Re: Stratton's Treatment Recommendations

[Guest guest]

Thank you, Jim. I appreciate you posting this.

[infections] Stratton's Treatment Recommendations

Someone on the MS forum sent me a Word doc which is ahandout Stratton et al offer for their treatmentprotocal, pending their completed research. Thisperson noted: "Some of it, like theantibiotic regimen, needs updating- he's currentlyusing Minocycline/Zithromax/Flagyl (with, "considerAmoxicillin as well"), but what this handout doeshave, is the current instructions for managing thetreatment of the infection- diet, supplements, etc."I'm hoping I can get this in on one email, if not I'llbreak it up as it's long. Wheldon sent me a draft of apaper he's submitting for publication, and I'll passon what I glean from it also.THERAPY OF CHRONIC CHLAMYDIAL INFECTIONS INCLUDINGTHEIR ASSOCIATED PORPHYRIA AND VITAMIN B12 DEFICIENCY:SEVENTH VERSION W. Stratton, MD M. , MD PhDVanderbilt University School of MedicineNashville, Tennessee 37232IMPORTANT DISCLAIMERCurrently there are protocols for appropriate clinicaltrials for the therapy of a number of different formsof systemic/chronic chlamydial infections beingprepared at Vanderbilt. The preliminary suggestionsfor chlamydial therapy that are contained within thisdocument have been gleaned from early therapy forcompassionate reasons and may not represent the finaltherapy. The use of these suggestions is similarly forcompassionate therapy of patients suspected of havinga systemic/chronic chlamydial infection. I. THERAPEUTIC REGIMEN FOR SECONDARY PORPHYRIA Systemic/chronic chlamydial infections have beennoted to have an associated secondary porphyria.Porphyrins, including water-soluble porphyrins (e.g.,delta-aminolevulinic acid and porphyrobilinogen) andfat-soluble porphyrins (e.g., coproporphyrin III andprotoporphyrin) may produce clinical episodes ofporphyria. The presence of such porphyrins in anindividual patient with chronic/systemic chlamydialinfection can be confirmed pre- and during therapy byappropriate porphyrin tests such as obtaining 24-hoururine and 24-hour stool specimens for porphyrins. It is recommended that a therapeutic regimenaddressing porphyria should be instituted along withthe use of antimicrobial agents. This therapeuticregimen is aimed at controlling thechlamydial-associated secondary porphyria that may bepresent prior to antimicrobial therapy and/or may betriggered or increased during antimicrobial therapy ofthe chlamydial infection. This "porphyric reaction" toantimicrobial therapy should be recognized as such anddifferentiated from an expected cytokine-mediatedimmune response. Specific measures for the therapy ofporphyria as derived from published medical literatureon porphyria are employed and include:1. High Carbohydrate Diet Approximately 70% of the daily caloric intake shouldbe in the form of complex carbohydrates such as thosefound in bread, potato, rice, and pasta. The remaining30% of calories in protein and fat ideally should bein the form of white fish or chicken.2. High Oral Fluid Intake Drink plenty of oral fluids in the form of water(e.g., bicarbonated water or "sports-drinks" [waterwith glucose and salts]). This helps flushwater-soluble porphyrins. Moreover, dehydrationconcentrates porphyrins and makes patients moresymptomatic. The color of the urine should always bealmost clear rather than dark yellow. 3. Avoid Red Meats Red meats, including beef and dark turkey as well astuna and salmon contain tryprophan and should beavoided as much as possible.4. Avoid Milk Products Milk products contain lactose and lactoferrin, bothof which should be avoided as much as possible.5. Glucose, Sucrose and Fructose Glucose is an important source of cellular energy:cellular energy is reduced with chlamydial infections.Increasing the availability of glucose providesoptimal conditions for the cells to produce energy.However, sucrose is not the best way to increase theglucose availability. Sucrose is a mixture of glucoseand fructose. Fructose is the sugar contained infruit. Because high levels of fructose act as a signalto the liver to store glycogen, an