Biotoxin Illness Treatment Protocols

Chronic Inflammatory Response Syndrome (CIRS) is a combination of illnesses or ailments that directly relate to an individual’s work or home environments. CIRS is acquired following exposure to the interior of a water-damaged building with resident toxigenic organisms, including fungi, mold and bacteria. Two commonly used protocols for treating CIRS include the Shoemaker protocol and the Brewer protocol.

Dr. Ritchie Shoemaker’s 11-Step Biotoxin Removal Protocol

Dr. Shoemaker is a leading figure in the treatment of biotoxin illness. His website,, is a go-to resource for both physicians and patients.

Step 1: Identify and Eliminate Mold Exposure

The first and most important step is removal from exposure. Most CIRS patients attribute water-damaged buildings as their source of exposure. Once identified, every effort must be made by the patient, to remove themselves from the source of exposure.

Step 2: Remove Biotoxin Load

The next step is to interrupt enterohepatic recirculation of biotoxins using either Cholestyramine (CSM) or Welchol for at least a month. The dose of cholestyramine is 4 grams ½ hour before eating 4 times a day. If cholestyramine cannot be tolerated, a less effective alternative is Welchol 2 tablets three times a day with food. A number of people are sensitive to the fillers in cholestyramine so using compounded cholestyramine without fillers is a good alternative. The success of this step can be monitored by seeing improvements in the VCS (Visual Contrast Sensitivity) Test. If there is no improvement, the most common cause is persistent exposure to a water damaged building.

Step 3: Eliminate MARCoNS

MARCoNS stands for Multiple Antibiotic Resistant Coagulase Negative Staphylococcus. It colonizes the deep nasal aerobic spaces of the majority of people with CIRS. This bacteria forms biofilms and releases biotoxins that can cleave MSH (melanocyte stimulating hormone), an anti-inflammatory neuropeptide. It is diagnosed by a deep nasal swab, which is sent to a lab for analysis. If it is present and there are at least 2 classes of antibiotic resistance, the treatment is the use of compounded BEG Nasal Spray (bactroban, EDTA, and gentamicin) 2 sprays three times a day for 1 month.

Step 4: Correcting Antigliadin Antibodies (Eliminate Gluten)

If patients test positive for celiac or have positive antigliadin antibodies, gluten needs to be eliminated completely from the diet.

Step 5: Correction of Androgens

Many people with CIRS will have low androgens due to excessive activity of the aromatase enzyme. Dr. Shoemaker has shown that this will correct with VIP. In cases of those with low DHEA levels, supplemental DHEA may help correct androgen levels.

Step 6: Correction of Antidiuretic Hormone/osmolality problems

Most people with CIRS will have ADH (antidiuretic hormone) and osmolality levels that are out of proportion to each other. The most common pattern is a relative or absolute deficiency of ADH. Typically, one will see an ADH level either low or low normal with osmolality mid or high normal. ADH causes the kidney to retain free water. Therefore, when levels are relatively low, patients will commonly experience excessive thirst and urination. In more severe cases, people will experience frequent static shocks. The treatment is to use desmopressin 0.2 mg every other night. Sodium levels must be checked in 5 days then again in 10 days as hyponatremia can sometimes occur. If hyponatremia occurs, patients may experience poor appetite and nausea.

Step 7: Correction of MMP- 9 and VEGF

MMP-9 (Matrix Metalloproteinase 9) is an enzyme that breaks down extracellular tissue. VEGF (Vascular Endothelial Growth Factor) stimulates the growth of new blood vessels. If MMP-9 is high and VEGF is low, then both are treated with a low amylose diet and high dose fish oil.

Step 8: Correction of C3a

Assuming first all chronic bacterial infections have been eradicated and there is a persistent elevated C3a, suggest the utilization of Coenzyme Q10 150mg once daily followed by a high dose statin drug (Lititor, Crestor or Zocor).

Step 9: Correction of Elevated C4a

Correct Complement C4a if levels are greater than 2830 ng/ml. In earlier versions of Dr. Shoemaker’s protocol, erythropoietin (Procrit) injections were given. Now that VIP* is available, VIP* is the current treatment of choice.

Step 10: Correction of TGF-beta1 (Transforming Growth Factor Beta 1)

If elevated (over 2380 pg/mL), the treatment is Losartan up to 25mg twice daily. A metabolite of losartan called exp3179 lowers TGF beta.

Step 11: VIP* (Vasoactive Intestinal Polypeptide)

If the patient remains symptomatic after following all of the above steps, then the use of VIP* is needed. It is a nasal spray that is dosed at 50mcg/mL, 1 spray 4 times a day. The first dose should be given in the office. TGF-beta1 and C4a labs should be drawn before the first spray and again in 15 minutes. If the levels rise, there is a hidden mold exposure. It is critical that there be no continued mold exposure before starting VIP* otherwise it will be ineffective. VCS must also be normal and MARCoNS must not be present to ensure that VIP* will be effective.

*VIP nasal spray is not currently offered by Woodland Hills Compounding Pharmacy.

Dr. Joseph Brewer’s Protocol

Dr Joseph Brewer developed a protocol to eliminate nasal colonized mycotoxins.  Through research with his colleagues he determined that the sinus area was the most likely reservoir for the colonization of mycotoxins. Colonized bacteria are protected by a biofilm coating that prevents their elimination. In order to eliminate the bacteria, the biofilm coating must be removed first. This requires two treatments working together to first remove the biofilm coating then attack the bacteria. Usually this will involve atomized treatments first with EDTA to remove the biofilm then amphotericin-b to eliminate the bacteria.