Updated on March 19, 2015

Step 2: Binders – Article Outline

For folks with Chronic Inflammatory Response Syndrome (CIRS), taking binders to remove unwanted biotoxins is essential to getting better. The two binders that have been shown to work consistently at bringing down inflammation and improving visual VCS scores are Cholestyramine (CSM) and Welchol. Unfortunately, taking these two binders properly is not as straight forward as taking a daily multi-vitamin. As a result, I personally believe CSM and Welchol get more of a “bad rap” than they deserve and that consequently, quite a few people are missing out on the benefit these binders afford.

To give you some examples of what I mean, consider the person that has high inflammation (MMP9) or has been exposed to either Lyme or various co-infections. It is virtually guaranteed that this person will have an intolerable intensification in symptoms if they don’t go on a special diet and take high dose oils for at least 30 days prior to taking CSM or Welchol. Likewise, it is essential to monitor VCS visual scores and blood markers like MMP9, C3a, and C4a before and during administration of CSM or Welchol. If not, then if there is an intensification in symptoms, there will be no way to tell is this is short-lived and can simply be dealt with by reducing dosage or, if it’s indicative of active Lyme necessitating stopping CSM and Welchol all together until the Lyme is knocked out. Similarly, older folks and people with a range of gut issues like the roughly 50% of those with CIRS that have slow moving bile (cholestasis) or bile reflux, need to take extra precautions to try to ensure they have the best possible chance at keeping the gas, bloating, and constipation that tend to trouble this group within tolerable limits.

Don’t get me wrong, I have absolutely no qualms with taking alternative binders to CSM and Welchol. However, as I discuss below, unfortunatley there isn’t any hard evidence like there is for CSM and Welchol that binders like charcoal, clay, zeolite, and such are effective against CIRS. I dearly wish there was especially for those that even when following proper protocol, just can’t tolerate CSM or Welchol. Certainly there is some nice research showing alternative binders are good at removing toxins of various sorts; it’s just that no one has ever gathered any data showing they work to improve VCS visual scores and reduce inflammation in CIRS. Having said this, I have no qualms against hedging my bets by adding in other binders. Personally, I take one to two daily maintenance doses of CSM mixed with acid-washed USP activated charcoal and Redmond Bentonite Clay.

So the material in all of the sections on binders, except for the one on Alternative Binders, comes primarily from Dr. Shoemaker’s work. It is a sort of CliffsNotes for binders. It represents only a fraction of the valuable amount of information in Dr. Shoemaker’s FAQs. It is my attempt to provide a little more clarity on the subject of how to take CSM and Welchol properly along with providing what little insight I can into alternative binders.

• CSM & Welchol Basics
• Dosing and Monitoring
• Side Effects & Complications
• Lyme & Co-Infections
• Alternative Binders

