obtaining Rifaximin / insurance fraud

naturowhat Sep 8th, 2015 310 Never
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  1. obtaining Rifaximin status?
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  3. laurarepola
  4. Message 1 of 19 , Sep 2 8:46 PM
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  6. Another rifaximin denial.
  7. I can almost diagnose this patient with IBS with chronic diarrhea and get her insurance to cover the rifaximin.  But she actually has colitis and SIBO.  So they wont.
  8. Am I correct to ask my pharmacy to obtain a bulk amount from McKesson?
  9. A local MD apparently has a lead on this but I also know another local doc who just paid a huge fine for obtaining and distributing drugs from Canada. ?
  10. Is there a naturopathic protocol that is as effective or nearly as effective as Rifaximin?
  11. Flagyl? My patient is totally compliant and is willing to drive to Canada she just emailed me this. lol
  12. Laura Repola, ND
  13. Butte MT
  16. Emily Kane
  17. Message 2 of 19 , Sep 2 10:30 PM
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  19. Laura
  20. Interestingly the MD (Dr Arata) who gave the LDN webinar I listened to last night treats a lot of SIBO pts and says LDN is very effective, along with anti-microbials.  He said he thinks herbal antimicrobials work just as well as Rifaximin.  He cited Allicin, Neem and Oregano oil in particular.
  21. Cheers
  22. Emily Kane ND
  23. Juneau AK
  27. Mona Morstein
  28. Message 3 of 19 , Sep 3 7:14 AM
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  30. Hello, Laura,
  32. The symptoms of SIBO ARE the symptoms of IBS. I always code for IBS to have the insurance cover the Rifaximin.
  34. Mona Morstein, ND, DHANP
  35. Tempe, AZ
  38. Mona Morstein
  39. Message 4 of 19 , Sep 3 7:21 AM
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  41. You know, I would disagree that herbal antibiotics work as well as prescription antimicrobials. I’ve seen enough patients who were treated with herbs, but not retested and just assumed better, but when I did the SIBO test, they were still (+). My experience is that in two weeks I can get 90% of patients clear with Rx meds, vs. maybe 30-40% of botanticals after one month. And, that is all verified with retesting.
  43. You’d be surprised how many patients are not retested out there. In my mind, there is ZERO reasons to NOT do Rifaximin—the vast majority of patients and physicians do not understand this antibiotic is completely not active in the colon so there is zero microbiome wipeout. There is not resistance development to it. If insurance covers it it’s nearly free, vs. the >$300/month it costs out of pocket to do the botanicals, which work less effectively.
  45. Outside of cost, why NOT do Rifaximin?
  47. LDN is my #1 prokinetic agent AND since it helps reduce auto-immunity, is also valuable to decrease the auto-immune reaction against the vinculin protein of the ICC cells, causing the post-infectious type of SIBO IBS.
  49. Mona Morstein, ND, DHANP
  50. Tempe, AZ
  53. Sheila Frodermann
  54. Message 5 of 19 , Sep 3 10:38 AM
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  56. Hi Mona,
  57. One of the main reason to NOT do Rifaximin & LDN is a lack of prescribing rights, as in the remaining unlicensed states in which NDs practice, (which are many). Thus, it is helpful to know that herbs work.
  59. Here in RI, I rely on the herbal and supplemental anti-microbial protocols for SIBO, which do have some supportive studies. I find it important to know which herbs have been researched as effective ,and how long those treatment protocol must be. I am finding one month of herbs woefully inadequate in most of my SIBO patients (and no, I cannot run breath tests and the MDs deny repeat testing), and have done 3-6 months of herbal protocols, with concomitant work on rebuilding the gut.  
  61. I am also finding healing support by using castor oil pack, breathing exercise, daily exercise, drainage remedies or constitutional homeopathy, Bowen therapy, etc (none studied in SIBO), in addition to the recommended SIBO diet and supplements.
  63. In an unlicensed state I confidently rely on the full scope of our traditional 'black bag' of tricks, and give the time necessary.
  65. The other reason may be clients' preference for a natural approach.
  67. Respectfully,
  68. Sheila
  70. Sheila M. Frodermann, MS, ND, DHANP, CCH
  71. Naturopathic Doctor
  72. Diplomate of the Homeopathic Academy of Naturopathic Physicians
  73. Certified Classical Homeopath
  74. Bowen Practitioner
  75. RIANP Treasurer & past President
  78. scaricohen
  79. Message 6 of 19 , Sep 3 11:44 AM
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  81. Ditto to what Sheila said.  No access to Rifaxamin here in unlicensed PA.  Same with LDN. So the more we can share clinical pearls about non-prescription ways to treat people with SIBO, the better!
