Week of June 5, 2023

1/ CSM guidelines

 

Question: What type of food and drinks can we take with cholestyramine to help those who have a hard time getting cholestyramine down?

 

Answer: The main thing to remember is that cholestyramine should not be taken with food as the food will be bound by cholestyramine. Any liquids can be used to assist “getting CSM down,” aid digestion, prevent reflux and help prevent constipation (often these symptoms naturally resolve within a few days). Mixing CSM with Gator-Ade and processing that mixture in a blender has helped a lot of people. Or try apple juice, cranberry juice, or dissolving CSM in luke warm water then adding ice helps reduce heart burn.

 

For years we have given cholestyramine mixed in apple sauce to children but the cholestyramine will be bound to some of the particulates in the apple sauce material. Similarly the dosing of CSM with ice cream reduces its efficacy understanding that no tolerance of CSM really knocks out its efficacy.

 

Some individuals will benefit from starting the CSM dosage slowly and building up to the full dosage over the course of a few weeks.

 

For those who are sensitive to any additives that may be in CSM, you may want to seek out a compounding pharmacy where you can get the raw, pure form of the medication (such as Woodland’s Compounding Pharmacy). https://www.twcprx.com/

 

For more information, you may be interested in the CSM learning module created by Dr. Shoemaker available for purchase.

 

 

2/ How long is CSM commonly prescribed in the Shoemaker Protocol?

 

ANSWER: VCS will show typical deficit in 92% of patients. Once they’ve begun CSM or Welchol, if the patient is a case with normalizing VCS, you can still see interval improvement in the VCS, although going from 8 to 9 is a stretch. Follow labs and symptoms re the clinical time to stop CSM or switch to Welchol. If you are suggesting stopping meds, also verify that the ERMI or HERTSMI-2 in the home is safe.

 

 

3/ Cholestyramine dosing

 

QUESTION: I find it hard to take cholestyramine four times a day when I follow the package insert. Will it be helpful if I only take it twice a day?

 

ANSWER: Cholestyramine at twice a day is a reasonable dosage for maintenance to avoid relapse with casual exposures likely to occur from day to day. It is not a dose to be used for effective treatment. The suggestion on using cholestyramine in the package insert I find misleading in that the stomach needs to be empty for a short period of time and not two or four hours. So the dose of cholestyramine is 30 minutes before breakfast, 30 minutes before lunch, 30 minutes before supper and at bedtime. This protocol may require some careful timing and some reminders on when to take medications but thousands of people have been able to use this dosing protocol successfully.

 

 

4/ Cholestyramine, long term

 

QUESTION: I am a 4-3-53. I become ill rapidly with re-exposure to contaminated environments. Is it possible for me to take cholestyramine on a regular basis for a long time?

 

ANSWER: Given your reactivity and your genetic susceptibility, it will be necessary for you to observe your responses to additional environments besides your home carefully. I would make sure your home was shown (by HERTSMI-2) testing to be safe for you. If your home is not safe then you can not conclude that other areas are also not safe. Having a home fixed is the first step.

 

Cholestyramine (CSM) was used before for years to lower cholesterol (basically ending in 1987, the first year of the statin treatments!). People stayed on CSM year after year, putting up with the expected gastrointestinal side effects. For people who have been on cholestyramine for more than six months I do recommend use of a one a day multiple vitamins that will prevent depletion of vitamins A, D, E and K. 

 

(Also see the question above for typical dosing guidelines)

 

 

5/ Cholestyramine taken with mag citrate

 

QUESTION: I don’t like the taste of CSM or its texture; it’s like trying to swallow sand. My physician has given me the product called Natural Vitality Calm, which is ionic magnesium citrate, citric acid, organic raspberry and lemon flavorings and stevia. Now the CSM mixture has a pleasant texture and is very easy to swallow.

 

My question is, is the cholestyramine still as beneficial as before?

 

ANSWER: Years ago I used to ask patients to save stool specimens in their freezer before and after use of cholestyramine so that at some time in the future I would have been able assay for cholestyramine bound to a biotoxin in stool. That assay never developed. Needless to say I didn’t advertise that one of my freezers was full of stool specimens.

 

If we did have a stool assay we could say whether the Natural Vitality was creating a problem for absorption of biotoxins by cholestyramine. But we don’t so you are “flying blind,” a bit here.

 

There is nothing in what you have written, however, that sounds like there would be a problem as the positive charge of magnesium and citrate will each not bind to the positive charges of cholestyramine (see FAQ on Zeolite). Stevia does not bind to cholestyramine. I see no basis for the organic raspberry flavors either to bind to CSM but here you may need to ask your physician what the structures of the chemicals are in the flavoring. In the meantime, by having cholestyramine that you can tolerate I am sure that will be facilitating use of cholestyramine four times a day and not hating every dose thereby impacting on compliance.

 

6/ Cholestyramine, mixing with maple syrup

 

QUESTION: Are there problems mixing cholestyramine with maple syrup?

 

ANSWER: To date, we have had no anyone show reduced benefit of cholestyramine by mixing it with liquid medications that did not have a large preponderance of negatively charged ions (one person took CSM with bicarbonate and complained of no benefit).

 

Maple syrup was the preferred method of use of cholestyramine by one of our patients from Canada and it worked for them. I know of no differences in the light, medium or extra dark syrup and CSM.

 

7/ Cholestyramine, taken with non-sweetened almond milk.

 

QUESTION: Can I use cholestyramine with almond milk and water?

 

ANWER: I have no experience with use of almond milk mixed with cholestyramine. I frequently recommend taking CSM with Gatorade without compromising the effect.

 

Because almonds are considered a food, it is reasonable to assume they have the potential to bind with the CSM and reduce its effectiveness. If it’s a watered down amount, it may not completely cancel the effects of CSM.