Guest Case Study by Dr. Robert Abbott
- Chris is a 34-year-old male with a successful career who has been challenged by multiple symptoms since 2016 primarily affecting his eyes, genitourinary tract, and his gut.
- 1: IBS, 2016
- 2: Petechia, 2016
- 3: Prostatitis, Early 2017
- 4: Meibomian Gland Disease, Blepharitis, Ocular Rosacea?, 2017
- 5: Acute Respiratory Failure – Levaquin related, 2018
- 6: Achilles tendon rupture – Levaquin related, 2018
- 7: Recurrent SIBO 2017, 2018, 2019
- 8: Pleurisy, 2019
- 9: C. difficile, 2019
- 10: Goiter, (ultrasound confirmed) Mid 2019
- Low Dose Naltrexone 4.5 mg nightly
- Xiidra (lifitegrast) eye drops
- 1: Burning and inflamed eyes/eyelids
- 2: GI discomfort and stool irregularity
- Chris was recently diagnosed with acute C. difficile colitis in the setting of long term herbal antimicrobial use. He appears in a tenuous state needing significant support. It appears that aggressive and perhaps misguided functional medicine therapies have led to his current worsening state.
(Focused mostly on 2019)
- Chest X-ray: Trace right pleural effusion with clinical diagnosis of pleurisy
- Connective Tissue Autoantibodies: Negative Ro/SSA and La/SSB for Sjogren’s
- Early Sjogren’s Antibody Panel: + Carbonic Anhydrase antibody – unknown significance
- Skin Biopsy: Multiple negative autoantibodies assessing for blistering diseases like pemphigus, etc
- Genova Lactulose Breath Tests: Multiple normal to equivocal tests with retesting over the course of months in 2019
- Serum nutritional markers: Markedly elevated iodine on supplementation, low normal serum vitamin A
- Thyroid antibodies (TPO and Tg): Negative
- Thyroid Ultrasound: Slight thyroid enlargement and increased vascularity
- Hospital Stool PCR C. difficile Toxins: Positive in setting of clinically severe diarrhea
- Reports first onset of IBS-M pattern around 2016. Reported predominantly looser stools. Up to that point, he had been fit and well with only occasional M/S complaints. There was some concern for small petechia on upper thighs at about the time of developing looser stools.
- 2 months after developing the change in stools, he felt symptoms suggestive of acute prostatitis with perineal pain, fever, and burning in his upper thighs. GI symptoms evolved, disappearing for some time, then switched towards more constipation, eventually alternating in nature.
- Eventually developed eye issues without confirmed diagnosis. There were suspicions for meibomian gland disease, ocular rosacea, or an autoimmune condition behind eye symptoms. Symptoms waxed and waned for the next 2 years until suffering a setback related to fluoroquinolone toxicity in 2018 after another treatment for suspected prostatitis.
- He began work with a functional medicine practitioner in 2018 who sought to address his GI concerns through antimicrobial gut-directed therapies and supplements. He had a thyroid ultrasound performed showing a slightly enlarged thyroid. Negative thyroid antibodies. 1-2 months prior to our visit, after a period of continued use of herbal antimicrobials, he developed worsening stools, 8-10 daily. Evaluated in the ER where he was diagnosed with C. difficile colitis based on abdominal CT and stool PCR. He then completed a multi-week course of vancomycin prior to our visit.
- Uncle: Prostate Cancer
- PGF: Colon Cancer, Heart Attack, Stroke
- PGM, MGM: Alzheimer’s Dementia
- No notable autoimmune disease history
- Multiple Pharmaceutical: Bactrim, Keflex, Levaquin
- Probiotics: Spore-based, Lacto-bifido blend
- Bovine Immunoglobulins
- Longer-term combinations of anti-microbial herbs
- Resolving C. difficile colitis
- Secondary gut dysbiosis, potential yeast overgrowth as a result of C. difficile colitis
- IBS-M secondary to neuromuscular gut-based autoimmunity
- Inflammatory bowel disease (History of +ASCA)
- Early Sjogren’s Disease, Connective Tissue Autoimmune Disease?
- Vasculitis? HSP?
- Chris is certainly in a tough spot at high risk for early C. difficile recurrence. I expect that he can respond well to gut-directed therapy that minimizes broad-spectrum antimicrobials.
