DSF, dose, activated charcoal managing the Herxheimer reaction

My patient is feeling optimistic. The best she has felt in years.  Disulfiram/Antabuse, AKA DSF is the game changer.  She takes a tiny amount.  I prescribed 10 mg compounded capsules, a very low dose. She started with one capsule every 4 days and has increased the dose to 2 caps, 20 mg daily. She reacts to this small dose, significantly.

She feels OK the first day of disulfiram pulse. The second day she is assaulted with a variety of symptoms: fatigue, brain fog, muscle/joint pain, shooting pains, muscle twitching, head pressure, etc. She feels increasingly better over the next 4 days and the cycle repeats.
She is happy. No longer depressed. Really happy.

She tells me she manages the second day Herxheimer reaction with doses of activated charcoal.
I’m naturally skeptical.  Everything has to make sense. Scientifically and logically.

Herxheimer reactions are modulated by the immune system, something like a cytokine storm. This is all very complicated so let’s not get lost in the weeds. These cytokines are a complex set of proteins which regulate activity of the immune system (traffic the immune system). When Lyme is killed cytokines and the immune system are kicked into high gear. This leads to inflammation, too much inflammation, a bad thing. We need to reduce cytokine activity and/or cytokines themselves.

It’s exciting to learn that activated charcoal is incredibly effective at binding cytokines. When blood is filtered through activated charcoal cytokines are removed.

How does that help us? Blood has to be removed from your body and filtered. Not likely. Activated charcoal is the “universal antidote” and good for reducing bloating and gas. It stays in the gut. It does not get into the blood where cytokines live.

Ah ha. Like cholestyramine, it interferes with the natural recycling of bile (from the liver) to the intestines and back to the liver. OK. And..

A published study looked at oral charcoal in mice loaded with malaria and treated with an intravenous antimalarial drug.  Charcoal reduced brain swelling and reduced key cytokines. Gut only charcoal did all this. 

Cytokines may be cycled through enterohepatic pathway and processed through the intestines.  Charcoal may be there waiting to gobble them up. (Conjecture on my part).
I finally have an idea why Wellchol/cholestyramine lowers C-reactive protein. CRP is cytokine driven.

Normal functioning of the enterohepatic pathway impacts the concentration of medicines, toxins and other substances present in serum. I discussed this in another post. Messing with the enterohepatic re-circulation of bile can do good and bad things. This is a very complex and vital part of our physiology.

The best treatment for Herxheimer reactions may be antioxidants (oxidative stress) and activated charcoal.

I do listen to my patients and believe what they say. I worry that many desperate patients are taken advantage of by various scams. I worry about overpromoted nostrums, a mass placebo effect.  Think-- The Emperor’s New Clothes.

My patient today snickered at my skepticism.  I am humbled.  She was right and I was wrong.

I still want people to stop think Herxheimer reactions are caused by toxins and cholestyramine/Wellchol and charcoal remove toxins. Speaking of  toxins specific to the Herxheimer reaction. This does not make scientific sense. (I am not saying other toxins are not removed, I am speaking of the mechanism of the Herxheimer response).

Yes, the best starting dose (and ending up dose) of disulfiram is variable.  Starting low is a good idea. 10 mg seems to be a good starting place, for sensitive patients. Options include 25 mg, 62.5 mg and others generally are well tolerated.  Gradually increasing the dose likely mitigates damage caused by an overly eager immune system.

Take home points:  DSF, start low.  Herxheimer reactions -- antioxidants and charcoal.
Also, if you had a bad reaction with a higher dose of DSF you may do well with a small starting dose.