As we have more people on the CAPi protocolsi longer, our community is accruing clincal priceless experience with the different medications used and course of improvement and diffficulties on the CAP. One of these areas for observation and discussion has been use of Tinidazole versus Flagyli, and it's effect on treatment and course of recovery. There has been another thread discussing these, but I thought it was time to restart the discussion now that a number of people have experienced switching back and forth between these meds. So my own comments (posted on Rica's blog also) below.

Tini vs Flagyl-- interesting questions.

I have to say, after doing Tini since pulse 3 and then trying Flagyl again for my last pulse (pulse 16) they do have different effects. Not just different side effects. It is possible, as our clinical experience accumulates, that there could even be good reason to do courses of both, or alternate them for pulses.

Post pulse reactions are a bit of a mystery. Please help us to gather some preliminary data about reactions CAPi users attribute to a pulse of metronidazolei or tinidazole by completing this survey.

YOU MUST BE LOGGED IN AS A REGISTERED USER FIRST OR YOUR SURVEY DATA WON'T SUBMIT!

If you haven't done a pulse yet, await ye the results!

What follows is an interview with a physician who has significant expertise in treating Cpni who has closely followed the Vanderbilt research over the years. He has garnered a lot of clinical experience, and his insights provide a lot of information both for patients and physicians who are looking to treat for Cpn. He prefers to remain anonymous. We’ll call him Dr. A for this interview.

Testing for Cpn
JimK- So what about serological testing for Cpn?
Dr. A-Testing for Cpn is only useful if you get a positive result. Because Cpn is an intracellulari pathogen, PCRi testing may be negative unless infected cells containing the DNA of the organism are directly tested. That is a problem for any PCR or antigen forms of testing. Serological testing has two problems. The first is that by middle age, most people have been exposed to Cpn and will have IgGi titers against this organism. If you are exposed and have a positive titer, then you most likely have a persistent infection somewhere, but this infection may not be causing symptoms. Thus, a positive serological test cannot distinguish asymptomatic persons from symptomatic persons. The second problem is that even persons with culture-proven Cpn in their coronary arteries only had a 35% positive rate by serological testing in a study done in Germany.
The most sensitive test appears to be reverse transcriptase PCR testing for messenger RNA produced by infected cells. This testing, for example, showed 18.5% of blood donors to have messenger RNA from Cpn in their peripheral blood mononuclear cells.  

JIMK- So there’s no easy way to test for the intracellular phase of Cpn?
Dr. A- It’s very difficult to test for the intracellular phase because the organism isn’t readily available to be tested unless you have infected cells to be tested. Testing for messenger RNA from infected cells appears to be the most sensitive method. However, this method is not commercially available.

JIMK- So PCR is just the most sensitive test for detecting DNA or RNA floating around in the serum or tissues.
Dr. A- If you test for antibodies you are testing for the response of the patient. If you test with PCR you are testing for DNA or RNA from the actual organism.

JIMK- You have said that they are useful if they are positive, but not particularly useful if they are negative.
Dr. A- Right

JIMK- That’s when you might decide to do an empirical course of treatment or something?
Dr. A- Exactly.

Empirical Diagnosis
JIMK- When you make a medical judgment on that, is it based on the disease? Are there also sets of symptoms you might be looking at? In David Wheldoni’s web site, he refers to history of respiratory illness. Are there other useful indicators?

Dr. A- The problem is that there are no symptoms that will hone in specifically on chronic Cpn infection. So if you have a suspicion, based on symptoms or the disease process, you begin with serologyi. And if you have positive serologyi then you may feel you have something to treat. If you don’t have positive serology and you are still convinced that Cpn is causing infection, then my approach would be to try a combination antibiotic protocol empirically, and if the patient has the side effects seen with the so-called “die-off” effect, such as those David Wheldon has described in his WebSite (Ed: these reactions typical of endotoxaemia include fever, chills, sweating, and muscle pains, coryza, widespread arthralgia and myalgia, and temporary worsening of neurological symptoms) then they may well have a Cpn infection. Once you treat for Cpn infection, all these side effects eventually go away!

JIMK- What about Borrellia that creates similar side affects when treated with metronidazolei? Any way to distinguish based on symptoms? I suggested to one person that porphyriai might be a distinguishing factor, any others?)
Dr. A- Metronidazole shouldn’t cause these effects, as it has no activity against Borrellia. It is probably killing Cpn. (Ed. Actually, this is not accurate. Dr. A does not treat Borrellia and was at this time unfamiliar with the way Flagyl is active against the cystic form of Borrellia- see Brorson & Brorson 2004, 1999. In I have been told that some Lyme doctors are using Wheldon's protocol as a primary Lyme Disease treatment. It is true that co-infection of Lyme and Cpn may be an unsuspected complication).