excess of fructosemay temporarily reduce the availability of glucose atthe cellular level. Fructose should be avoided as muchas possible. Instead, "sports-drinks" containingglucose (as well as containing importantcations/anions) can be used. Glucose tablets also canbe used.6. Avoid Alcohol. Alcohol is a well-known aggravator of porphyria andshould be avoided as much as possible.Vitamins/Antioxidants/Supplements7. B-Complex Vitamins Glucose is needed by host cells that are infected bychlamydiae. The availability of glucose to the host isassisted by taking B-complex vitamins. These includefolic acid (400 mcg twice per day), vitamin B-1(thiamin 10 mg twice per day), vitamin B-2 (riboflavin10 mg twice per day), vitamin B-5 (pantothenate 100 mgtwice per day), vitamin B-6 (pyridoxine 100 mg twiceper day or pyridoxal-5 phosphate 25 mg twice per day),and vitamin B-12 (5000 mcg sublingual three to six perday). 8. Antioxidants Antioxidants and related agents should be taken twiceper day. These should include vitamins C (1 gram twiceper day) and E (400 units twice per day) as well asL-carnitine (500 mg twice per day), ubiquinone(coenzyme Q10; 30 mg twice per day), biotin (5 mgtwice per day), and alpha-lipoic acid (400 mg twiceper day). Bioflavinoids (also called proanthocyanidinsof which pygnoginol and quercetin are two examples)are very effective antioxidants. Selenium (100 mcgtwice per day) should be taken with the vitamin E.L-Glutamine (2 - 4 grams twice per day), querceten(400 - 500 mg twice per day), glucosamine (750 - 1000mg two or three times per day) and chondroitin sulfate(250 - 500 mg twice per day) should also be included. Antiporphyrinic Drugs9. Benzodiazapine Drugs The specific benzodiazapine drugs used depends, inpart, on the symptoms. For example, if panic attacksare the problem, xanax (0.5 mg three or four times perday) can be used. If sleeping is a problem, restoril(30 mg at night) can be used.10. Hydroxychloroquine Hydroxychloroquine (100 - 200 mg once or twice perday) is often used to treat porphyria. For patientswith symptoms of porphyria, a single 100 mg dose ofhydroxychloroquine may be tried. If this trial doserelieves the symptoms, hydroxychloroquine may becontinued. The hydroxychloroquine dose must beadjusted for each patient. This is done by increasedthe dose slowly, starting with 100 mg every other day,then slowly increasing to a maximum dose of no morethan 200 mg twice per day. Most patients do well on100 mg once per day. Visual/eye exams should be doneperiodically as per manufacturer’s recommendations(See PDR).Miscellaneous11. Oral Activated Charcoal Activated charcoal absorbs fat-soluble porphyrins.Treatment with oral activated charcoal, which itselfis nonabsorbable, binds these porphyrins in thegastrointestinal tract and hence prevents them frombeing reabsorbed in the small intestine. Start with 2grams (eight 250 mg capsules) of activated charcoaltaken three times per day on an empty stomach (i.e., 2hours after and 2 hours before a meal). Graduallyincrease this to 4 grams taken three times per day.Much more activated charcoal can be safely taken; upto 20 grams six time a day for nine months has beentaken without any adverse side effects. It isimportant that this charcoal be taken on a completelyempty stomach without any food, vitamins, ormedications taken within 2 hours before or 2 hoursafter charcoal ingestion as the charcoal may absorbthe food, vitamins, or drugs as well as theporphyrins. Activated charcoal can be obtained from<puritanspride.com>.II. THERAPEUTIC REGIMEN FOR VITAMIN B12 DEFICIENCY Many patients with systemic/chronic chlamydialinfection appear to have a subtle and unrecognizedvitamin B12 deficiency at the cellular level. Thisfunctional B12 deficiency can be documented in anindividual patient by obtaining both a vitamin B12level (usually normal or low) and serum homocysteineand methylmalonate levels (one or both of thesemetabolites will be elevated). This vitamin B12deficiency can corrected by high-dose vitamin B12therapy as follows:1. Vitamin B12 Therapy Prior to Chlamydial Therapy Adults normally have approximately 3,000 