CSM & Welchol Basics

1. The first step of Dr. Shoemaker’s protocol is living and working in relatively mold-free environments. Check out Mold Testing to confirm your environment is safe. The second step is taking binders to remove biotoxins from the body. Note: In practice, it takes some a long time to finally move to a clean home or a healthy work place. Rather than wait until they’re mold-free, a person diagnosed with CIRS should start taking binders right away.
2. Biotoxins from mold, Lyme, algae, and the like consist of very small, negatively charged molecules that form anion-rings called Ionophores. These Ionophores are incredibly tiny in size ranging from 200-1,500 Daltons – one Dalton has the mass of one neutron. Furthermore, due to their structure, biotoxins are able to readily cross cell membranes. Nevertheless, the liver is capable of capturing these toxins and excreting them into bile that is then held by the gallbladder until food is eaten. At that time, the biotoxin laden bile is released into the small intestine. Unfortunately, because of their unique structure, biotoxins are readily reabsorbed during the recycling process in the body called enterohepatic circulation that serves to reuse bile and bilirubin. Without a binder that can prevent reabsorbtion, biotoxins remain in the body of folks with CIRS indefinitely setting off a cascade of inflammation driven symptoms. For healthy individuals with intack immune systems, biotoxins are removed through the normal route of antibody creation.
3. Cholestyramine (CSM) is the binder of choice. CSM has been FDA-approved for lowering cholesterol for approximately 50 years and comes in powder form. Cholesterol patients have taken CSM for many years without complications proving that CSM is safe. Using CSM for treating CIRS is perfectly safe but considered “off-label” as it has only been FDA approved for cholesterol. Dr. Shoemaker recommends taking a one-a-day vitamin for people who are on CSM or Welchol for more than 6 months to prevent deficiencies in vitamins A, D, E and K.
4. Welchol is the alternative binder to CSM when CSM isn’t tolerated. Welchol has fewer side-effects. Since it can be taken with food and is in pill form, it can also be carried when you’re away from home and taken in the event of an unexpected mold exposure. Since Welchol has only 25% as many positively charged sites to bind Biotoxins compared to CSM, it is much less effective.
5. On a molecular level, Cholestyramine (CSM) and Welchol are long polystyrene chain molecules with side groups of positively charged nitrogen – called quaternary ammonium. It is the shape and size of the positive charges on CSM and Welchol that allow them to latch onto the negatively charged Biotoxins. The bound biotoxins are then held captive in the gastrointestinal track and are excreted in stool.
6. Cholestyramine and Welchol bind Ionophores from fungi (mold), cyanobacteria, dinoflagellates, spirochetes, apicomplexans, and others. In addition, CSM also binds organic molecules like DDT, DDE, PCB’s, and Kepone to name a few. In cases of secretory diarrhea, CSM has helped by latching onto toxins from clostridium difficile (C-difficile). CSM and Welchol do not bind heavy metals.
7. In general, within a week of starting CSM, Visual Contrast Sensitivity (VCS) test scores should begin to improve unless the person has MARCoNS or gets an “intensification” reaction either due to high MMP9 or active Lyme. In general, 75% or patients will see a 75% improvement of symptoms with CSM alone depending on a person’s haplotype, severity, and duration of exposure. MARCoNS and Lyme can prevent the typical improvement in VCS and symptoms. Note: In my experience, this statistic seems rather optimistic.
8. It takes longer for Ciguatera patients to be cleared using CSM because the biotoxins bind more tightly to cells. As such, the biotoxins do not enter into the blood stream nearly as often where they are vulnerable to removal by the liver and subsequent binding by CSM.
9. Cholestyramine comes in three forms – Regular, Light, and Pure. Regular CSM contains fructose and other additives. One 9 gram dose of Regular CSM contains 4 grams of CSM mixed with citric acid, fructose, mono ammonium glycyrrhizinate, pectin, propylene glycol alginate, sorbitol, sucrose, xanthan gum, artificial orange flavor, D&C yellow No. 10 aluminum lake, and FD&C yellow No. 6 aluminum lake to make up the other 5 grams. Note: I sleep worse if I take regular CSM before bed. Also, when I was taking 4 doses a day, I had significant weight lose.
10. As if all the additives in Regular CSM weren’t bad enough, Light CSM LIGHT contains aspartame and other additives. One 9 gram dose of Light CSM contains 4 grams of CSM mixed with aspartame, citric acid, colloidal silicon dioxide, D&C Yellow No. 10, FD&C Red No.40, flavor (natural and artificial Orange), maltodextrin, propylene glycol alginate and xanthan gum to make up the other 5 grams. Note: Aspartame has been linked to birth defects, cancer, diabetes, emotional disorders, and seizures among others and should be avoided like the plague.
11. The sugar alone in Regular CSM is enough to cause serious gut microbe imbalances in some. Many with multiple chemical sensitivities (MCS) can’t tolerate all the additives. Thankfully, you can obtain Pure CSM. Compounding pharmacies that carry pure CSM include Hopkinton Drug and Woodland Hills Pharmacy.
12. On a personal note, I’d been taking pure CSM for about six months when my insurance company said it would no longer pay for the pure form. In speaking with the folks at Hopkinton Drug, I was told that the amount billed insurance for a one-month supply of pure CSM was around $9,000! As of late 2014, they sold a virtually identical product to individuals without insurance for around $400. What non-sense. Apparently, insurance won’t accept the less expensive alternative. When insurance is then faced with covering the over-priced CSM, they balk and say it’s too expensive! As a result, I’m essentially forced to pay for pure CSM out of pocket or use the Regular CSM with all the additives. Talk about insult to injury.
13. A reader wrote in saying that a batch of pure CSM from a compounding pharmacy turned out to be bad. Instead of the usual slight fishy smell, the powder smelled like VOCs from chemicals. Upon using the product, there was a temporary bad reaction. If you have any doubts, you may want to consider contacting your compounding pharmacy and asking for a small, free sample before committing to buy.
    

