or ongoing exposure to
Factors, genetic or environmental or lifestyle insults such as toxic exposures, or stress.)
acquired, that
predispose individual
to an illness or pattern
(genetics, past illness,
nutrition, occupational Triggers are factors that provoke the symptoms and signs of illness
exposure, lifestyle.)
(microbes, allergens, trauma, toxins, etc.)

Matrix
• Collect and organize patient’s history, S&S, lifestyle
• S&S classified as clinical imbalances in seven core physiological
systems that transcend organ boundaries
• Assimilation, Defense and repair, Transport, Communication, Structural
integrity, Biotransformation and elimination, Energy
• Modifiable Personalized Lifestyle Factors
• Sleep & Relaxation, Exercise & Movement, Nutrition, Stress,
Relationships

GO TO IT
Gather • Gather information from the patient (MSQ, Timeline)
Organize • Organize patient history (Timeline and Matrix)
Tell • Tell the story back to the patient
Order • Order and prioritize treatment strategies
Initiate • Initiate further assessment and treatment (FM RX, Food Plans)
Track • Track progress (MSQ)

Describe the pharmacist's
role in addressing drug-
induced nutrient depletions
Pharmacists’ Patient Care Process - by Joint
34
Commission of Pharmacy Practitioners (JCPP)
https://jcpp.net/patient-care-process/
FUNCTIONAL Pharmacists’ Patient Care Process
35
GATHER à MSQ, Timeline
ORGANIZE & TELL

TRACK à Matrix
INITIATE ORDER à Matrix
https://jcpp.net/patient-care-process/
MTM Core Elements Service Model
https://www.pharmacist.com/sites/default/files/files/core_el
ements_of_an_mtm_practice.pdf
FUNCTIONAL MTM Core Elements Service Model
GATHER, ORGANIZE, ORDER

TELL à Timeline & Matrix à Matrix INITIATE TRACK
https://www.pharmacist.com/sites/default/files/files/core_el
ements_of_an_mtm_practice.pdf
Pharmacist-Led FM Interventions
1. Drug Interactions
Drug-Induced Nutrient Depletions
2. Deprescribing
Opioid Stewardship & Pain Management
3. Functional MTM / Pharmacists’ Patient Care Process
Pharmacogenomics
4. General non-medical nutrition information
Weight Loss
5. Compounding
Low Dose Naltrexone
Resources for DIND
Resources for DIND
www.mytavin.com
Resources for DIND
Common DIND
Medication(s) Nutrients Medication(s) Nutrients
Anticonvulsants Calcium Estrogens
Folic acid
•Phenytoin Vitamin D •Oral contraceptives
•Carbamazepine H2-Blockers Vitamin B12
Folic acid
Loop Diuretics Calcium
Biguanides
Vitamin B12 Potassium
•Metformin Loop Diuretics &
Magnesium
Vitamin A Thiazide Diuretics
Thiamine
Bile Acid Sequestrants Vitamin D
Thiazide Diuretics Zinc
Vitamin K
Pancreatic Enzymes Folic acid
Corticosteroids Calcium
•Hydrocortisone Proton Pump Inhibitors Magnesium
•Prednisone Potassium Statins Coenzyme Q10
https://naturalmedicines.therapeuticresearch.com/tools/ch
arts/drug-induced-nutrient-depletions.aspx
Symptoms of nutrient deficiency
If you have these symptoms ... ... you may have
Muscle cramps, irregular heartbeat, mood changes Low magnesium
Muscle weakness, irregular heartbeat, tiredness, constipation Low potassium
Weakness, numbness, tingling in hands and feet Low vitamin B6

Low red blood cells, tingling sensation, weakness, numbness, Low vitamin B12
confusion
Low red blood cells, fatigue, pale skin, tender tongue Low vitamin B9 (folic acid)
Weakened bone, bone loss Low vitamin D and calcium