mcg ofvitamin B12 in body stores, mostly in the liver.Initial vitamin B12 therapy before chlamydial therapyincludes replacement therapy for any vitamin B12deficit in these body stores. Therefore, over thefirst several days of antiporphyrin therapy, 6,000 mcgof parental (intramuscular or subcutaneous) vitaminB12 is given. For each of the next 3 weeks, 6,000 mcgof parental vitamin B12 is given once per week.2. Vitamin B12 Therapy During Chlamydial Therapy Chlamydial antimicrobial therapy is associated withincreased need for vitamin B12. Therefore, 6,000 mcgof parental vitamin B12 (3,000 mcg in each anteriorthigh) is given once per week while the patient isreceiving antimicrobial therapy for systemic/chronicchlamydial infection. This is in addition to the 5,000mcg of sublingual vitamin B12 taken three times eachday.3. Vitamin B12 Therapy Post Chlamydial Therapy Following the completion of antimicrobial therapy ofsystemic/chronic chlamydial infection, the vitamin B12and serum homocysteine/methylmalonate levels should berechecked. If the methylmalonate level remainselevated, it suggests a continued vitamin B12deficiency. Oral therapy with 5,000 mcg of sublingualcobalamin three times per day should be continued.After several months, 6,000 mcg of parental vitaminB12 may be given as a therapeutic trial. If thepatient’s energy is not increased by the parentaldose, continued therapy with sublingual vitamin B12 isprobably adequate. Periodic trials of parental vitaminB12 can be used to assess the sublingual therapy.See the following note and web site for additionalinformation on B12. Sublingual B12 can be obtainedfrom <puritanspride.com>.Below is an introduction from the article: "VitaminB12: Surprising New Findings" by Terri The whole article can be found at:http://www.lef.org/magazine/mag2000/dec2000_report_b12_1.htmlFor years, vitamin B12 languished as the vitamin thatcures anemia. Hardly any research was done into whatthis vitamin could do for non-anemic people. It turnsout that it may do a lot. New studies show that theright amount of B12 can protect against dementia,boost immune function, maintain nerves, regeneratecells and more. B12 is in the news because it lowershomocysteine and protects against atherosclerosis.It's also vital for maintaining methylation reactionsthat repair DNA and prevent cancer. One of the crucialareas for B12 is the brain. It's not surprising thatpeople with B12 deficiency develop mental disorders.The vitamin is crucial for the synthesis orutilization of important neuro-factors includingmonoamines, melatonin and serotonin. In addition, B12is absolutely critical for the function andmaintenance of nerves themselves. B12 is needed formethylation reactions that maintain these cells, andenable them to function. B12 contributes to brainfunction by lowering homocysteine. Homocysteine is atoxic by-product of methionine metabolism that candamage neurons. Importantly, homocysteine interfereswith the methylation reactions criticalfor brain function. Studies show that people withelevated homocysteine can't think.III. THERAPEUTIC ANTIMICROBIAL REGIMEN When the presence of chlamydia in the blood isdetected by blood culture and/or serum PCR and activeinfection is suspected per elevated IgM and IgGantibody titers, a presumptive diagnosis of systemic/chronic chlamydial infection can be made. Theantimicrobial regimen described is directed primarilyagainst the cryptic form of chlamydia, which explainsthe use of some agents that are not active againstreplicating organisms.Step 1: Patient education begins with an explanationof the clinical significance of the test results andthe potential for associated effects such as porphyriaand vitamin B12 deficiency. Additional laboratorytests may be useful in defining the extent of thechlamydial infection and associated metabolic/vitamindisorders. Initial blood work can be obtained for thefollowing tests: 1) CBC, 2) liver function tests, 3)uric acid, and 4) serum iron studies. Other usefultests include: red blood cell ALA dehydratase, redblood cell PBG deaminase, vitamin B-12 level, serumhomocysteine level, and serum