- Semi-elemental diet
- Tests Ordered:
- GI MAP
- AVISE-CTD Autoantibody testing
- Chris has had multiple, mostly excessive blood chemistry tests. While blood chemistry tests are my first go-to for assessing baseline health, I do not feel that there is anything worth doing at this time given previous labs. I would like to better evaluate the gut ecosystem via a PCR-based stool test and see if he still has detectable levels of C. difficile amidst other pathogens. Lastly, given his constellation of unexplained multi-organ system symptoms, I will perform a comprehensive autoantibody profile reassessing for connective tissue autoimmune markers related to lupus, scleroderma, etc. as well as marked for thyroid autoimmunity and rheumatoid arthritis. Paired with the previous testing, this will provide more evidence for/against these primary pathologies.
- AIP dietary template
- S. boulardii probiotic
- Spore-based probiotic
- L-Glutamine powder
- 50 billion CFU Lactobacillus/Bifidobacterium Probiotic
- Digestive Enzymes
- Betaine HCl
- Bovine protein-based meal replacement protein powder
- Cod Liver Oil
- Encourage to discontinue other products recommended my previous functional medicine provider in order to simplify and focus treatment regimen
- We are avoiding the use of antimicrobial products and instead are choosing to focus on broad-spectrum probiotics as well as digestive support. We have recommended a hypoallergenic protein meal replacement that may be easier to consume/digest in which he can also add additional L-glutamine powder. We also suspect that the temporary removal of a few paleo compliant foods as part of the AIP diet may help in the short term.
- Bowel movements have been more formed, less gassy, and less mucous-like. Reports that he is not having big fluctuations of diarrhea and constipation. Has been able to take supplements and follow the AIP dietary pattern.
- Negative AVISE-CTD autoantibody screen
- GI MAP Findings
- C. difficile Toxins A and B
- Opportunistic dysbiosis (Morganella, Proteus, Citrobacter being the most notable)
- Elevated clostridial species
- Elevated candidal species
- Low normal fecal elastase
- Normal calprotectin
- No H. pylori
- Resolving C. difficile colitis with positive toxins and significant dysbiosis with overgrowth of several bacterial and fungal species
- No signs of connective tissue or thyroid autoimmunity
- Chris’ GI MAP showed an expectant dysbiotic stool. Autoimmune testing was reassuring. We must be quite cautious with our use of antimicrobials to prevent relapse while simultaneously addressing the dysbiotic flora.
- S. boulardii – higher dose powder
- Targeted B Complex
- Combination of oregano oil, myrrh oil, and black cumin seed oil
- Feels like his stool pattern has improved since starting our treatment for C. difficile. He only seems to notice perianal irritation and pain while sitting for a long period of time. His main complaints have now shifted to his eyes.
- He is now using two topical medications including a steroid and combination steroid and antibiotic that has been helpful.
- He continues to report mild depression when his eye symptoms worsen but is feeling better currently given the steroids.
- Has questions about long term options for his eyes given the short term viability of the steroids. He also wonders if his eye symptoms are related to his GI symptoms.
- Chris is improving with regards to his GI symptoms and while not back to what he considers normal (circa 2016) he is encouraged. While I certainly would have expected him to gradually improve from the acute C. difficile without intervention, it does appear that our interventions are accelerating and increasing this progress. I have some speculations about his eye symptoms and possible connections to mast cell activation given the known issues in his gut.
- Stop Antimicrobial herbs: oregano oil, myrrh oil, black cumin seed oil
- Start complex of intestinal lining supporting nutrients to go with continued use of L- glutamine
- Continue digestive support
- Continue probiotics with titration down of S. boulardii to “normal” dose
- Encouraged to consider a trial of anti-inflammatory phytonutrient and a phytonutrient combination of luteolin, rutin, and quercetin to see if he noticed any changes with his eyes
- Can broaden his diet to be more ancestral without AIP restrictions
- Continues to make progress after his last visit, but things have somewhat stalled in terms of getting back to his GI “normal”
- He has been focused on seeking evaluations and treatments for his eyes. Making little progress.
- Supplements seeking to address his eye did not really help in his opinion.
- He has broadened his diet and feels good in this domain.
- Has questions about the utility of repeat stool testing, would like to see what has changed.
- Additionally has questions about the utility of testing we discussed assessing for neuromuscular autoimmunity in the gut.