Dosing and Monitoring

1. Adults take 9 grams of Cholestyramine (CSM) powder (each scoop contains 9 grams of which 4 grams are cholestyramine powder) mixed in liquid on an empty stomach four times a day for a total of 36 grams daily either 30 minutes before a meal or one hour after with plenty of water. Children under 18 and less than 120 pounds should take 60 mg/kg (27mg/lb) of CSM each dose three times daily – not including any additives. If no other medications are being taken, CSM should be taken 30 minutes before food or 1 hour after.
2. As an alternative to CSM, adults take two Welchol 625 pills three times daily with or without food – although there is less risk of stomach upset if taken with food. Note: If at all possible, it’s much better to take CSM.
3. Continue taking CSM or Welchol until VCS is normal. If re-exposed or you have a susceptible haplotype, expect to be taking maintenance and recovery doses until a more lasting cure is found. If symptoms worsen dramatically when binders are stopped, a hidden mold exposure is likely.
4. Liquid medications that do not have a lot of negatively charged ions (ask your doctor) can be mixed with CSM – CSM binds only negative charged particles.
5. Maple syrup, Gator-Ade, and tea can all be used instead of water when mixing CSM. If all else fails, almond milk (not cow’s milk), apple sauce, and ice cream can also be used but expect some reduction in benefit that gets worse the longer the time CSM is in contact with the food – don’t premix and then let it sit out.
6. In general, waiting 30 minutes before eating or taking other medications like Bio Identical Hormones ensures both CSM and the medications are not diminished. Dr. Shoemaker suggests that drugs that require sustained levels in the blood like theophylline, warfarin, and digoxin can be taken with CSM. He also suggests that other drugs like thyroid hormones, Dilantin, theophylline, and Coumadin should be taken 2 hours before or 2 hours after CSM. In general, it is recommended that you check with your doctor if you’re taking blood thinners, digoxin, propranolol, diuretics, thyroid hormones, birth control pills, hormone replacement, seizure medicines, or antibiotics.
7. The exception to all the rules regarding timing of CSM and Welchol is for those with gastroparesis wherein the stomach is slow to empty – see Side Effects & Complications below.
8. Taking CSM 3 times a day is still effective but healing will take more time. After getting better, CSM may be taken 2 times daily as a preventative to offset brief and unexpected exposures. Taking CSM 1 time daily has no benefit other than helping with irritable bowel syndrome.
9. After getting better and upon unexpected exposure to biotoxins, take CSM 4 times daily for at least 3 days and up to a week to prevent re-triggering CIRS. If the expected symptoms don’t get better, you’ll need to have VCS, C4a, and TGF-beta1 checked.
10. CSM and Welchol take time to clear biotoxins. Even if they’re taken pro-actively before an exposure, the best that can be expected is that symptom will abate more quickly. Binders are not like armored steel is to lead bullets.
11. For those with CIRS that are very weak, elderly, or have MCS, start with very small doses of Welchol and work up slowly.
12. According to Dr. Ben Lynch in this video at 55 minutes, CSM should be taken away from folate supplementation for methylation support.
    