methymalonate level. A24-hour urine and stool may be collected forporphyrins. Step 2: Next, the patient is placed on theantiporphyric regimen and vitamin B12 therapy. This iscontinued throughout the antimicrobial therapy and isan important component as it minimizes cellular damageand facilitates cellular repair. Step 3: Following initiation of the antiporphyricregimen, the first antimicrobial agent is started. Theantimicrobial agents are given in a stepwise fashionin order to minimize side effects. The first agent isamoxicillin (500 mg) and is given only once for thefirst week. It is then given daily twice a week (e.g.,Monday and Friday) on the second week, daily threetimes on the third (e.g., Monday, Wednesday, andFriday), and once daily on the fourth week. The sameschedule is followed for the second dose ofamoxicillin until 500 mg of amoxicillin is given twiceper day. The amoxicillin is then combined withprobenecid (500 mg). The same schedule is used for theprobenecid until it is being given twice per day. Ifthe patient is penicillin-allergic, penicillamine (125mg q 12 hours) can be substituted for the amoxicillin.As mentioned, it is best to start the amoxicillinfirst and then gradually add the probenecid. Again,this is done by giving amoxicillin once per day ononly one day for the first week, then twice a week,three times a week and then every day. The amoxicillinis then increased to twice per day using the sameschedule. The probenecid is added using the sameschedule. The patient is closely monitored on thesefirst two agents for side effects. These agents arecontinued for the entire course of chlamydial therapy.Step 4: After the patient has adjusted to theamoxicillin/probenecid therapy, additionalantimicrobial agents directed at cryptic andreplicating chlamydiae are added. These agents, likethe amoxicillin and probenecid, are introduced verygradually, being given initially once per day on onlyone day per week. Once an additional agents is welltolerated (This may take 2-4 weeks or longer.), theantimicrobial combination is increased to twice perweek, given on Monday and Friday with continuedmonitoring for side effects. After 2-4 weeks or moreof this twice-per-week combination therapy, theantimicrobial combination is increased to three timesper week, given on Monday, Wednesday, and Friday. Thistriweekly combination therapy is continued untiltolerated before being increased to daily therapy. The additional antimicrobial agents that can be addedto the amoxicillin/probenecid (or penicillamine)include a number of choices. These include rifampin(300 mg twice per day) azithromycin (250 mg MWF),clarithromycin (500 mg twice per day). Note that theazithromycin is given only on Monday, Wednesday, andFriday due to its long half-life. The combination ofamoxicillin, rifampin, and azithromycin seems to workquite well.Step 5: The duration of antimicrobial therapy may takemonths to years and is based on the results ofrepeated testing for the presence of chlamydiae.Repeat blood tests for chlamydia are recommended everysix months. The goal is a negative blood culture orwhole blood PCR for chlamydia (Blood collected incitrated tube.), negative IgM titers (< 1:50), and lowIgG titers (< 1:200) (Blood collected in red toptube.). IV. ANTI-INFLAMMATORY AGENTSChlamydial cell wall includes lipopolysaccharides(LPS) which can produce an inflammatory response ascell wall LPS is released when chlamydia are killed.In addition, the major outer membrane protein (MOMP)of chlamydia has been found to be a potent inducer ofcytokines. These antigens (LPS and MOMP) released bychlamydial cell death can produce an Herxheimer-likeinflammatory response that may be prolonged. As thisinflammatory response is related to chlamydial celldeath, it may be present over many months. It can beminimized by adding the antimicrobial agents in a slowstepwise manner. This prolonged inflammatory responsemay be a problem for which anti-inflammatory agents,up to and including steroids, may be useful. Inparticular, newer anti-inflammatory agents such asCelebrex (200 mg once per day) appear to be veryuseful in this regard.