  82. I have yet to find a local MD willing to acknowledge and treat SIBO adequately, but I'm still looking...
  84. Sari Cohen, ND
  85. Pittsburgh, PA
  88. James Mullane, ND
  89. Message 7 of 19 , Sep 3 11:48 AM
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  91. I am here in CT where I am licensed, but have no prescriptive rights. Only have "traditional" naturopathic modes of treatment. But I can order labwork!
  93. Jim
  95. James Mullane, ND
  98. Mona Morstein
  99. Message 8 of 19 , Sep 3 10:31 PM
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  101. Oh, sorry, Sheila, sure that is a very good reason to not do Rifaximin. My bad!
  103. The main herbs are garlic, oregano oil, neem, berberines. One doc on the SIBO FB group said she uses Allimed 3 caps tid for 14 days. That’s expensive and aggressive but she says that’s how she also controls MRSA, too. That would be around $260 for two bottles of Allimed for that.
  105. I am experimenting with Alli-Syn from Pharmax (sp) instead of AlliMed. It’s very concentrated and patients cannot handle more than 1 tid without gut upset, so that’s the limit of my dosing with that, but I do it for a month. It’s cheaper than AlliMed and seems quite strong, but probably does not have quite as much active allicin. It’s a good product, though.
  107. Berberine, like from ITI, is 2 caps tid. That can also cause gut upset. I dose slippery elm with these botanicals, to help the gut handle it. It’s okay during Abx treatment as Dr. Shaver clarified.
  109. I’m not much into Neem, but I know Dr. SSL at NCNM is an advocate of it.
  111. I use ADP Oregano oil; it’s strong, and I do 2 3x/day for ideally a month but not all guts can handle it.
  113. I still think Bio-Vegetarian, what I use to cure strep and bronchitis might be a good idea. Uva Ursi was shown for years and years to be a wonderful antimicrobiol in the gut, too. I get freeze dried UU from Eclectic Institute and dose 2 tid.
  115. Artesmia is sometimes used, but I haven’t do it.
  117. Also, there are products out there folks have tried from Biotics, like Dysbiocide, and also from Metagenics, their Candibactrin products.
  119. Again, I apologize for forgetting not everyone has Rx rights.
  121. Mona Morstein, ND, DHANP
  122. Tempe, AZ
  125. Erin Holston Singh, N.D.
  126. Message 9 of 19 , Sep 4 5:10 AM
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  128. Sheila,
  129. Can you say more about not being able to order breath tests? Is that because the labs won't accept your order or because the insurance companies won't pay?
  131. Thanks,
  132. Your pal
  133. Erin Holston Singh, ND
  134. Cleveland, OH
  137. Eric Yarnell
  138. Message 10 of 19 , Sep 5 11:27 PM
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  141. Hide message history
  142. On Sep 2, 2015, at 8:46 PM, lrepola@... [NaturopathicChat] <> wrote:
  143. Is there a naturopathic protocol that is as effective or nearly as effective as Rifaximin?
  147. I have had as good of success with this program:
  149. Low FODMAP diet x 2 mon
  151. The following for 1 mon:
  152. ADP (oregano oil caps) 2 tid
  153. Lactoferrin 250 mg tid
  154. Berberine Complex 2 tid (which is bitter, the old word for prokinetic)
  156. Follow with probiotics and fermented food.
  158. Find and treat the underlying cause of the SIBO!!! Most posts I see about SIBO ignore this point: something caused it. I find that the treatment failures have been in patients who just go back to their same lives as before and don’t change anything, and slip back into the problem. Sometimes there is an obvious cause like acid blocking drug use, other times it is a bit mysterious. But I am spending more and more time looking into this. I’m just about ready to say all patients need a Heidelberg acid test because pretty often I’m finding hypochlorhydria as an underlying problem.