- Chris appears to have reached a plateau with his GI improvements, but it is challenging to discern what “normal” we are trying to obtain. The irritation and redness of his eyes, eyelids clearly remains an issue that is not going away. Given his desires and the nature of the findings on the stool test, I suggested we could repeat the GI MAP to assess ecosystem shifts that could help tailor our treatment recommendations going forward. As you will see in the research reviews, we may want to reserve repeat stool testing for those with whom we are asking very specific pathogen questions such as in Chris’ case ex. C. difficile, Candida or H. pylori eradication versus changes in commensal or opportunistic pathogens whose changes may not correlate to the clinical picture.
- Perform GI MAP testing
- Perform IBS Smart testing (anti-vinculin, anti CdtB)
- Follow-up in 4-6 weeks
- No major changes. Stressors with working from home, but managing and feeling well overall.
GI MAP retesting
- No presence of C. difficile Toxins A and B
- No presence of Morganella, Citrobacter
- Normalized Clostridial species
- Normalized Candida species
- Normalized fecal elastase
- Continued normal calprotectin
- Normalized sIgA
- Continued high elevation in Proteus spp.
- Now a High normal level of H. pylori (none previous) without virulence factors
- False Positive EHEC
IBS Smart testing
- Negative anti vinculin and anti-CdtB antibodies
- There are marked changes in the stool test, nearly all positive. He still remains with a now even higher level of Proteus– curious to think if this played a role early on in the setting of early IBS-M and prostatitis. Despite all the changes on the stool test, however, it would be a stretch to say his GI symptoms have been completely eliminated and his stool pattern has normalized. Given the larger positive clinical and laboratory changes, I believe we can scale back some of his supplements even further.
- Continue with 3 classes of probiotics, digestive enzyme PRN, cod liver oil and discontinue others.
- Can explore the use of vitamin C, quercetin powder in water
- Perform urinalysis looking for blood, protein, casts, etc in urine
- Fecal microbiota transplant (FMT)- if the patient feels that his symptoms remain functionally impairing, based on his clinical history and research presented in this month’s research reviews, FMT would be an interesting treatment option. Challenges remain about its availability where the patient lives.
- Explore the use of an elemental diet reset
- To evaluate the effectiveness of a simplified dietary intervention to improve thyroid function and quality of life in pediatric patients with subclinical hypothyroidism (SH) defined as TSH between 4.2 and 10 μIU/mL and normal (0.78–1.94 ng/dL) free T4 hormone levels.
- 62 children between the ages of 1-12, (average age ~ 8 years old) were recruited from outpatient pediatric clinics in the Netherlands. The children were randomized to either follow dietary recommendations that included the regular consumption of beef, green vegetables, butter (on bread), and whole milk as part of their larger dietary pattern or were placed in a control group that did not receive specific dietary guidance. Baseline TSH, Free T4, Free T3, anti-TPO antibodies, and a basic lipid panel were assessed over the 6-month study. The authors also assessed changes in the children’s quality of life, sleep, and fatigue.
- TSH scores trended downward in both groups, but still stayed above 4 μIU/mL by the end of the 6 month study period
- There were no significant changes in Free T4 levels in either group
- There were no significant changes to the lipid profiles in either group
- There was a significant improvement in overall quality of life including more specific improvements in fatigue and sleep within the dietary intervention group.
- During the 6 months of the study, the intervention group showed an improvement over time on all PedQL fatigue scale domains (Table 2). In comparison to the control group, the intervention group showed significant improvement in the total PedQL fatigue scale scores and PedQL sleep scores.
- “In children with SH, a dietary intervention consisting of green vegetables, beef, whole milk, and butter did not improve thyroid function in terms of thyroid hormone production, but it did reduce tiredness, as measured with the PedQL fatigue scores. Hence, this lifestyle (dietary) intervention could be a possible tool to improve the wellbeing of children with SH, independent of thyroid function”
- “The overall adherence to the diet was 88.5% in the intervention group and 40% in the control group (p < 0.001). The consumed amounts were not normally distributed; some children ate almost 100% of the dietary advice, others only a few components. From the four components of the dietary advice, the control group consumed a median of 58.5% of the beef advice (e.g., 100% beef advice was three times beef per week), 0% whole milk (e.g., 100% = every day 300 mL whole milk), 0% butter (e.g., 100% = everyday butter on their bread) and 80% of the green vegetables advice (e.g., 100% = 5 times green vegetables per week).”