[Guest guest]

/Penny/Jim

What is the ideal treatment of porphyria? Would dialysis as in

kidney failure make a difference to porphyria?I alway's speculated

that we possably need serious attempts at cleaning our blood of by

products of bacteria and toxins.This porphyria sounds like a

strategy that may be desigtned to fix some of this. I'm not a huge

fan of detox chemicals bel;ieveing they really don't work. I would

think a fasting regime would be more cleansing than just topping up

with chemicals.

I believe the clay and charcoal would be a bonus so I'm not knocking

everything. I just prefer to clean my blood like a patient on

dialysis because they KNOW They feel better afterwards. We are

constantly speculating about feeling better after throwing something

in the mix.

It's a little like those oil additives that are supposed to helpo

your engine when commonsense alway's see's that an oil change at the

right intervals is far more appropriate.

> Thank you, Jim. I appreciate you posting this.

>

> [infections] Stratton's Treatment

Recommendations

>

>

> Someone on the MS forum sent me a Word doc which is a

> handout Stratton et al offer for their treatment

> protocal, pending their completed research. This

> person noted: " Some of it, like the

> antibiotic regimen, needs updating- he's currently

> using Minocycline/Zithromax/Flagyl (with, " consider

> Amoxicillin as well " ), but what this handout does

> have, is the current instructions for managing the

> treatment of the infection- diet, supplements, etc. "

>

> I'm hoping I can get this in on one email, if not I'll

> break it up as it's long. Wheldon sent me a draft of a

> paper he's submitting for publication, and I'll pass

> on what I glean from it also.

>

> THERAPY OF CHRONIC CHLAMYDIAL INFECTIONS INCLUDING

> THEIR ASSOCIATED PORPHYRIA AND VITAMIN B12 DEFICIENCY:

> SEVENTH VERSION

>

> W. Stratton, MD

> M. , MD PhD

> Vanderbilt University School of Medicine

> Nashville, Tennessee 37232

>

>

> IMPORTANT DISCLAIMER

> Currently there are protocols for appropriate clinical

> trials for the therapy of a number of different forms

> of systemic/chronic chlamydial infections being

> prepared at Vanderbilt. The preliminary suggestions

> for chlamydial therapy that are contained within this

> document have been gleaned from early therapy for

> compassionate reasons and may not represent the final

> therapy. The use of these suggestions is similarly for

> compassionate therapy of patients suspected of having

> a systemic/chronic chlamydial infection.

>

> I. THERAPEUTIC REGIMEN FOR SECONDARY PORPHYRIA

> Systemic/chronic chlamydial infections have been

> noted to have an associated secondary porphyria.

> Porphyrins, including water-soluble porphyrins (e.g.,

> delta-aminolevulinic acid and porphyrobilinogen) and

> fat-soluble porphyrins (e.g., coproporphyrin III and

> protoporphyrin) may produce clinical episodes of

> porphyria. The presence of such porphyrins in an

> individual patient with chronic/systemic chlamydial

> infection can be confirmed pre- and during therapy by

> appropriate porphyrin tests such as obtaining 24-hour

> urine and 24-hour stool specimens for porphyrins.

> It is recommended that a therapeutic regimen

> addressing porphyria should be instituted along with

> the use of antimicrobial agents. This therapeutic

> regimen is aimed at controlling the

> chlamydial-associated secondary porphyria that may be

> present prior to antimicrobial therapy and/or may be

> triggered or increased during antimicrobial therapy of

> the chlamydial infection. This " porphyric reaction " to

> antimicrobial therapy should be recognized as such and

> differentiated from an expected cytokine-mediated

> immune response. Specific measures for the therapy of

> porphyria as derived from published medical literature

> on porphyria are employed and include:

>

> 1. High Carbohydrate Diet

> Approximately 70% of the daily caloric intake should

> be in the form of complex carbohydrates such as those

> found in bread, potato, rice, and pasta. The remaining

> 30% of calories in protein and fat ideally should be

> in the form of white fish or chicken.

> 2. High Oral Fluid Intake

> Drink plenty of oral fluids in the form of water

> (e.g., bicarbonated water or " sports-drinks " [water

> with glucose and salts]). This helps flush

> water-soluble porphyrins. Moreover, dehydration

> concentrates porphyrins and makes patients more

> symptomatic. The color of the urine should always be

> almost clear rather than dark yellow.

> 3. Avoid Red Meats

> Red meats, including beef and dark turkey as well as

> tuna and salmon contain tryprophan and should be

> avoided as much as possible.

> 4. Avoid Milk Products

> Milk products contain lactose and lactoferrin, both

> of which should be avoided as much as possible.

> 5. Glucose, Sucrose and Fructose

> Glucose is an important source of cellular energy:

> cellular energy is reduced with chlamydial infections.

> Increasing the availability of glucose provides

> optimal conditions for the cells to produce energy.

> However, sucrose is not the best way to increase the

> glucose availability. Sucrose is a mixture of glucose

> and fructose. Fructose is the sugar contained in

> fruit. Because high levels of fructose act as a signal

> to the liver to store glycogen, an excess of fructose

> may temporarily reduce the availability of glucose at

> the cellular level. Fructose should be avoided as much

> as possible. Instead, " sports-drinks " containing

> glucose (as well as containing important

> cations/anions) can be used. Glucose tablets also can

> be used.