Length of Treatment
JIMK- I’ll tell you, it seems it can take quite a while…
Dr. A- It can take years, much as the initial treatment for tuberculosis did. It’s just like treating tuberculosis in that it takes many months to years of combination therapy.

JIMK- It Seems like people respond faster or slower.
Dr. A- People respond at different rates, which probably has to do with how much Cpn they have, what tissues are infected, and how good their immunei system is.

JIMK- Supposedly, you’re recovering your immune system function over time from disinfecting the monocytes and macrophages. It seems, just from being on it myself for 10-11 months that different tissues get reached at different times. Also, that different agents reach different tissues. When I added amoxicillini to the doxyi/zithi/tinadazole I got a big flare up in body areas I had not had pain in for a while. It surprised me how much additional effect I had, since I’d been on antibioticsi so long.

That’s one of the questions I had. The different protocolsi use different combinations of antibiotics. Do you find different effectiveness in different antibiotics, or is it more a practical matter of what’s available?
Dr. A- I think there are differences in tissue penetration, as well as a lot of other factors that aren’t yet clear.

Choice of antibiotics
JIMK Do you just tend to have a preference starting with certain antibiotic with a patient?
Dr. A- I’m pretty pragmatic and generally use the least expensive and safest antibiotics. I start them on: doxycyccline (Dr. A will attend to patient reaction and have them work up to 100mg twice a day over longer or shorter period, depending on tolerance with any of these medicines), and then I add azithromycin 250 mg working up to once per day Monday/Wednesday/Friday, I work up to 500 mg twice a day for metronidazole. I’ll finally add 300 mg twice a day of Rifamcini to that.
But I may start out working up to 500 mg twice a day of amoxicillin rather than doxycycline.

JIMK you start out with that because it’s the easiest on the patient?
Dr. A- It’s cheap, safe, and tolerated the best. Then after a month or two add the azithromycin Monday/Wednesday/Friday for a month, then the doxycycline, see how they do on all three. I’ve generally added the metronidazole into this and see how they do. I wouldn’t mind pulsing it as David Wheldon does in his protocol (Ed. This is a reference to the Wheldon protocol’s method of pulsing the metronidazole for 5 days every 3 weeks). By pulsing, you can give them time to recover from the side effects.

JIMK- But it sounds like you used to give the metronidazole as a constant, then?
Dr. A- Yes, that’s generally how I proceed.

JIMK- That’s one drug, the metronidazole, that I had the hardest time tolerating.
Dr. A- You think that one’s tough, wait until you get to the Rifamcin!

JIMK- That’s one my doctor isn’t real enthused about giving me (the Rifamcin). Not sure exactly why.
Dr. A- Well, most physicians aren’t familiar with it unless they’ve treated TB.

JIMK- Do you think the Rifamcin is a necessary one for this protocol?
Dr. A- Let me tell you what Rifamcin specifically does. When chlamydial EB’s germinate and transform into the RB’s, which is the replicating form, the first enzyme out of the EB’s is DNA-dependent-RNA-polymerase that Rifamcin specifically blocks.
EB’s are like spore-like infectious form of Cpn. The cryptic formi is also different to treat; it is metabolizing but is not replicating (Ed. The cryptic form is what the metronidazole is directed at, since it is metabolizing but in an anaerobic mode. Our expert is noting here that the EB’s are not metabolizing nor replicating, therefore are not affected by antibiotics that interfere either with bacterial metabolism or with bacterial replication. They are effected only by disulphide reducing agents, like amoxicillin, which breaks the disulphide latice bonds of the EB cell membrane). If you have a large EB load you’re going to keep getting cells reinfected. If you stop them before they start, that’s much better than letting them get started and then trying to kill them.