Side Effects & Complications

1. Just like with MARCoNS, it is important to take the VCS visual test and get MMP9 measured through a blood draw prior to starting either CSM or Welchol. The reason is that for some, symptoms worsen initially. Without these tests, you won’t be able to determine if this worsening in symptoms is indicative of Lyme (thereby requiring a change in protocol) or simply a temporary condition.
2. If VCS scores fall by two or more places in column E followed by a worsening in column D along with a rise in MMP9, stop binders and re-evaluate the possibility of Lyme. If Lyme is still active, it needs to be treated. To prevent intensification in post-Lyme folks, a no-amylose diet must be followed and high dose omega-3 fatty acids must be taken for 1 month prior to re-starting CSM or Welchol – see Lyme Disease below.
3. Personally, I recommend high dose fish oil and cutting out sugar and fast-acting carbohydrates regardless of a person’s Lyme status. Better yet, consider Dave Asprey’s Bulletproof Diet or Doug Kaufmann’s Phase One Diet.
4. Those with high MMP9, exposure to ciguatera, or MARCoNS are more likely to have a temporary worsening of symptoms. If MMP9 and VCS don’t significantly worsen, cut back dosage for symptom relief. You may need to take as little as 1 dose of CSM daily or even two Welchol 625 tablets three times daily, and slowly work up to 4 doses of CSM daily. Post-Lyme individuals can also experience symptom intesification – see Lyme Disease below.
5. Statistically, about 10% of Dr. Shoemaker’s patients could not tolerate the bloating, gas, and constipation that CSM can cause. People experiencing difficulty should try low doses of Welchol 625 and work up slowly.
   Cholestyramine Side Effects
6. For constipation, Dr. Shoemaker recommends soluble fiber that is found in prunes, dried apricots, cashews and walnuts. Pectin and soluble oat bran fiber (most is insoluble so read the label) can also be helpful. If you can’t get enough fiber from your diet, natural fiber capsules or powder like psyllium, pectin, and guar gum can work. Chamomile tea, magnesium, and higher doses of vitamin C also act as laxatives.
7. About 10% of folks with CIRS have confirmed gastroparesis wherein food takes hours to empty from the stomach. These folks must use Welchol as CSM will bind to food sitting in the stomach. Start out with 1/2 of a Welchol 625 tablet and increase by 1/2 tablet every few days until taking 2 tablets 3 times daily.
8. Roughly 50% with CIRS have either slow moving bile (cholestasis) or bile reflux. Bile reflux upsets the stomach and treating with reflux drugs like Prilosec and Zantac has no benefit. If bile is refluxed all the way to the mouth, the taste will be very bitter. Dr. Shoemaker has pre-treated with the gastrointestinal (GI) medicine, Sucralfate, to help those with bile reflux.
9. As a matter or course, you can expect some acid reflux when first taking CSM.
10. CSM in capsules can help get around some GI side-effects.
11. To prevent GI problems, do not take CSM with antibiotics – especially Doxycycline.

Lyme & Co-Infections

1. Dr. Shoemaker recommends trying to treat active Lyme with 3 weeks with Doxycycline for women and Amoxicillin for men – amoxicillin causes yeast problems in women. Since antibiotics reduce inflammation, people with CIRS will feel better while they’re on antibiotics. Note: The inflammatory blood marker called MMP9 (reflects cytokine levels) will remain high in Lyme patients even when they are given antibiotics if they have a susceptible HLA genotype.
2. Those with a Lyme susceptible geneotype make up 21% of the population. These folks will remain sick from an inability to clear Lyme biotoxins even after the spirochetes are beaten into submission. Regardless of whether you have a susceptible Lyme haplotype or not, labs that include VCS, TGF-beta1, C3a, C4a, and the like should be taken prior to treatment and at various steps along the way.
3. After attempting to knock out Lyme, it is essential that a no-amylose diet be followed along with taking omega-3 fatty acids (fish oil) at a daily dosage of 2.4 g EPA and 1.8g DHA for 1 month prior to starting CSM – to reduce inflammation. Without pre-treating with diet and fish oil, Lymies can expect a major “intensification” reaction between day 2 and 3 from toxin movement – regardless of whether Lyme is still active or not. This is not the same as a HERX. Mold, dinoflagellate, and cyanobacteria biotoxins do not cause an intensification reaction. Note: I bet there are a lot of Lymies with multisusceptible genes that tried CSM or Welchol without first moving to a clean place and pre-treating with diet and oil. As a result, we know they most likely had wild swings in symptoms from the mold toxins in their homes and work places. On top of that, we know they’re quite likely to have an intensification reaction as a result of not having driven down inflammation for 30 days prior to starting CSM or Welchol. How many then incorrectly concluded that CSM and Welchol don’t work? My guess is quite a few. As they say, “the devil is in the details”!
4. Once CSM is tolerated, continue until VCS is normal (or as good as it’ll get as MARCoNS can hamper improvement) and symptoms are as good as they’ll get at this point in the protocol. To confirm that Lyme has been successfully treated, stop CSM and then measure C3a and C4a after one week and then again at one month. If symptoms worsen after one week, continued mold exposure is very likely. If both C3a and C4a rise after a month, active Lyme is very likely. If C4a only rises after a month, continued mold exposure may be an issue – not all the time. If neither C3a nor C4a rise, the coast is clear and the next step in the protocol can be started along with testing again at two months to confirm C3a and C4a are not rising. One caveat is that Lyme that has gone untreated for more than 6 months will not show a rise in C3a. Bartonella does not cause C3a to rise.
5. If C3a and C4a rise indicating that a 3 week course of antibiotics was ineffective, you now have a case for going to IV antibiotics that insurance companies should support. Although, if the patient wants to take another trial of oral antibiotics, this is OK too.
6. On rare occasions, Dr. Shoemaker has seen Lyme patients that did not have a tick bite or an ECM (bull’s-eye rash), had low C3a and C4a, and had a negative Western Blot Lyme test. If VCS does not improve as expected, continue to consider the possibility that Lyme may be the issue.
7. NeuroQuant is an excellent tool for distinguishing between Lyme and mold patients. MRI scans of the brain using specialized software look at areas in the brain that includes the forebrain, cortical, hippocampus, caudate, pallium, cerebellum, thalamus, putamen, and posterior gray. When mold is an issue, certain area will be smaller while others will be larger than normal. For Lyme, the signature of variations in sizes will be completely different. For under $100, this is an amazing tool that we have Dr. Shoemaker to thank for.
8. CD57 values are the same in mold and Lyme patients so it’s not a good marker for Lyme. Besides, there are problems with accurate lab results.
9. You can test for Babesia by having Quest run “Haptoglobin” on a blood sample. If Haptoglobin is low, then Babesia is likely the issue. You can also look at hemolysis blood smears for diagnosis. Use Mepron and then follow with Dr. Shoemaker’s protocol. Babesia can activate innate immunity in HLA susceptible individuals leading to CIRS.
10. Per the work of Dr. Sam Donta, Borrelia makes a neurotoxin. Like Lyme, its essential to take high dose omega-3 fatty acids (2.4g EPA plus 1.8g DHA) and follow a no-amylose diet for 1 month prior to starting CSM. Otherwise, expect symptom intensification.
    