- A simplified dietary intervention seeking to improve nutrient density in children with SH may help to improve quality of life through improvements in fatigue and sleep scores independent of changes in thyroid function.
Dr. Ruscio Comments
- This is a new exciting study out of the Netherlands that sought to examine the effects of a simplified dietary intervention for children with SH. It was interesting to note that while the control group did not receive direct dietary advice, they were asked to keep food diaries surrounding the 4 food groups and the parents may have inferred some of the food groups to be included in the children’s diet (as evidenced by the high rate of green vegetable intake in the control group) despite not receiving the guidance directly. One could argue that the significant effects seen in the intervention group could be attributed to a phenomenon known as “regression to the mean”, as the intervention group had clinically lower scores than the control group at baseline and by the end of the study, simply looked more similar to the control group, but given the low-risk nature of the dietary intervention itself and the positive trends seen in quality of life, it certainly seems reasonable to consider at least simplified dietary guidance for children with SH. It should be reiterated as well that the children consumed full-fat dairy as well as bread with butter throughout the study and perhaps restrictive elimination diets for children should not be recommended as initial therapy in the setting of abnormal thyroid function tests or the presence of thyroid antibodies.
- The study author’s conducted a systematic review with meta-analysis to determine the clinical utility of fecal calprotectin as a non-invasive predictive marker for relapse in patients with previously diagnosed Ulcerative Colitis (UC)
- The authors selected a total of 14 studies that included just over 1,000 patients to explore the pooled specificity and sensitivity of various thresholds (cutoff values) of fecal calprotectin levels to predict clinical relapse. The studies included were separated into those with a cut off value greater than 150 μg/g or less than 150 μg/g.
- The pooled analysis for the usefulness of fecal calprotectin as a predictive marker of clinical relapse revealed a sensitivity of 0.75 or 75% and a specificity of 0.77 or 77% which the authors reported was similar to a previous meta-analysis assessing the subject.
- Fecal calprotectin markers appear to be more clinically useful when measured consecutively (i.e. at least 2 in close proximity) and in patients with longer follow-up >1 year.
- “Thus, many studies held that consecutive fecal calprotectin measurements could better predict relapse in patients with UC . De Vos et al. suggested that two consecutive measurements >300 mg/kg were more specific than a single measurement for predicting relapse .”
- “Subgroup analysis shows that the diagnostic accuracy is higher in studies with longer follow-up time (≥1 year), compared with those with shorter follow-up time. This suggests that FC is more useful in predicting long-term ”
- “Our results confirm the diagnostic utility of FC for the detection of UC relapse in adults. Due to its simplicity and noninvasiveness, measuring FC levels at clinical remission appears to be a reliable and reproducible indicator for predicting UC relapse. To further explore its utility, more well-designed studies are required to confirm our results and find the best cutoff value of FC concentration to identify recurrence in UC patients with remission.”
- Studies that used cutoff values to detect clinical relapse >150 μg/g showed significantly better specificity without major compromises in sensitivity as compared to the studies using cut off values <150 μg/g. (Table 2 of the Study)
- Combining fecal calprotectin with fecal immunochemistry tests (FIT) may help to improve the sensitivity and specificity of non-invasive diagnostic assessments for clinical relapse in UC.
- Non-invasive stool tests such as fecal calprotectin can play a critical role in the evaluation of patients with UC who are at risk for clinical relapse.
Dr. Ruscio Comments
- Fecal calprotectin is a lab marker used widely on a number of functional medicine stool tests. Its clinical relevance in different patient populations remains unclear. While we have highlighted research previously that sought to clarify calprotectin’s diagnostic potential in individuals with gastrointestinal symptoms (discerning IBD from IBS for example), this particular meta-analysis was an attempt to identify calprotectin’s predictive utility in those with previously diagnosed UC. Clinically speaking, it appears that fecal calprotectin should be incorporated into a broader assessment of a patient’s symptoms and other laboratory findings to better predict clinical relapse. Doing so may help the patient avoid unnecessary colonoscopy and help the clinician modify treatment targets effectively. While consensus on an optimal cutoff value for predicting relapse could not be obtained from this study, it appears that a cutoff value near 250 μg/g best balances the optimization of sensitivity and specificity.