> 6. Avoid Alcohol.

> Alcohol is a well-known aggravator of porphyria and

> should be avoided as much as possible.

>

> Vitamins/Antioxidants/Supplements

> 7. B-Complex Vitamins

> Glucose is needed by host cells that are infected by

> chlamydiae. The availability of glucose to the host is

> assisted by taking B-complex vitamins. These include

> folic acid (400 mcg twice per day), vitamin B-1

> (thiamin 10 mg twice per day), vitamin B-2 (riboflavin

> 10 mg twice per day), vitamin B-5 (pantothenate 100 mg

> twice per day), vitamin B-6 (pyridoxine 100 mg twice

> per day or pyridoxal-5 phosphate 25 mg twice per day),

> and vitamin B-12 (5000 mcg sublingual three to six per

> day).

> 8. Antioxidants

> Antioxidants and related agents should be taken twice

> per day. These should include vitamins C (1 gram twice

> per day) and E (400 units twice per day) as well as

> L-carnitine (500 mg twice per day), ubiquinone

> (coenzyme Q10; 30 mg twice per day), biotin (5 mg

> twice per day), and alpha-lipoic acid (400 mg twice

> per day). Bioflavinoids (also called proanthocyanidins

> of which pygnoginol and quercetin are two examples)

> are very effective antioxidants. Selenium (100 mcg

> twice per day) should be taken with the vitamin E.

> L-Glutamine (2 - 4 grams twice per day), querceten

> (400 - 500 mg twice per day), glucosamine (750 - 1000

> mg two or three times per day) and chondroitin sulfate

> (250 - 500 mg twice per day) should also be included.

>

> Antiporphyrinic Drugs

> 9. Benzodiazapine Drugs

> The specific benzodiazapine drugs used depends, in

> part, on the symptoms. For example, if panic attacks

> are the problem, xanax (0.5 mg three or four times per

> day) can be used. If sleeping is a problem, restoril

> (30 mg at night) can be used.

> 10. Hydroxychloroquine

> Hydroxychloroquine (100 - 200 mg once or twice per

> day) is often used to treat porphyria. For patients

> with symptoms of porphyria, a single 100 mg dose of

> hydroxychloroquine may be tried. If this trial dose

> relieves the symptoms, hydroxychloroquine may be

> continued. The hydroxychloroquine dose must be

> adjusted for each patient. This is done by increased

> the dose slowly, starting with 100 mg every other day,

> then slowly increasing to a maximum dose of no more

> than 200 mg twice per day. Most patients do well on

> 100 mg once per day. Visual/eye exams should be done

> periodically as per manufacturer's recommendations

> (See PDR).

>

> Miscellaneous

> 11. Oral Activated Charcoal

> Activated charcoal absorbs fat-soluble porphyrins.

> Treatment with oral activated charcoal, which itself

> is nonabsorbable, binds these porphyrins in the

> gastrointestinal tract and hence prevents them from

> being reabsorbed in the small intestine. Start with 2

> grams (eight 250 mg capsules) of activated charcoal

> taken three times per day on an empty stomach (i.e., 2

> hours after and 2 hours before a meal). Gradually

> increase this to 4 grams taken three times per day.

> Much more activated charcoal can be safely taken; up

> to 20 grams six time a day for nine months has been

> taken without any adverse side effects. It is

> important that this charcoal be taken on a completely

> empty stomach without any food, vitamins, or

> medications taken within 2 hours before or 2 hours

> after charcoal ingestion as the charcoal may absorb

> the food, vitamins, or drugs as well as the

> porphyrins. Activated charcoal can be obtained from

> <puritanspride.com>.

>

>

>

> II. THERAPEUTIC REGIMEN FOR VITAMIN B12 DEFICIENCY

> Many patients with systemic/chronic chlamydial

> infection appear to have a subtle and unrecognized

> vitamin B12 deficiency at the cellular level. This

> functional B12 deficiency can be documented in an

> individual patient by obtaining both a vitamin B12

> level (usually normal or low) and serum homocysteine

> and methylmalonate levels (one or both of these

> metabolites will be elevated). This vitamin B12

> deficiency can corrected by high-dose vitamin B12

> therapy as follows:

> 1. Vitamin B12 Therapy Prior to Chlamydial Therapy

> Adults normally have approximately 3,000 mcg of

> vitamin B12 in body stores, mostly in the liver.

