Recovery line · adversarial-audit correction · rev 7.13

Durable Day-Sheet · The Freeze

Three changes to August 1 — everything else is measurement. The adversarial audit pulled L-citrulline, deferred the telmisartan step, capped NAC, and resolved the stop rule. HMB is split 1.5 g × 2. CGM card → · Gate board →

What changed — the adversarial audit, and the freeze

Three changes to August 1. That is the entire budget. ① L-citrulline removed (done 7/10) · ② omeprazole taper before ~7/14 · ③ ProBiota HistaminX, alone, ~7/21. Everything else is measurement, not modification.
L-citrulline removed. A vasoactive agent whose perioperative indication expired at week two — additive NO vasodilation on the ARB, into a documented postprandial diastolic of 50. An indication call, not an effect-size one.
Telmisartan holds at 40 mg. The 80 mg step is deferred to ~8/1 and decoupled from the omeprazole stop; when it goes, dose it in the evening. Anemia is doing the vasodilating — correct the Hgb first and the 80 mg question may dissolve.
Stop rule resolved — it is OR, not AND. Below 100 systolic or below 55 diastolic → hold at 40 mg. A postprandial diastolic of 50 does not clear 55.
NAC capped at 1,200 mg. Ramp suspended; the overnight 1,800 mg bolus is gated on ulcer-healing confirmation, not a clean-step counter.
Cascade re-dated: ProBiota ~7/21 · SPM ~8/1 · MegaSpore ~8/5 · Turkey Tail ~8/8 · Cordyceps ~8/19.
HMB split — 1.5 g × 2 (Meal 1 + Meal 2), both clear of Zn/Mg.
Retracted: the "alpha cells are gone" claim (anatomically false — the head/uncinate are PP-rich and alpha-poor; the Puestow resects no parenchyma). The true argument is stronger: C-peptide 2.1 with impaired glucagon counterregulation.
New facts to obtain: PT/INR from 6/29–7/3 · Ret-He (not ferritin alone) · B12 + MMA · fructosamine (not HbA1c) · ferric derisomaltose if IV iron. Lab plan →

Why berberine is held — rebuilt without the CGM

1 · The cuff. 39 Apple Health readings, Jul 4–8. Fasted 138/68. Postprandial 115–128 / 50–62. Berberine lowers BP ~3–5 mmHg. Your diastolic margin to your own stop rule is five points. Both doses bracket dinner — the one postprandial window with no reading at all — alongside theanine 200, taurine, Magtein, Mg, Holy Basil, on top of L-citrulline, during a telmisartan 40→80 step, at Hgb 8.3 / Hct 25.2, eleven days after syncope.

2 · Pharmacology. Broad-spectrum antimicrobial at SIBO-range dosing (500 mg BID–TID is the SIBO protocol), one day before ProBiota and three before MegaSpore. Its <1% bioavailability exists because it stays luminal; the remodeling is the mechanism. You cannot time-separate from a mechanism.

3 · It has no measurable endpoint. Not glycemic — the instrument is unvalidated. Not lipid — there is no lipid panel anywhere in your record. Berberine is currently running blind, into a hemodynamic risk window, during a five-variable week.

The Adderall rationale also inverts. With both IR doses held, XR-1 (6:30 AM) peaks ~1:30 PM and XR-2 (11:45 AM) peaks ~6:45 PM. 6:15 and 7:45 PM sit on the combined amphetamine peak of the day. And d-amphetamine t½ ≈ 10 h across two XR doses gives continuous coverage 6:30 AM → midnight — no waking hour separates them. Which is fine: that interaction (hepatic CYP2D6, in vitro, at concentrations oral berberine never reaches) was never the binding constraint. BP card →

Why gymnema is removed — rebuilt without the CGM

1 · Nutrition. Its primary consumer effect is sweet-taste suppression and appetite reduction. You are 22 days post-Frey, Hgb 8.3, total protein 5.5, globulin 1.5, albumin only just back to 4.0, running HMB specifically for anti-catabolism. An intake-reducing agent is working against your own recovery objective.

2 · Anatomy. Insulinotropic + SGLT1 inhibition, with C-peptide 2.1 (residual beta cells) and no alpha cells. Every glucose-lowering agent carries asymmetric risk in you — that follows from the necrosis, not from a sensor.

3 · Logic. It is dosed 7:45 PM to blunt "the carb load." Your 8 PM dessert is annotated light — Creon 1 cap, milk thistle. An SGLT1 inhibitor before a light dessert is doing nothing.

