Recovery line · post-audit · rev 7.14

Durable Day-Sheet · The Freeze

The current sheet, post-audit. Three protocol changes through Aug 1 — everything else is measurement. Adderall is reconciled to its full prescribed 70 mg (Wancata-approved, 7/13). L-citrulline is out, telmisartan holds at 40 (step gated on the 8/1 draw), the cascade is re-paced, and the nocturnal sub-54s are settled as compression artifacts. CGM card →

What changed — rev 7.14 (7/13): Adderall reconciled + audit corrections

Adderall — full prescribed dose restored (7/13). XR 30 mg × 2 + IR 5 mg × 2 = 70 mg/day. Dr. Wancata approved full resumption at both discharges; the slower taper-up was self-directed. Not a freeze-budget change — a return to prescribed baseline — but not inert: the 4 PM IR restores a late-afternoon pressor (re-read the 8 PM BP), and the amphetamine load on the Na differential is now 70, not 60.
Audit corrections. ALCAR label flagged — scheduled doses sum to 2,500, not the 2,250 on the totals line (reconcile the label, don’t move a dose). Anatomy fixed — the surgery was a Frey that cored the alpha-poor head, not a Puestow that "resects no parenchyma"; the conclusion is unchanged. The old "both IR doses held" pharmacokinetic aside is now void.
The freeze. Eighteen protocol changes in twenty-four hours — nearly all safe (subtractions, deferrals, tests), but attribution was collapsing. Only three stand through Aug 1: L-citrulline removed · omeprazole taper by 7/14 · ProBiota alone ~7/21. Everything else is measurement.
L-citrulline — removed (7/10). Perioperative indication expired at week two; vasoactive, additive with telmisartan, unknown benefit vs nonzero risk. Out of the 7 AM slot. This also removes the reason the 8 AM BP reading existed.
Telmisartan — holds at 40 mg. The step to 80 is gated on the ~8/1 draw, not dated 7/16: doubling 48 h after the omeprazole stop broke the ≥72 h rule, and your fasted highs are Hct-25.2 anemia, not stiffness — they fall as Hgb climbs. Correct the anemia first.
Nocturnal sub-54s — settled as compression artifacts (confirmed 7/10). Positional, never real glucose. The "hypoglycemia you cannot feel" overlay drops to a floor; nothing is gated on it.
Cascade re-paced. ProBiota ~7/21 (after omeprazole stops and rebound settles); SPM and MegaSpore slide past the 8/1 draw. Fewer moving parts per week = attributable reactions.
Fingerstick over-reads at Hct 25.2. Your meter reads glucose falsely high when anemic — stop calibrating the G7 against it. The old sensor-looks-low bias lived in the reference, not the sensor.
Open lab flags added: PT/INR (never checked · EPI + vitamin K), MCV 91 (possible masked mixed deficiency), the hyponatremia workup, free-water quantification.
Unchanged and still correct: gymnema out · berberine held · potassium cut · breakfast cut · NAC at the 1,200 ramp · CGM is a weak prior, not a gate.
8 AM BP slot suspended — it watched the telmisartan step + citrulline; reinstate when the dose eventually doubles. 8 PM slot and 1:30 PM (→7/30) continue.

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/berberine interaction was never binding — and matters even less now. With Adderall back to the full 70 mg (IR at 6:30 AM + 4:00 PM), d-amphetamine covers 6:30 AM → midnight continuously; no waking hour separates it from the 6:15/7:45 PM berberine slots. That never mattered: the CYP2D6 interaction is a hepatic in-vitro finding at concentrations oral berberine never reaches systemically. Berberine stays held on hemodynamics, not this. 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 25 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 · held

Adderall

70 mg

BP log

5:55·1:30·8p

Changes

3 · to 8/1

Omeprazole

→ 7/14

3 PM meal

→ 7/31

Cascade ahead — re-paced 7/10 · the freeze

~7/21 · ProBiota HistaminX — Meal 1. Deferred past the omeprazole stop (7/14), so tolerance reads across the acid rebound, not into it. The one addition standing before 8/1. Single-variable.

~post-8/1 · SPM Pro-Resolve — Dinner, fat-anchored. Slid past the 8/1 draw — the freeze runs only three changes before then.

~8/5 · MegaSporeBiotic — Dinner. After ProBiota tolerance and the 8/1 draw.

~7/14 · Omeprazole ends — rebound hypersecretion peaks over the following two weeks. This will do more to the probiotics than berberine ever would. Read tolerance across the transition, not into it.

~8/1 · Telmisartan → 80 mg (gated, not dated) — steps only if the 8/1 draw clears: Hgb ≥10, Na workup + UACR back and clean, postprandial margin intact. Dose it in the evening then. Draw not clean → keep holding.

— · R-ALA (OptimALA) — un-dated. Gated on ferritin + iron saturation. ALA chelates iron; you are mid-erythropoiesis at Hgb 8.3. It is also a fasted 6 AM dose into a duodenum that bled twelve days ago, during acid rebound. Nothing is lost by waiting — NAC already carries the glutathione axis.

~7/19 · Lion's Mane / Erinamax · ~8/8 · Turkey Tail · ~8/19 · Cordyceps — mushroom track, unchanged. Protocol →

~8/1 · IF gate + draw — Wancata check-in. Bilberry and Panax GS15-4 both move behind this. Both are glucose-active; neither can get a clean CGM window while telmisartan-80, acid rebound, and probiotic establishment are all running.

~mid-Aug · Truvaga Plus — vagal stimulation lowers HR and BP. Correctly deferred. Morning fasted, never postprandial.

The CGM is not currently a competent gate. Four glucose-active reintroductions — R-ALA, Bilberry, Panax, Cordyceps — were each queued behind "its own CGM window." That instrument is unvalidated. Run the 5-day rehabilitation protocol first — stop calibrating, discard day 1 and day 10, ten paired fingersticks, establish the sign of the bias. CGM card → · NAC ramp: 1,200/day → +500 per clean 7-day step → 4,800; overnight bolus lands last; every addition stays ≥72 h from a step, and the eventual telmisartan step counts as an addition.

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.