> Initial vitamin B12 therapy before chlamydial therapy

> includes replacement therapy for any vitamin B12

> deficit in these body stores. Therefore, over the

> first several days of antiporphyrin therapy, 6,000 mcg

> of parental (intramuscular or subcutaneous) vitamin

> B12 is given. For each of the next 3 weeks, 6,000 mcg

> of parental vitamin B12 is given once per week.

> 2. Vitamin B12 Therapy During Chlamydial Therapy

> Chlamydial antimicrobial therapy is associated with

> increased need for vitamin B12. Therefore, 6,000 mcg

> of parental vitamin B12 (3,000 mcg in each anterior

> thigh) is given once per week while the patient is

> receiving antimicrobial therapy for systemic/chronic

> chlamydial infection. This is in addition to the 5,000

> mcg of sublingual vitamin B12 taken three times each

> day.

> 3. Vitamin B12 Therapy Post Chlamydial Therapy

> Following the completion of antimicrobial therapy of

> systemic/chronic chlamydial infection, the vitamin B12

> and serum homocysteine/methylmalonate levels should be

> rechecked. If the methylmalonate level remains

> elevated, it suggests a continued vitamin B12

> deficiency. Oral therapy with 5,000 mcg of sublingual

> cobalamin three times per day should be continued.

> After several months, 6,000 mcg of parental vitamin

> B12 may be given as a therapeutic trial. If the

> patient's energy is not increased by the parental

> dose, continued therapy with sublingual vitamin B12 is

> probably adequate. Periodic trials of parental vitamin

> B12 can be used to assess the sublingual therapy.

> See the following note and web site for additional

> information on B12. Sublingual B12 can be obtained

> from <puritanspride.com>.

>

> Below is an introduction from the article: " Vitamin

> B12: Surprising New Findings " by Terri

>

> The whole article can be found at:

> http://www.lef.org/magazine/mag2000/dec2000_report_b12_1.html

>

> For years, vitamin B12 languished as the vitamin that

> cures anemia. Hardly any research was done into what

> this vitamin could do for non-anemic people. It turns

> out that it may do a lot. New studies show that the

> right amount of B12 can protect against dementia,

> boost immune function, maintain nerves, regenerate

> cells and more. B12 is in the news because it lowers

> homocysteine and protects against atherosclerosis.

> It's also vital for maintaining methylation reactions

> that repair DNA and prevent cancer. One of the crucial

> areas for B12 is the brain. It's not surprising that

> people with B12 deficiency develop mental disorders.

> The vitamin is crucial for the synthesis or

> utilization of important neuro-factors including

> monoamines, melatonin and serotonin. In addition, B12

> is absolutely critical for the function and

> maintenance of nerves themselves. B12 is needed for

> methylation reactions that maintain these cells, and

> enable them to function. B12 contributes to brain

> function by lowering homocysteine. Homocysteine is a

> toxic by-product of methionine metabolism that can

> damage neurons. Importantly, homocysteine interferes

> with the methylation reactions critical

> for brain function. Studies show that people with

> elevated homocysteine can't think.

>

> III. THERAPEUTIC ANTIMICROBIAL REGIMEN

> When the presence of chlamydia in the blood is

> detected by blood culture and/or serum PCR and active

> infection is suspected per elevated IgM and IgG

> antibody titers, a presumptive diagnosis of systemic/

> chronic chlamydial infection can be made. The

> antimicrobial regimen described is directed primarily

> against the cryptic form of chlamydia, which explains

> the use of some agents that are not active against

> replicating organisms.

> Step 1: Patient education begins with an explanation

> of the clinical significance of the test results and

> the potential for associated effects such as porphyria

> and vitamin B12 deficiency. Additional laboratory

> tests may be useful in defining the extent of the

> chlamydial infection and associated metabolic/vitamin

> disorders. Initial blood work can be obtained for the

> following tests: 1) CBC, 2) liver function tests, 3)

> uric acid, and 4) serum iron studies. Other useful

> tests include: red blood cell ALA dehydratase, red

> blood cell PBG deaminase, vitamin B-12 level, serum

> homocysteine level, and serum methymalonate level. A

> 24-hour urine and stool may be collected for

> porphyrins.