- The study was designed to assess the role of fecal microbiota transplant (FMT) to improve symptoms and modify the intestinal bacterial profile in individuals with IBS
- Just over 150 patients with IBS were randomized to receive a placebo (own feces), a small dose of FMT or a larger dose of FMT. Doses of FMT were administered from one donor via a gastroscopic intervention into the duodenum. Around 40% of participants were classified with IBS-D, 40% with IBD-C and 20% with IBS-M. In addition to clinical questionnaires, GA-map stool tests were performed before and after the 3 month follow-up period to assess bacterial abundance and levels of dysbiosis.
- Using the GA-map stool test, roughly 60% of the participants in each group were classified with dysbiosis at baseline. There were no statistically significant changes in the dysbiosis scores dysbiosis index) in any of the groups after 3 months.
- “Dysbiosis was present in 57%, 55% and 61% of the patients in the placebo, 30 g FMT and 60 g FMT groups before transplantation, respectively, in 53%, 50% and 39% of them after transplantation (p=0.836, 0.828 and 0.108, respectively).”
- There were clinically and statistically significant improvements in IBS symptoms including abdominal symptoms in both FMT groups compared to the placebo.
- “In more detail, there were clinical improvements in abdominal symptoms in 5.5%, 35.2% and 47.3% of the patients in the placebo, 30 g FMT and 60 g FMT groups, respectively, in fatigue in 21.8%, 53.7% and 52.7% of them, and in the quality of life in 7.3%, 61.1% and 58.2% of them.”
- “FMT is an effective treatment for patients with IBS. Utilizing a well-defined donor with a normal DI (Dysbiosis Index) and favorable specific microbial signature is essential for successful FMT. The response to FMT increases with the dose.”
- The Dysbiosis Index of the GA-map test was statistically and clinically unchanged after FMT despite individuals receiving clear clinical benefit.
- Those receiving FMT experienced more intermittent abdominal pain, constipation, and diarrhea in the first few days after receiving FMT as compared to placebo. There were only 2 adverse events with 2 individuals with previous histories of diverticulitis developing diverticulitis after receiving FMT. It appears unclear if FMT was actually the triggering factor for these 2 adverse events.
- Individuals in this study had not previously consumed a low FODMAP diet but had previously followed a diet outlined by NICE which suggested restrictions of certain (digestively) resistant starches and to be mindful of triggering foods. Participants in this study (they were considered non-responders to the NICE diet) were asked to discontinue the NICE diet and were not following any uniform dietary pattern during the course of the study.
- This study is the second positive randomized controlled trial to show clinical improvements in individuals with IBS after FMT. Given the low rate of adverse events in this study, FMT is certainly appearing like a more reasonable therapy for those with treatment-resistant IBS independent of IBS categorization.
Dr. Ruscio Comments:
- I was really excited to see this study published and was encouraged by the positive clinical results alongside the low number of adverse events. It was interesting to see that the participants had been given some dietary guidance to try and address symptoms prior to receiving FMT, which should certainly be one of the first starting points in any treatment hierarchy for IBS. There was a significant clinical response in the placebo group after 2 weeks that disappeared at 1 and 3 months, but again, this points to a common theme of clinically significant placebo responses with a number of IBS therapies. It remains unclear to me how useful stool testing that seeks to assess changes in abundance or dysbiosis will be from a clinical perspective as there were no meaningful changes in these parameters at 3 months despite the clinically significant changes in symptoms. We should likely exercise caution when using repeat stool testing to assess treatment response independent from clinical symptoms.
The Autoimmune Protocol Diet Modifies Intestinal RNA Expression in Inflammatory Bowel Disease
- This study was a sub-analysis of the previously reviewed study assessing the role of the autoimmune protocol (AIP) diet to improve clinical outcomes in individuals with IBD. The researchers found unique patterns of altered gene expression involving the immune response as well as mucosal healing in mucosal biopsies taken from 4 individuals before and after the 10-week study. These results indicate positive modulation of genetic expression in immune-related genes after the dietary and lifestyle intervention and point to a potential genetic and cellular mechanism behind the observed positive clinical changes.