  160. Note if they have high methane, I include neomycin because I don’t know what will kill Methanobrevibacter spp.
  162. Eric Yarnell, ND, RH(AHG)
  163. Seattle, WA
  166. Eric Yarnell
  167. Message 11 of 19 , Sep 5 11:55 PM
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  169. Show message history
  172. You’d be surprised how many patients are not retested out there.
  174. My theoretical concern is the patient who becomes completely asymptomatic but still has a positive test. They stay asymptomatic for a long time. Should we really retreat them based solely on the results of a lab test? I have to also emphasize that breath testing is far from perfect,
  176. In my mind, there is ZERO reasons to NOT do Rifaximin—the vast majority of patients and physicians do not understand this antibiotic is completely not active in the colon so there is zero microbiome wipeout.
  178. Given that almost 100% of the drug is excreted unmetabolized in the feces, it seems impossible to me that it is inactive in the colon. There is in fact evidence and discussion of its use to treat, for example, diverticulitis and as bowel preparation before colon surgery, which would strongly imply it is both reaching and active in the colon (PMID 19442033 and 15855748 for example).
  180. There is not resistance development to it.
  182. Not only is there resistance to rifaximin, it’s a little scary:
  184. (association to E. coli resistant to rifaximin with ulcerative colitis)
  186. PMID 15897530 (clinical trial in which amount of rifiaxmin needed to kill E. coli went up 1 log in patients treated with rifaximin for 2 wk compared to no change in resistance in those treated with placebo)
  188. (resistance in Clostridium difficile)
  190. And from "Resistance to rifaximin is caused primarily by mutations in the rpoB gene. This changes the binding site on DNA dependent RNA polymerase and decreases rifaximin binding affinity, thereby reducing efficacy. Cross-resistance between rifaximin and other classes of antimicrobials has not been observed."
  192. I also want to correct the common myth that rifixamin is “non-absorbed.” It is absorbed, very clearly, it is just very poorly absorbed. Some is getting into our patients bodies. This may be irrelevant, I just don’t want us to believe the drug maker’s hype about it being “nonabsorbed” because that’s not true.
  194. (human pharmacokinetic study showing it is absorbed, albeit only a little)
  196. Also note the absorption goes way up in patients with liver disease (I’m not talking about naturopathic liver impairment, but people with hepatic encephalopathy and such):
  198. If insurance covers it it’s nearly free, vs. the >$300/month it costs out of pocket to do the botanicals, which work less effectively.
  200. Outside of cost, why NOT do Rifaximin?  
  202. Well that is a pretty big reason (it’s about twice as expensive to do the drugs if insurance won’t cover, which in my experience is close to half the time even coding for IBS as the diagnosis). Actually the problem I keep running into is they will only pay for 550 mg bid because that is what FDA approved and tid, even though studies show tid dosing is more effective.
  204. I also have patients who have had some bad experiences with multiple other antibiotics in their life, and so prefer to avoid another agent (particularly when it seems like antibiotics triggered their gut issues). I’m not sure that’s scientific but it is certainly a reason to consider other options.
  206. Failure of rifaximin to work at least once should give pause for using it again (because of the threat of resistance at least).
  208. Because head-to-head studies haven’t been done comparing it to natural products in randomized trials, so we don’t really know if there is something more effective. Just assuming it is more effective in the absence of good quality evidence is problematic to say the least. How many conventional meds have we avoided based on this exact argument and been really right because those drugs turned out to be a serious problem or were removed from the marketplace? A lot...
  210. Finally, for the very reason that we don’t do the same antibiotic over and over generally: that resistance is going to develop if we do this. This hasn’t always happened as I admitted above, but the risk is very high that we are going to breed resistant flora and the drug will lose efficacy.
  214. Eric Yarnell, ND, RH(AHG)
  215. Seattle, WA
  218. Jared Zeff, ND
  219. Message 12 of 19 , Sep 6 8:56 AM
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  221. And I just want to reiterate Eric's previous post, that it is very important to seek the CAUSE of the SIBO, and address it. He mentioned hypochlorhydria, which is major.  Also, ileocecal valve competence is another.
  223. Jared Zeff, ND
  224. Salmon Creek, WA
  227. Sheila Frodermann
  228. Message 13 of 19 , Sep 6 10:58 AM
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  230. Hi Erin,
  231. Insurance won't pay, that is a given; i haven't tried to set up an account with Commonwealth labs. Many labs who use to accept NDs from RI no longer do, i.e. Genova/Metametrix. Our Dept of Health has dictated this more strictly, in the last several years, similar to NY situation, so that many new NDs set up accounts with new labs. I have not yet tried NCNM and will consider this approach if referring back to primary care and GI docs becomes too difficult.
