Provocation Considerations: Deciding if it’s Right for Your Patient

Most functional medicine providers order the Vibrant Total Toxic Burden test to illustrate to their patients how much they need to detox. For this reason, many providers use provoking agents to avoid test results showing no elevated markers. 

However, provocation isn’t one-size-fits-all—nor is it safe for all patients. The decision to provoke depends on the individual patient’s health status and what you hope to learn.

Let’s take a closer look.

What is Provoked Testing?

Provoked testing, also known as challenge testing, involves the use of a detoxification support and/or chelating agent prior to urine collection to determine the level of toxic burden in the body.

Provoking agents work by pulling toxins from an individual’s tissues so higher levels are present in the urine—thus leading to more “moderate” or “high” test results.

Why Do Some Providers Choose to Use Provoking Agents?

Some providers use provoking agents because they believe they are necessary to release toxins stored in the tissues, while others provoke to avoid the cost of the double testing method (ordering both pre- and post-provocation) discussed below.

According to Dr. Joseph Pizzorno, ND, there is scientific agreement that DMSA (Hg, Pb), DMPS (Hg), and EDTA (Pb) increase toxic metal excretion, and provoked testing may be necessary because standard testing indicates current exposure, not total body load.

Why Do Some Providers Choose Not to Use Provoking Agents?

Some providers choose not to use provoking agents because it could cause harm to their patients. Provoking agents mobilize toxins stored in body tissues and fat cells, moving them into circulation.

While toxins stored in tissues can be largely unreactive (picture criminals locked in a jail cell), circulating toxins tend to create more oxidative stress and damage (picture criminals breaking into shops and stealing all the goods).

This is particularly problematic for patients who:

• Are unable to remove toxins from their body due to dehydration, constipation, or the inability to sweat.
• Have impaired biotransformation and detoxification pathways, due to genetics or micronutrient deficiencies. 

Do Well-Established Provoked Reference Ranges Exist?

No, there are no standardized reference ranges for provoked tests. This is likely related to the numerous variations in the types of provocation agents used and variations of dosages, routes of administration, and variability related to each specific analyte.

What Are the Limitations of Using Non-Provoked Reference Ranges to Interpret Provoked Results?

As there are no standardized reference ranges for provoked tests, when a patient utilizes a provocation before testing, their levels may appear falsely elevated when interpreted using non-provoked reference ranges.

What Reference Ranges Does Vibrant Wellness Use?

The reference ranges on the Heavy Metals, Environmental Toxins, and Mycotoxins tests and are based either on Vibrant America’s internal validation study or results from the National Health and Nutrition Examination Survey (NHANES).  

NHANES Reference Ranges

For a list of all markers using NHANES reference ranges, please visit the FAQ.

Internal Validation Study Reference Ranges

All other markers on the Heavy Metals, Environmental Toxins, and Mycotoxins reports use the Vibrant Wellness internal validation study of 1,000 adults.

Specifically, the analyte levels of 1,000 healthy individuals were measured and plotted on a Gaussian curve.

• • • In Control: Levels that are less than the 75^th percentile
    • Moderate: Levels between the 75^th and 95^th percentile
    • High: Levels greater than the 95^th percentile

Can the Total Toxic Burden Test Indicate If Exposure is Past or Current?

The Vibrant Total Toxic Burden tests (Heavy Metals, Mycotoxins, and Environmental Toxins) can reflect both past and current exposure.

However, results cannot be interpreted to determine the timing or duration of exposure.

How Can I Gain Insight into Past Versus Current Exposure?

For the deepest insight into current versus past exposure, consider the following systematic method:

• Step 1: Run an unprovoked Total Toxic Burden test.
• Step 2: Do a second, provoked Total Toxic Burden test.
• Step 3: Compare the two results to investigate which toxins increased after provocation.

Does Vibrant Wellness Recommend Provocation?

Because provocation agents can potentially harm certain patients (especially patients with impaired biotransformation and detoxification pathways), the Vibrant Wellness Clinical Team cannot provide guidance for provocation agents, dosage, or timing of provocation before testing.

Ultimately, it’s up to you to decide whether to use a provocation agent before Heavy Metals, Mycotoxins, and/or Environmental Toxins testing, as well as the specific provoking agent, dose, and timing of provocation before testing.

Your decision should be based on your knowledge of the patient’s clinical history, and whether you believe the patient can handle increased toxin circulation secondary to provocation.  

For more information, please see the Provocations Considerations Handout.