Weakened immune system, taste or smell changes, rash, hair Low zinc
loss, diarrhea
https://www.health.harvard.edu/staying-healthy/are-your-medications-
causing-nutrient-deficiency
Interactive Case Study
Case #1 ME
• ME is a 63-year-old female who lives on a wheat farm with 2
indoor/outdoor cats and outdoor dog. She has been married for 45 years.
She works long hours on her feet as a cook and has arthritis in her hands
and 1 shoulder from repetitive use. She has a history of periodontal
disease (resolved with teeth extraction and full dentures), osteoarthritis,
hypothyroidism, seasonal allergies, frequent sinusitis, Hepatitis C
(spontaneously resolved), pernicious anemia, varicose veins, peripheral
neuropathy and lumbar foraminal stenosis.
• She is currently attending weight watchers and has lost 50 pounds in the
last year and her current weight is 245 lbs. Her goal weight is 175 lbs.
• Chief Complaint: “I hurt all the time. If it is not one thing, it is another. I’d
like to lose more weight so my family won’t have a hard time if they ever
need to care for me.”
Case #1 ME
Medications:
1. Cyanocobalamin 1000mcg IM Q 30 9. Hydrocodone/APAP 5mg/325 mg 1
days po Q6h PRN PA
2. Levothyroxine 75 mcg daily 10. Diclofenac 1% Topical Apply 2 gm
to the affected joint QID PRN
3. Gabapentin 300 mg BID
4. Benzonatate 100mg BID 11. Furosemide 20 mg 1 po QD PRN
swelling
5. Diclofenac 75 mg BID
12. Mometasone Nasal Spray 1 spray
6. Losartan/HCT 50/12.5mg QD each nostril BID
7. Premarin 0.3mg QD 13. APAP/Diphenhydramine 500/50mg
8. Tizanidine 4mg BID 1 to 2 po QHS PRN sleep
Factors, biochemical or psychosocial, that contribute to pathological
changes and dysfunctional responses (cytokines, hormones,
neurotransmitters, free radicals, or ongoing exposure to
Factors, genetic or environmental or lifestyle insults such as toxic exposures, or stress.)
acquired, that
predispose individual
to an illness or pattern
(genetics, past illness,
nutrition, occupational Triggers are factors that provoke the symptoms and signs of illness
exposure, lifestyle.)
(microbes, allergens, trauma, toxins, etc.)

Spouse not supporting in healthy eating. Case #1 ME
Convenience, pain prevents exercise
Vaginal birth
Timeline
Breast fed for
first 6 months
of life, genetic She works long Thyroid rental owner;
IF deficiency hours on her feet as Medication high stress
a cook and has started in 2013 evicting
arthritis in her hands New Rental criminal
and 1 shoulder from Tenants in tenants
repetitive use. 2016 (age 57) (age 63)
Tonsillectomy 1960, Allergy shots about 5

hysterectomy/ years ago, allergist
oophorectomy 1993, said she was allergic osteoarthritis,
total teeth extraction to wheat (inhaling it hypothyroidism, seasonal
1997, cholecystectomy during the harvests), allergies, frequent
2000. Steroid injections but that she could sinusitis, pernicious
in wrists, shoulder and still eat it. She was anemia, varicose veins,
low back. Hepatitis C also allergic to many
peripheral neuropathy and
(spontaneously different local plants
resolved). and trees. lumbar foraminal stenosis.
Case #1 ME - Polling Question
What are this patient’s core imbalances?
A. Assimilation and Defense and Repair

B. Structural Integrity and Transport
C. Communication and Biotransformation and Elimination
D. Assimilation, Defense and Repair, Structural Integrity, Transport,
Communication, Biotransformation and Elimination, and Energy
Case #1 ME - Polling Question
What are this patient’s core imbalances?
A. Assimilation and Defense and Repair