- “Results from this RNA substudy would suggest dietary elimination, along with emphasis on a nutrient-dense diet, has the potential to positively modify inflammation and reduce symptoms in UC”
- “Results from this RNA substudy would suggest dietary elimination, along with emphasis on a nutrient-dense diet, has the potential to positively modify inflammation and reduce symptoms in UC”
Thyroid Disease in Pregnancy: ACOG Practice Bulletin, Number 223
- While not an individual study, this practice bulletin provides a short summary of the recommendations given to obstetricians about how to properly screen and manage thyroid function/thyroid disease in pregnancy. This guideline is an update from a 2015 guideline, however, little has changed, and it remains as an arguably inadequate and controversial guideline. Essentially the recommendations continue to state that there should NOT be universal screening for thyroid disease/suboptimal thyroid function in pregnant women, and if screening is indicated to only start with TSH. If the TSH falls within normal limits, no further testing is indicated. These guidelines show what non-obstetric providers, functional and non-functional may expect from obstetricians regarding thyroid screening and management despite the controversial nature of the guidelines.
- “Universal screening for thyroid disease in pregnancy is not recommended because identification and treatment of maternal subclinical hypothyroidism has not been shown to result in improved pregnancy outcomes and neurocognitive function in offspring.”
- For context, this study appears to be the primary study behind the conservative screening and treatment guidelines from ACOG for subclinical hypothyroidism or hypothyroxinemia (low T4) in pregnancy
- And this study from the American Thyroid Association (ATA) published in 2017 is their comprehensive assessment of evaluating and managing thyroid disease during pregnancy
- It’s interesting to note that they recommend testing for TPO antibodies for any woman with a TSH above the pregnancy-specific range. From there, things are a little more gray, but treatment with replacement therapy is more strongly encouraged for those with positive TPO antibodies and at least considered for those with negative TPO antibodies. You can decide which of these guidelines seems more reasonable, but the ATA is clearly more nuanced.
Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake
- 20 individuals participated in a metabolic ward study where they followed two separate dietary protocols, one an ultra-processed food diet and the other an unprocessed, whole food diet. In both cases, the diets were ad-libitum such that individuals could eat as much as desired. Despite the meals in both dietary protocols being “matched for presented calories, energy density, macronutrients, sugar, sodium, and fiber” individuals consumed more calories and gained weight while consuming the ultra-processed food diet as compared to consuming fewer calories and losing weight while following the unprocessed food diet. It was also noted that individuals consumed more total carbohydrates and fat during the ultra-processed foods, the primary reason for the overall increased calorie intake, but kept protein intake essentially unchanged when compared to the unprocessed food diet.
- Energy intake was greater during the ultra-processed diet (508 ± 106 kcal/day; p = 0.0001), with increased consumption of carbohydrate (280 ± 54 kcal/day; p < 0.0001) and fat (230 ± 53 kcal/day; p = 0.0004), but not protein (-2 ± 12 kcal/day; p = 0.85). Weight changes were highly correlated with energy intake (r = 0.8, p < 0.0001), with participants gaining 0.9 ± 0.3 kg (p = 0.009) during the ultra-processed diet and losing 0.9 ± 0.3 kg (p = 0.007) during the unprocessed diet.
- This well-designed study showed what many of us have come to expect from hyper-palatable “non-food” food and it appears that basic dietary guidance instructing individuals to follow a whole foods diet is likely to improve the individual’s ability to eat to or below metabolic energy demands.
How to Efficiently Personalize Your Treatments
I have often seen a spread of approaches in functional medicine with many providers simplifying the use of the exact same protocol on all patients, or “diagnosing” patients with the same condition to fit a standardized protocol. While there are obvious reasons why this is problematic, clinicians can also run into issues when they try to make what I call “overly-personalized” protocols. In many cases, the overly-personalized protocols take much more time to create than the clinical outcomes warrant. Some simple tips to help make more practical protocols include:
- Adding a question to your intake questionnaire assessing someone’s readiness or desire to take supplement medications
- Assessing if a patient has a preference or even requirements for pills versus capsules.
- Does the person at any time express concerns during the interview or intake questionnaire about always forgetting things or having poor memory (even for things that are not medically related)?
I have found these three simple clinical tools are helpful when creating treatment recommendations that won’t waste my time or that of the patient.
“Anything I should know about treating SIFO with antifungal drugs?”
Drugs (PPI, H2 blockers) that lower stomach acidity will lower the levels of many antifungal medications and itraconozole should always be taken with food.