4 · Your own bar. Small, uncontrolled trials in T2D at A1c 8–9%. It is the weakest-evidenced compound in a stack held to NSF / USP / iTested / ISO-17025. It is also the only live compound with no entry on the gate board.

And under instrument uncertainty this argument gets stronger, not weaker: removing a glucose-active variable increases the interpretability of everything else in the cascade. Removal is free and reversible. Retention is not.

What the eating day looks like now

6:30 AM protein bite (Creon + fed Adderall anchor) · Meal 1 at noon · folded Meal 2 at 3 PM · dinner 6:30 · dessert 8 PM.

~Aug 1 is the last gate. Pending a positive Wancata check-in and draw, the 3 PM meal stays where it is and the day becomes canonical 12 PM–8 PM IF. Nothing else moves.

Single-variable rule still holds: each staged addition gets its own clean day. If a day isn't clean — new nausea, cramping, stool change, lightheadedness on standing — nothing new starts.

Telmisartan

40 · hold

Adderall

60 mg

BP log

5:55·1:30·8p

CGM gate

none

Omeprazole

→ 7/14

3 PM meal

→ 7/31

Cascade ahead — re-dated by the audit

~7/14 · Omeprazole taper — prescriber-driven, 40 → 20 mg daily through ~7/29. Not a cold stop; rebound acid peaks in the two weeks after.

~7/19 · Lion's Mane / Erinamax — gastroprotective; a healing duodenum argues for it. track →

~7/21 · ProBiota HistaminX — Meal 1, alone, single-variable, ≥1 wk after the acid environment settles.

~8/1 · IF gate + full draw + telmisartan reassessment — Wancata check-in → canonical 12–8 window. All six ARB gates clear, or it holds again.

~8/1 · SPM Pro-Resolve · ~8/5 · MegaSporeBiotic — new adds into a post-bleed window; MegaSpore alone, half-dose, gated on H. pylori resolved + anastomotic healing.

~8/8 · Turkey Tail · ~8/19 · Cordyceps — prebiotic waits for probiotic attribution; Cordyceps last, alone, half-dose.

~mid-Aug · Truvaga Plus — lowers HR and BP; morning fasted, never postprandial.

undated · R-ALA · Berberine · Bilberry · Panax — R-ALA gated on Ret-He + TSAT; berberine on a lipid panel + ABPM + Hgb ≥10; Bilberry/Panax behind the 8/1 draw and a validated CGM.

NAC ramp is suspended at 1,200/day. Resume +500 per clean 7-day step only after the PPI question closes; the overnight bolus lands last. Every addition stays ≥72 h from any other change. CGM validation →

Still open — none of it blocks this sheet

UACR (urine albumin:creatinine). Add it to the ~Aug 1 draw. Microalbuminuria means RAS blockade is indicated regardless of what the cuff says.

Orthostatic vitals. Supine, then 1 and 3 minutes standing. Postprandial hypotension plus Type 3c is a screenable pattern and nobody has looked.

24-hour ABPM. Would settle the dose question in a day instead of two weeks. Needs an order.

Med reconciliation. The chart at both Virginia Mason and Providence says telmisartan 80 mg daily. You were taking zero, at 149/74 fasted. It was a perioperative hold nobody reconciled — not a discontinuation. Portal message to Dr. Kuhlman documents the hold and the 7/9 restart.

Ferritin + iron saturation — draw this week, do not wait for 8/1. It gates the iron-repletion decision at Hgb 8.3 / Hct 25.2, and it gates R-ALA. Iron is mucosally irritating into a healing duodenum; ALA chelates it. Two decisions, one tube.

Lipid panel + ApoB + Lp(a) — add to the 8/1 draw. There is no lipid panel anywhere in your record — not Oct '24, not Jan '26, not Mar '26, not 7/3 discharge, not 7/7. Berberine's best-evidenced indication is lipids, and that endpoint is completely uncharacterized in you. It is the only endpoint on which berberine can earn its way back.

PPI plan past 7/14. Sets the ulcer runway and the acid environment the probiotics land in. Rebound hypersecretion peaks in the two weeks after stopping.

These are a phone call, not a supplement question

Dark or tarry stool · visible blood · new dizziness · resting HR climbing · fever or rigors · any reading ≥180/120. Pause every addition and call the team. Clinical suspicion outweighs a normal WBC — your inflammatory markers run supplement-suppressed.