B. Structural Integrity and Transport
C. Communication and Biotransformation and Elimination
D. Assimilation, Defense and Repair, Structural Integrity, Transport,
Communication, Biotransformation and Elimination, and Energy
• Answer is D. Refer to matrix to see how the patient’s medical history was
organized to identify her imbalances.
Case #1 ME
Timeline
allergies,
cholecystectomy,
sinusitis,
diuretic
Hepatitis C
(resolved),
Vaginal birth
Breast fed for first 6
months of life, genetic IF
neuropathy
deficiency Arthritis,
lumbar
foraminal
stenosis
long days flare
arthritis
hypothyroid, pesticides,
hysterectomy, air quality,
Spouse not supporting in neuropathy medications
healthy eating, (opioids,
convenience, pain estrogens)
prevents exercise pernicious anemia, varicose veins, diuretic
poor quality due to pain 3.5 mi/day steps, mindful of sugar and
stressed over tenants satisfied in marriage of
can’t use bike due to portions, eats salads
45 years,
pain & veggies when
involved at church
convenient; crock pot
w/ seasoning packets
Case #1 ME
Symptoms
Nutrient
Drugs
Depletions
Case #1 ME
Medications:
days po Q6h PRN PA
swelling
Case #1 ME – Polling Question
• What medications may be contributing to nutrient deficiencies?
Case #1 ME – Polling Question
Medications:
days po Q6h PRN PA
swelling
TRC
https://naturalmedicines.therapeuticresearch.com/
TRC
https://naturalmedicines.therapeuticresearch.com/
TRC
NUTRIENT: SYMPTOMS OF DEFICIENCY: REF:
fatigue, carpal tunnel, irritability, depression, premenstrual syndrome, poor
B6 123
concentration, memory loss, heart disease
muscle pain, poor appetite, nausea, vomiting, weakness, insomnia,
osteoporosis, irritability, hypertension, fatigue, constipation, abnormal heart 1 2 3
MAGNESIUM
rhythm, elevated blood sugar, numbness, seizures, personality changes, 45
migraines, headaches, premenstrual syndrome
anemia, fatigue, weakness, constipation, weight loss, neuropathy,
B12 depression, confusion, memory loss, rash, poor appetite, sore mouth, 12
tongue inflammation, incontinence, heart disease
POTASSIUM weakness, fatigue, muscle pain, indigestion, abnormal heart rhythm 12
tongue inflammation, gingivitis, poor appetite, shortness of breath, diarrhea,
FOLIC ACID 12
irritability, brain fog, heart disease
poor wound healing, weakened immunity, taste abnormalities, erectile
ZINC dysfunction, poor appetite, hair loss, diarrhea, amenorrhea, white spots on 12
fingernails
www.mytavin.com
NUTRIENT: SYMPTOMS OF DEFICIENCY: REF:
fatigue, depression, irritability, memory loss, confusion, weakness, abnormal
THIAMINE (B1) heart rhythm, poor coordination, indigestion, decreased stomach acid, poor 12
appetite
congestive heart failure, hypertension, elevated cholesterol, elevated blood
C0Q10 12
sugar, cardiomyopathy, muscle pain, periodontal disease
osteoporosis, numbness, muscle pain, tremors, fatigue, poor appetite,
CALCIUM 1
abnormal heart rhythm
poor appetite, bone pain, fragile bones, arthritis, fatigue, irritability,
PHOSPHORUS 1
numbness, weakness, weight loss
SODIUM weakness, poor concentration, confusion, dehydration, poor appetite 12
GLUTATHIONE weakened immunity, weakened liver detoxification, hair loss 12
scurvy, fatigue, malaise, gingivitis, poor wound healing, arthritis, depression,
VITAMIN C 1
iron deficiency, urinary tract infection, asthma, increased cancer risk
weakness, impaired vision, unsteady gait, liver problems, kidney problems,
VITAMIN E 1
neuropathy
www.mytavin.com
Symptoms of nutrient deficiency
If you have these symptoms ... ... you may have
Muscle cramps, irregular heartbeat, mood changes Low magnesium
Muscle weakness, irregular heartbeat, tiredness, constipation Low potassium
Weakness, numbness, tingling in hands and feet Low vitamin B6

Low red blood cells, tingling sensation, weakness, numbness, Low vitamin B12
confusion
Low red blood cells, fatigue, pale skin, tender tongue Low vitamin B9 (folic acid)
Weakened bone, bone loss Low vitamin D and calcium

