QUESTION: 27yo female initial meds Wellbutrin Lexapro Adderall XR -Used slippery elm, DGL and diet change to improve GI dysfunction- skin cleared up and GI appears to be working well -Weened off Wellbutrin with addition of niacinamide and tyrosine Pt felt great i.e. motivated, improved mood -added low dose tryptophan and B6 with goal to ween off of Lexapro – on hold
-She changed her Adderall dose to non XR and felt drowsy then changed back but still feels drowsy upon waking I though she may no longer need the niacinamide and d/c but no change in drowsiness felt- did notice decrease in motivation I know niacinamide is given in the case that niacin is deficient where tryptophan is being used to make niacin instead of serotonin I also know niacin is used with MAO to break serotonin down My question: Why is niacinamide needed if diet is adequate and GI is performing correctly- is there a mutation I should be considering?
ANSWER: Regarding Niacinamide and it’s dose in this case (and extrapolating to most other Vitamins) I’ll use your narrative to illustrate:
I thought she may no longer need the niacinamide and d/c but no change in drowsiness felt- did notice decrease in motivation –> Hmmm. If the niacinamide was involved in resolution (or partially so some help) what would lead to this not being needed idea?
I know niacinamide is given in the case that niacin is deficient where tryptophan is being used to make niacin instead of serotonin. I also know niacin is used with MAO to break serotonin down. –> You ‘know’ correctly. Something to consider: In addition to these uses B3 is used likely in more quantity as a co-factor than most other B-Vits all throughout the body.
Why is niacinamide needed if diet is adequate and GI is performing correctly- is there a mutation I should be considering? Your question is very common, and a very common misunderstanding that physicians have. Regardless of (but especially in the face of) the need for medications to cause a neuropsychiatric or other physiologic effect AND the influence of a nutrient in relieving or lessening the symptoms of the condition: In the asymptomatic and biochemically balanced human your logic works. A short burst of a nutrient will work just fine and the diet may be enough in the long run. In the symptomatic person often a three phase dose strategy (test dose, therapeutic / pharmacologic dose / maintenance dose) is the best as to outcomes overall. This being that once safety and tolerance is assured with a test dose an actual supraphysiologic dose is required to balance the functions that are not in balance.
After balance is achieved one of two pathways in dosing occur: (1) The imbalance was not of great “depth” (depth being the sum total of deficiency, poor GI absorption, genomic SNP’s etc) and the repletion phase was sufficient. In this case return to dietary dosing and maybe a supplement are enough for maintenance. (2) The imbalance is “deep” due to above factors and while the repletion-pharmacologic dosing may not need to be excessive forever the person may require higher than “normal maintenance” doses for a long time or life. Many reasons exist for this but basically the depth of the deficit is the key. Sadly that depth is only assayed by therapeutic trial. If repletion is faster and maintenance is achieved by diet and minor supplementation then that is the answer. If not then longer term repletion at higher levels is necessary. I discuss this concept of multi-phase dosing in many presentations, the Genomic series is one that it applies to commonly.