Alternative Binders

It doesn’t take long searching the Internet to realize there are many types of binders besides Cholestyramine and Welchol. Just to name a few, these include various types of activated charcoal, clays, chlorella (single-celled green algae), and zeolite (aluminosilicate mineral). In addition, there are numerous publications that discuss the types of biotoxins each of these binders are capable of removing. Below are a few such publications.

Mold and Mycotoxins – Often Overlooked Factors in Chronic Lyme Disease
A Review of the Mechanism of Injury and Treatment Approaches for Illness Resulting from Exposure to Water-Damaged Buildings, Mold, and Mycotoxins
Herbal Transitions – Biotoxin Removers

Although many of the studies are “in vitro”, where substances are mixed together in a laboratory, the agricultural industry has been studying the real-life adverse health effects of mold biotoxins for decades. Weight loss, reduced fertility, miscarriages, liver lesions, pulmonary edema, diarrhea, and intestinal hemorrhaging, are just a handful of the documented ill health effects that occur when animals consume foods with higher levels of mold. You don’t have to look very hard to find numerous University studies looking at what binders are most effective for alleviating symptom in animals depending on the particular mold. In fact, there are quite a few commercially available binders in the form of food additives for binding mold toxins in animals. When added to animal feed, these binders greatly diminish the negative effects of contaminated feed.

Mycotoxin Adsorbents and Binders
Mycotoxins & Animals
Alkalinization of Urinary pH Accelerates Excretion of Ochratoxin A

Now before I go any further, I want to make a few very important points. The first is that the studies that I have seen done on binders focus exclusively on Mycotoxins. Mycotoxins are chemicals that mold produces to kill off competing molds and bacteria. It is how fungi stake out territory on that decaying piece of organic matter. They coat themselves with mycotoxin chemicals and exude it into the surrounding air. Anything that comes into contact with mycotoxins, including humans, has their health attacked by these chemicals.

Now get this. Mycotoxins make up only 2% of the total number of biotoxins created as mold and bacteria break down decaying matter! That’s right; the other 98% of toxic inflammagens consist of endotoxins, beta glucans, hemolysins, proteinases, mannans, spirocyclic drimanes, and volatile organic compounds (VOC). Furthermore, there are thousands of mycotoxins each with its’ own chemical structure. Which of all of these inflammatory toxins are causing CIRS? No one knows.

Mold and Mycotoxins: Effects on the Neurological and Immune Systems in Humans

The second important point is that when you clear mycotoxins using these non-proven binders, this does not mean you’ll get better! More specifically, if you look through the literature on alternative binders for those with CIRS that has been put out by either well-meaning individuals or alternative doctors, they commonly make claims like charcoal works well for binding the mycotoxin called Aflatoxin and that clay works well for binding the mycotoxin called Trichothecene. Well that’s nice; but as a matter of fact, Dr. Shoemaker tried all sorts of binders including high dose Chlorella, activated Charcoal, Chitosan, Pectin, Bentonite Clay and others. That’s quite the contradiction; don’t you think?