> Step 2: Next, the patient is placed on the

> antiporphyric regimen and vitamin B12 therapy. This is

> continued throughout the antimicrobial therapy and is

> an important component as it minimizes cellular damage

> and facilitates cellular repair.

> Step 3: Following initiation of the antiporphyric

> regimen, the first antimicrobial agent is started. The

> antimicrobial agents are given in a stepwise fashion

> in order to minimize side effects. The first agent is

> amoxicillin (500 mg) and is given only once for the

> first week. It is then given daily twice a week (e.g.,

> Monday and Friday) on the second week, daily three

> times on the third (e.g., Monday, Wednesday, and

> Friday), and once daily on the fourth week. The same

> schedule is followed for the second dose of

> amoxicillin until 500 mg of amoxicillin is given twice

> per day. The amoxicillin is then combined with

> probenecid (500 mg). The same schedule is used for the

> probenecid until it is being given twice per day. If

> the patient is penicillin-allergic, penicillamine (125

> mg q 12 hours) can be substituted for the amoxicillin.

>

> As mentioned, it is best to start the amoxicillin

> first and then gradually add the probenecid. Again,

> this is done by giving amoxicillin once per day on

> only one day for the first week, then twice a week,

> three times a week and then every day. The amoxicillin

> is then increased to twice per day using the same

> schedule. The probenecid is added using the same

> schedule. The patient is closely monitored on these

> first two agents for side effects. These agents are

> continued for the entire course of chlamydial therapy.

>

> Step 4: After the patient has adjusted to the

> amoxicillin/probenecid therapy, additional

> antimicrobial agents directed at cryptic and

> replicating chlamydiae are added. These agents, like

> the amoxicillin and probenecid, are introduced very

> gradually, being given initially once per day on only

> one day per week. Once an additional agents is well

> tolerated (This may take 2-4 weeks or longer.), the

> antimicrobial combination is increased to twice per

> week, given on Monday and Friday with continued

> monitoring for side effects. After 2-4 weeks or more

> of this twice-per-week combination therapy, the

> antimicrobial combination is increased to three times

> per week, given on Monday, Wednesday, and Friday. This

> triweekly combination therapy is continued until

> tolerated before being increased to daily therapy.

> The additional antimicrobial agents that can be added

> to the amoxicillin/probenecid (or penicillamine)

> include a number of choices. These include rifampin

> (300 mg twice per day) azithromycin (250 mg MWF),

> clarithromycin (500 mg twice per day). Note that the

> azithromycin is given only on Monday, Wednesday, and

> Friday due to its long half-life. The combination of

> amoxicillin, rifampin, and azithromycin seems to work

> quite well.

> Step 5: The duration of antimicrobial therapy may take

> months to years and is based on the results of

> repeated testing for the presence of chlamydiae.

> Repeat blood tests for chlamydia are recommended every

> six months. The goal is a negative blood culture or

> whole blood PCR for chlamydia (Blood collected in

> citrated tube.), negative IgM titers (< 1:50), and low

> IgG titers (< 1:200) (Blood collected in red top

> tube.).

>

> IV. ANTI-INFLAMMATORY AGENTS

> Chlamydial cell wall includes lipopolysaccharides

> (LPS) which can produce an inflammatory response as

> cell wall LPS is released when chlamydia are killed.

> In addition, the major outer membrane protein (MOMP)

> of chlamydia has been found to be a potent inducer of

> cytokines. These antigens (LPS and MOMP) released by

> chlamydial cell death can produce an Herxheimer-like

> inflammatory response that may be prolonged. As this

> inflammatory response is related to chlamydial cell

> death, it may be present over many months. It can be

> minimized by adding the antimicrobial agents in a slow

> stepwise manner. This prolonged inflammatory response

> may be a problem for which anti-inflammatory agents,

> up to and including steroids, may be useful. In

> particular, newer anti-inflammatory agents such as

> Celebrex (200 mg once per day) appear to be very

> useful in this regard.

>

>

>

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