Weakened immune system, taste or smell changes, rash, hair Low zinc
loss, diarrhea
https://www.health.harvard.edu/staying-healthy/are-your-medications-
causing-nutrient-deficiency
Case #1 ME
• ME is a 63-year-old female who lives on a wheat farm with 2
indoor/outdoor cats and outdoor dog. She has been married for 45 years.
She works long hours on her feet as a cook and has arthritis in her hands
and 1 shoulder from repetitive use. She has a history of periodontal
disease (resolved with teeth extraction and full dentures), osteoarthritis,
hypothyroidism, seasonal allergies, frequent sinusitis, Hepatitis C
(spontaneously resolved), pernicious anemia, varicose veins, peripheral
neuropathy and lumbar foraminal stenosis.
• She is currently attending weight watchers and has lost 50 pounds in the
last year and her current weight is 245 lbs. Her goal weight is 175 lbs.
• Chief Complaint: “I hurt all the time. If it is not one thing, it is another. I’d
like to lose more weight so my family won’t have a hard time if they ever
need to care for me.”
Case #1 ME- 5R/4R Protocol
• Replace
• Cyanocobalamin 1000 mcg IM Monthly
• Digestive Enzymes 1 po AC
• Melatonin 1 mg po HS
• Drug-Induced Nutrient Deficiencies
• Multiple Vitamin and Mineral Supplement with L-Methylfolate po QD
• Vitamin D3 1,000 IU po QD
• Magnesium Glycinate 400mg, 1 po QAM and 2 po QPM
• CoQ-10 100 mg po QD
A Word about Testing…
“Test, Don’t Guess?”
• Genova NutraEval
• Spectracell Micronutrient Test
• Great Plains Organic Acids Test (OAT)
• Precision Analytics DUTCH
• Nutrigenomics
*Start with what you have in front of you!*

Take-Aways
1. Look for ways to layer in a functional
medicine approach within your current
pharmacy practice.
2. Leverage your expertise in biochemistry.
3. Don’t let opportunities slip away;
you are the most accessible FM provider!
Questions?
►www.FMPhA.org
►www.facebook.com/FMPhA.org
►www.instagram.com/FMPhA

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Introduction to Functional Medicine

and Medication-Related Nutrient

Jeffrey Bland, PhD, FACN, Mark Hyman, MD

Jones, DS. Textbook of Functional Medicine. Institute for Functional

All Functional Medicine

but not all Integrative

Integrative Medicine: healing-oriented, body/mind/spirit, lifestyle approach that combined

Defense and repair: • immune, inflammation, infection/microbiota

Energy: • energy regulation, mitochondrial function

Biotransformation & elimination: • toxicity, detoxification

Transport: • cardiovascular and lymphatic systems

Communication: • endocrine, neurotransmitters, immune messengers

Structural integrity: • subcellular membranes to musculoskeletal integrity

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Replace Vitamins, minerals, enzymes, gastric acid, fatty acids, antioxidants

Reinoculate Probiotics, prebiotics, synbiotics

Repair L-glutamine, anti-inflammatory therapy

Rebalance Stress and lifestyle issues

Jones, DS. Textbook of Functional Medicine. Institute for Functional

• biologic, elemental, synthetic

• food, mold, dust, animal products, pollens, chemicals

• bacteria, yeast, viruses, parasites, worms

• standard American diet, or SAD

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Fill an unmet Get rid of

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Organize • Organize patient history (Timeline and Matrix)

Tell • Tell the story back to the patient

Order • Order and prioritize treatment strategies

Track • Track progress (MSQ)

Jones, DS. Textbook of Functional Medicine. Institute for Functional

GATHER à MSQ, Timeline

ORGANIZE & TELL

INITIATE ORDER à Matrix

GATHER, ORGANIZE, ORDER

Muscle weakness, irregular heartbeat, tiredness, constipation Low potassium

Weakness, numbness, tingling in hands and feet Low vitamin B6

Weakened bone, bone loss Low vitamin D and calcium

Jones, DS. Textbook of Functional Medicine. Institute for Functional

Tonsillectomy 1960, Allergy shots about 5

A. Assimilation and Defense and Repair

A. Assimilation and Defense and Repair

Muscle weakness, irregular heartbeat, tiredness, constipation Low potassium

Weakness, numbness, tingling in hands and feet Low vitamin B6

Weakened bone, bone loss Low vitamin D and calcium

*Start with what you have in front of you!*

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Start with what you have in front of you!