  232. Sheila
  234. Sheila M. Frodermann, MS, ND, DHANP, CCH
  235. Naturopathic Doctor
  236. Diplomate of the Homeopathic Academy of Naturopathic Physicians
  237. Certified Classical Homeopath
  238. Bowen Practitioner
  239. RIANP Treasurer & past President
  242. Kathleen Riley
  243. Message 14 of 19 , Sep 6 6:37 PM
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  245. In Ct for decades without Rx has not prevented success with SIBO.  I use HCL with enzymes and alternate Oil of Oregano one week with Berberine the next week. Patients have been sick for a while before they arrive on my doorstep, so I tend to do 2 or 3 cycles to insure success.  If the patient can not tolerate the Oil of Oregano,  I have had success rotating with Uva ursi.
  247. Kathleen Riley, ND
  250. Shiva Barton, ND
  251. Message 15 of 19 , Sep 7 4:57 AM
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  253. Hi Kathy and Jared,
  255. Kathy, I just wanted to shout out to you and tell you that I always love
  256. your posts. You continue to prove the power of natural medicine without
  257. meds, which is so relevant for us docs in the ND "wilderness". Thanks
  258. for your leadership. Also appreciating Jared Zeff's comments about
  259. treating the cause.
  261. Best,
  263. Shiva Barton, ND
  264. Winchester, MA
  267. Anne Van Couvering
  268. Message 16 of 19 , Sep 7 5:42 AM
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  270. Re: Dr zeff's comment: I have been trying to find a video or text "how to" on ileocecal valve closure for review and/or show patients. I keep finding wacky people and unfamiliar-looking manipulations when I look online, and I haven't found it in my notes or texts. Does anyone have such a thing to share? I would be very grateful.
  272. Anne Van Couvering, ND, CNS, LMT
  273. Watermill, NY
  276. Mona Morstein
  277. Message 17 of 19 , Sep 7 7:02 AM
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  279. Hello, Eric,
  281. Yes,  I’m going to stand by my views on Rifaximin as I feel studies have proven them to be accurate.
  283. Although Rifaximin was shown to useful for diverticulitis, the main study mainly showed when added to fiber, there was improvement in symptoms.
  285. Rifaximin is 100x more active in the small intestine due to bile salts and is considered minimally active in the watery colon.  In general is has been shown to have no impact on the microbiota and if it does, it ENHANCES it—it has raised bifidobacteria levels, it increases SCFA production. It has been shown to ENHANCE the vaginal microbiota, increasing lactobacillus vs. BV.  So, my statements about the safety of Rifaximin are accurate. Since less than 0.01% is orally absorbed there are not systemic reactions like amoxicillin rash, sulfa allergies, Cipro tendon damage, etc.  Scientifically it has also been shown to not cause resistance, in that there is plasmid and genetic resistance; rifaximin is genomic not plasmid type so it is not transmitted to other bacteria, so resistance is not common and if it does only affects a few gram positive aerobic bacteria.  
  287. If you wish I can send you also the powerpoints by Dr. Pimentel discusses his research and knowledge on Rifaximin.
  290. —
  291. —   No change in microbiome
  292. —Improves vaginal microbiome:
  293. —
  294. Rifaximin did not affect overall gut microbiome, but did increase bifidobacteria and a few others; and increased positive metabolic events, like increase in SCFA, which are beneficial to people.
  296. Mona Morstein, ND, DHANP
  297. Tempe, AZ
  300. Eric Yarnell
  301. Message 18 of 19 , Sep 7 1:01 PM
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  303. Thanks that’s great, yes please send the PowerPoint slide sets, I’d be interested.
  306. Eric Yarnell, ND, RH(AHG)
  307. Seattle, WA
  310. Mona Morstein
  311. Message 19 of 19 , Sep 7 1:29 PM
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  313. There are many reasons why people have SIBO. Most come from post-infectious gastroenteritis, but not all. The list otherwise is very long: Ehler-Danlos, pelvic adhesions, opiate use, hyper or hypochlorhydria (please note all patients should not get HCL acid supplements), chronic pancreatitis induced loss of enzymes, lack of bile, IgA deficiency syndrome, blind loop or other drastic surperies, small intestinal pseudo obstruction, scleroderma, diabetic neuropathy, post-surgical neuropathy, cirrhosis, radiation enteritis, jejunal diverticulitis, intestinal tumors, fistulas between colon and bowel.
  315. Mona Morstein, ND, DHANP
  316. Tempe, AZ
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