Dr. Neil Nathan’s Protocols

In his book, “Toxic: Heal Your Body from Mold Toxicity, Lyme Disease, Multiple Chemical Sensitivities, and Chronic Environmental Illness,” Dr. Neil Nathan provides a comprehensive look at multiple environmentally acquired, chronic inflammatory illnesses. His treatment recommendations are influenced by both previously established protocols like Dr. Ritchie Shoemaker’s and Dr. Joseph Brewer’s, as well as his own insights and clinical experience. The Shoemaker and Brewer protocols are the core of his treatment regimens for mold toxicity. However he adds additional suggestions on treatment that may help patients who are not responding with the standard medications and dosages.

Dr. Nathan’s book goes in-depth into lifestyle, diet, and exercise, as well as other illnesses related to those discussed here and their symptoms. Here we will be discussing only those treatments that pertain to pharmaceuticals and compounding pharmacies. Compounding pharmacies like ours have tried to fill the gaps in treatment for chronic inflammatory as few treatments are commercially available.  

Mold Toxicity

Amphotericin

Dr. Nathan discusses the use of amphotericin B for eradicating resistant infections in the nasal passages related to exposure to toxic mold. This has long been a standard treatment for mold toxicity as part of the Brewer protocol. He notes that the strength most often prescribed, which is 0.25%, may be too strong for some individuals. Instead, he often prescribes a 0.06% strength which he finds is better tolerated for both intranasal and oral use. That means the 0.06% solution can be administered in a nasal spray or atomizer and also be taken by mouth. According to Dr. Nathan, about 60% of patients can handle amphotericin well. For patients who are more sensitive to this treatment even at 0.06%, he often recommends the use of a nystatin nasal spray instead.

BEG and EDTA

BEG spray and EDTA nasal spray are a part of the Shoemaker protocol. BEG is a combination nasal spray that includes bactroban (mupirocin), EDTA, and gentamicin. EDTA is a chelating agent that helps remove the biofilm that harbors bacteria. Dr. Nathan recommends the use of hydrosol silver along with EDTA if it can be tolerated. Patients may be started with a silver spray before they start with antifungals to determine their level of sensitivity. Patients who are able to handle this nasal spray usually can proceed to the use of antifungals.

Dr. Nathan mentions that he sometimes will leave out gentamicin from BEG spray to prevent long-term bacterial resistance and because some patients are sensitive to its effects. One of the best takeaways from Dr. Nathan’s book is that rigid adherence to a particular protocol with specific dosages does not work for every patient. Adjusting a dose up or down or changing ingredients based on a patient’s response can lead to better treatment outcomes.

Cholestyramine

Binders are also a part of Dr. Nathan’s treatments derived from the Shoemaker protocol. The Shoemaker protocol calls for the use of a binder like cholestyramine, although he also lists other binders as options. In Dr. Nathan’s opinion, the standard dosage of 3-4 scoops of cholestyramine per day may be too much for some patients to tolerate. Some patients may only be able to tolerate 1 dose per day. Again, it is important to customize a treatment plan based on what a patient can tolerate and what works best for them.

The patient’s tolerance for binders is used to determine what antifungal should be used. Dr. Nathan has found that he can predict a patient’s tolerance for antifungals based on how they respond to treatment with a binder like cholestyramine. If tolerance for the binder is high, a full-strength antifungal treatment may be tried. If tolerance is low, a lower strength may be tried or different ingredients used.

Mast Cell Activation Syndrome

Dr. Neil Nathan mentions two compounded drug products that may help with mast cell activation syndrome. These are the mast cell stabilizers cromolyn sodium and ketotifen. He recommends ketotifen be started at one 0.5mg capsule taken at bedtime and increased if tolerated. For cromolyn sodium he does not offer a specific starting dose, but advises starting low and slowly increasing the dose. Our pharmacy commonly makes cromolyn sodium 100mg and 200mg capsules, but can make a different dose if needed.

Rebooting the Endocrine System

According to Dr. Nathan, a majority of patients suffering from chronic inflammatory illnesses also experience negative effects on their hormonal balance. Supplementation can sometimes help restore hormone levels when there is a deficiency caused by illness.

Adrenal Hormone Deficiencies

The adrenal glands produce the hormones DHEA and cortisol. DHEA is a precursor to estrogen, progesterone, and testosterone. Cortisol is a well-known hormone associated with managing stress. When either hormone is out of balance it can lead to low energy, stress, fatigue, and other symptoms. Dr. Nathan suggests DHEA and cortisol levels be tested and that supplementation be given if the patient is deficient.

Thyroid Hormone Deficiencies

Nature Throid

The thyroid gland produces hormones that are essential to metabolism throughout the body. The symptoms of thyroid deficiency (hypothyroidism) are similar to those of chronic inflammatory illnesses in general. Hyperthyroidism, which is an overproduction of thyroid hormone, results in increased heart rate and anxiety but is not as common for patients with chronic inflammatory illness. In general patients with mold-related illnesses will need to be treated for hypothyroidism not hyperthyroidism.

Dr. Nathan disagrees with the use of only TSH testing (hormone that regulates thyroid production) to determine thyroid levels. Instead he recommends measuring T3 and T4 as well. He acknowledges that the use of T4-only (levothyroxine) works for many patients. However he states that “many physicians are aware that for certain other patients, this form of treatment will only cause further buildup of RT3 [reverse T3] and make it even more difficult for their bodies to convert T4 to T3.”  For these patients he recommends the use of T3 in addition to T4. Examples given include liothyronine sodium and compounded sustained release T3.

There is no specific mention by Dr. Nathan of using natural desiccated thyroid, including Nature Throid or WP Thyroid. However these products do contain the full spectrum of thyroid hormones including T4 and T3.

Sex Hormone Deficiencies

Dr. Nathan views estrogen replacement for women in menopause as a “biological necessity” and not a luxury. He views estrogen deficiency as no different than thyroid hormone deficiency in that it affects a woman’s health in a variety of ways and should be treated if possible. He recommends measuring all three estrogens — estrone (E1), estradiol (E2), and estriol (E3) – as well as progesterone, testosterone, and DHEA. Treating the underlying chronic inflammatory illness may improve hormonal deficiencies. However according to Dr. Nathan this is not always enough, and sometimes the endocrine system needs to be “rebooted.”

His recommendation for hormone deficiency is to start bioidentical hormone replacement with a minimum of estrogen and progesterone. Other hormones like testosterone and DHEA may be added as needed. He focuses on the use of testosterone supplementation for men, but acknowledges that it is an important hormone for women as well and that both men and women may need supplementation to restore optimal health.

A compounding pharmacy is able to make multiple hormones into one combined transdermal cream. Estradiol, estriol, progesterone, and testosterone can be combined into an easy-to-use cream with a metered-dose dispenser. These combinations of hormones are not available commercially.

Glutathione

Glutathione has often been referred to as “the master antioxidant” and is taken to help with detoxification. However Dr. Nathan believes that glutathione supplementation may not be beneficial in the long-term. He states that “because glutathione is made from cysteine, glycine, and glutamine, there is the potential for these amino acids to build up in the body and have unintended consequences over time.” Instead, he recommends consuming natural substances that can indirectly lead to increased glutathione levels. These include broccoli, grapes and berries, milk thistle, and turmeric.

Summary of Prescription Recommendations