In terms of Dr. Shoemaker, we know that in his usual scientific manner, Dr. Shoemaker tried one binder only at a time with no other therapies while recording VCS visual scores and blood work results. He didn’t also give patients IV glutathione drips, anti-fungals, change their diet, treat parasites, and so on all at the same time. He didn’t rely on studies done in laboratories showing a particular binder should be able to bind certain mycotoxins. He didn’t assume that the ill-effects in cattle from consuming mold tainted grain were of the same nature as CIRS. Instead, he tried one binder at a time on people with confirmed CIRS and looked very carefully to see if their vision cleared and inflammatory blood markers consistently improved. Unfortunately, except for CSM and Welchol, they did not. Let me say that again, the other binders mentioned were not statistically helpful.

Does that mean if you take other binders that they won’t help? Certainly there are plenty of antidotal cases of people who’ve gotten better taking one of these non-proven binders and I don’t doubt that they did. Furthermore, the agricultural industry has lots of evidence showing relief from the ill-health effects in animals when mycotoxins are mopped up with various binders. So clearly there is some benefit. As an aside, Dave Asprey seems to believe when you eat moldy food it sets off the same inflammatory response as CIRS. On the other hand, when Dr. Shoemaker was first learning about CIRS, he had a small group of patients eat all the cheap peanut butter they could over the course of a couple weeks. Peanut butter is notoriously moldy. He didn’t see any change in inflammatory markers measured through blood work in these patients.

So who knows; maybe you’ll get lucky. Maybe the other 98% of inflammatory toxins aren’t as much of a problem for you because although mold has damaged your health, you don’t have a susceptible HLA DR genes and therefore are able to clear toxins with a lot less support. Maybe there is some unknown combination of therapies that includes these non-proven binders that works well for those with susceptible genes and CIRS. We won’t know for sure until some doctor or institution actually tests these combinations in a scientific way. Until then, alternative binders are in murky waters indeed.

From where I stand, it’s a roll of the dice when it comes to binders other than Cholestyramine (CSM) and Welchol. Personally, why would I want to dabble in various other binders if I didn’t have too? CIRS is hell. Dr. Shoemaker found time and again that CSM and Welchol worked. The only way I’d ever consider not taking CSM or Welchol is if I just couldn’t tolerate them for one of the limited number of reasons discussed. In those cases only, I’m all for taking the binders you can tolerate while avoiding biotoxins, changing diet, and whatever other alternative therapies you can think of that help to build up your body so you can actually tolerate either CSM or Welchol.

Knowing what I do, if I was having a hard time with CSM, I would stop taking CSM or Welchol and work for 1 month on bringing down inflammation. To do this, I’d go on a no-amylose diet and take omega-3 fatty acids (fish oil) at a daily dosage of 2.4 g EPA and 1.8g DHA for 30 days. I would do this regardless of whether Lyme was in the picture or not. I would also cut out inflammatory foods and take anti-inflammatory supplements like Tumeric. I’d make sure to choose a Tumeric without “biopure” which is a black pepper extract. According to Dave Asprey, not only does black pepper have a lot of aflatoxins but it also “raises bio-availability” which means it shuts down liver function.

While staying on the diet, fish oil, and supplements, I would then micro-dose Welchol at whatever level I needed to and then slowly, slowly build up from there. Knowing that symptoms can vary wildly for a whole host of reasons, I would try not to change my supplements and diet while keeping a journal before, during, and after trying Welchol. If after 2-3 weeks there was a steady worsening of symptoms, VCS, and an increase in MMP9, I’d switch to other binders that I could tolerate and re-evaluate the possibility of active Lyme and other factors like co-infections.

So I’ll leave it up to you to sort through the various publications and decide what alternative binder(s) to take when you absolutely can not figure out how tolerate either CSM or Welchol. Antidotal evidence suggests that there are other combination therapies that can help sometimes. Whatever binder(s) you chose, make sure to monitor VCS and inflammatory markers like MMP9, TGF-beta1, C3a, and C4a. That way you’ll be able to tell if the biotoxins are being cleared. I pray that if you end up having to travel these less well-lit paths that you find your way back to health.

Note: You can download the CSV text file with the current data from the Binder Survey at any time and import it into Excel for viewing.