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 Mold Illness Treatment Protocol

Dr. Shoemaker is a leading figure in the treatment of mold-related illnesses. His website, survivingmold.com, is a go-to resource for both physicians and patients. BEG nasal spray is an effective way to eliminate MARCoNS from the sinuses and nasal passages and was an important part of the initial protocol. While BEG is still effective, Dr. Shoemaker now recommends using a nasal spray with EDTA and colloidal silver to eliminate MARCoNS. The Shoemaker protocol involves going through a series of treatment steps until the disease is treated. Some patients will find success after a few steps, others will need to go through the entire protocol.

Step 1: Identify and Eliminate Mold Exposure/Removal from 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. If the patient can not remove themselves, every effort must be made to remediate the building. Removal from a moldy environment may be enough for some patients. If it is not, however, the rest of the steps should be followed.

Step 2: Remove Biotoxin Load – Get the Toxins Out of the Body

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. The treatment for MARCoNS is the use of EDTA nasal spray with hydrosol silver (a non-prescription dietary supplement). The most frequently prescribed dose is an EDTA 0.5% with a 23ppm silver. If the EDTA and hydrosol silver is ineffective, a compounded BEG Nasal Spray (bactroban, EDTA, and gentamicin) is prescribed.

Step 4: Correcting Antigliadin Antibodies (Eliminate Gluten)

If patients test positive for celiac, gluten needs to be eliminated completely from the diet. If test results show high anti-gliadin, gluten should be removed for three months. After three months the patient should be tested again.

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

MMP-9 (Matrix Metalloproteinase 9) is an enzyme that breaks down extracellular tissue. Biotoxins lead to elevated cytokines, which trigger the release of this enzyme from neutrophils and macrophages. Omega 3 fatty acids in combination with a low amylose diet are used to lower MMP9.

Step 8: Correction of VEGF

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 Omega 3 fatty acids. Graded exercise can also help correct VEGF, working up from 5 minutes per day up to 45 minutes.

Step 9: 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). Sometimes elevated levels of C3a are a sign that CIRS is related to Lyme disease and not exposure to a moldy environment.

Step 10: Correction of C4a

Levels of C4a are a marker of the overall severity of the disease. In earlier versions of Dr. Shoemaker’s protocol, erythropoietin (Procrit) injections were given but this is no longer recommended, mostly due to warnings about its use. Now that VIP* is available, it is the current treatment of choice.

Step 11: Correction of TGF-beta1 (Transforming Growth Factor Beta 1)

If elevated, the treatment is Losartan up to 25mg twice daily, starting at once a day and working up if it is well tolerated. A metabolite of Losartan called EXP 3179 lowers TGF beta. The dose used for treating CIRS is much lower than that used for blood pressure (50-100mg).

Step 12: VIP (Vasoactive Intestinal Polypeptide)

If the patient remains symptomatic after following all of the above steps, then the use of VIP is needed. 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. Also read this article by Drs. Ritchie Shoemaker, Dennis House, and James Ryan, which has clinical information on treatment with VIP.  Park Compounding Pharmacy does not compound VIP nasal spray.

Jarisch-Herxheimer Reaction

When going through the steps of a biotoxin illness treatment protocol, many patients will experience what is known as a Jarisch-Herxheimer reaction (also called a “herx” reaction). This refers to symptoms initially becoming worse after treatment is started before they start to get better. It is caused by the inflammatory response as the infection is cleared from the body. Patients should always be reminded that the Jarisch-Herxheimer reaction is normal and they should stick with their treatment plan.

Brewer Protocol

Dr Joseph Brewer, an infectious disease specialist, developed a protocol to eliminate nasal colonized mycotoxins with antifungals. This protocol calls for the use of a chelator to first disrupt the biofilm followed by an antifungal to eliminate the mycotoxins. Both are applied using either a nasal spray or an atomized solution. The standard medications used for the Brewer protocol are EDTA for the chelating agent and amphotericin B for the antifungal. The Rhino Clear Sprint atomizer is the best way to deliver biotoxin illness medications like amphotericin B to the nasal passages. The compact electronic atomizer releases the liquid medication into a continuous mist that gets inhaled into the nasal passages and sinuses. Recently, Dr. Brewer has been treating inflammatory conditions associated with CIRS that are related to mast cells. This includes Mast Cell Activation Syndrome (MCAS), which is often treated with ketotifen and cromolyn sodium. Both of these medications can be obtained from our compounding pharmacy.