JIMK- So doxy/zith is inhibiting the replicating form?
Dr. A- Yes. Remember, you are trying to formulate a combination therapy that attacks all of the potential forms of Cpn. And so, N-formyl-penicillamine, which amoxicillin is metabolized to in the body, destroys the EB. It is these spore-like, non-replicating, EB’s, which invade your body’s cells and once inside transform into RB’s capable of replicating. In this transformation the first enzyme employed is DNA-dependent-RNA-polymerase, which allow this transformation. If they are in the RB replicating form, then azithromycin and doxycycline will interfere with that. If they are in cryptic form then metronidazole goes after that. If they are EB’s the amoxicillin takes care of that. If they are transforming from EB’s to RB’s, where they are particularly vulnerable, Rifamcin takes care of that. It takes a lot of different antibiotics because there are lots of different life forms. Otherwise it just goes from one life form to the next.

JIMK- So, adding the Rifamcin is to be as complete as possible?
Dr. A- It is hard to say if you can get by without the amoxicillan, or the Rifamcin. I suspect that you can in younger healthy persons. I tend to think that they are especially important for those who have been sick for a long time, and likely have a lot of EB’s looking for homes. I want to destroy these EB’s (amoxicillin) or if they are finding homes I want to short-circuit them (Rifamcin). The transformation from EB to RB is where they are particularly vulnerable.

JIMK- That is really important information to get out there. Especially for those of us who have, indeed, been sick with this for a long time. I knew when I added the amoxicillin to the Wheldon protocol that I was killing something additional. And it was so clearly, highly inflammatory too; by the amount of pain and inflammationi I had in reaction to it.
Dr. A- You probably have a high EB load. Those were probably Elementary Bodies that you were destroying. By the way, you can use penicilamine directly, but that’s a very scary drug.

JIMK- And that tends to dump a big load of the endotoxini when they get popped?
Dr. A- That and a lot of other antigens. The response to the antigens is somewhat dependent on your body’s immune system.

JIMK- So you’re getting a cytokinei reaction.
Dr. A- Yes.

JIMK- Do you find tinidazole as effective as metronidazole?
Dr. A- I don’t see why it wouldn’t be. It’s just been recently approved in the US, so I have no experience with it, or what they are charging for it!

JIMK- I find I tolerate it much better than metronidazole. I got so sick on that, which I believe is more a drug side effect than a kill effect.
Dr. A- Well, I wouldn’t necessarily see it that way. My experience is that people who don’t have any Cpn organisms can tolerate metronidazole without any side effects. You’re talking to someone who has had patients taking metronidazole as a post treatment preventative for a number of years without side effects.

JIMK- So your bet then would be that I got sick from the metronidazole because it was killing cryptic Cpn, not because of drug side effects (Ed. which would suggest that tinidazole is not as potent in this as metronidazole).
Dr. A- There are two explanations as to why you are tolerating tinidazole better. One is that you just knocked down enough of your Cpn load with the earlier metronidazole pulses. And people have done that; they say they can’t tolerate the metronidazole and then after a time they can. The other is that you were getting better penetration with the metronidazole than with the tinidazole.

JIMK- So it may be that the tinidazole is not quite as strong, so it may be a good way to gear up over time to the metronidazole.
Dr. A- Yes, but if you were to try metronidazole for a couple weeks and you didn’t get any side effects, then you probably don’t have much Cpn.

Brain Fog
JIMK- You see brain fog a lot in Cpn patients; do you see this as CNSi involvement or more as an effect of endotoxin?
Dr. A- It is most likely a combination of endotoxinsi, porphyrins, and cytokinesi. It may largely be porphyrins for the simple reason that reactions from porphyrins last longer than those from cytokines and there’s no fever.

And you know you are better when…?
JIMK- So that’s the kind of “gold standard” test: that you can take metronidazole and not get hammered?
Dr. A- And Rifamcin. Rifamcin has deep tissue penetration too. So if you can tolerate the metronidazole and then I challenge you with Rifamcin and you tolerate that as well, you have very few Cpn left. I periodically challenge patients with a short course containing metronidazole and Rifamcin to see if they continue to be cleared of Cpn.

JIMK- The complete challenge.
The more I understand, the more I appreciate how tough a bug this is, and long it takes to get it, how complex it is, and all the tissues you need to penetrate to get there.
Dr. A- Not only the tissue penetration, but also both the organism and your cells have active efflux pumping mechanisms to pump out the antibiotic. You have to work against these natural mechanisms to keep adequate concentrations in the cells. Rifamcin tends to inhibit these efflux pumps. I also use another drug, Quercetin, a bioflavonoid that also acts as a cell efflux inhibiter. It works on a different efflux pump than Rifamcin. It’s, also active against Chlamydia on it’s own.

JIMK- Plus Quercetin is also an anti-inflammatory and free radical quencher.
Dr. A- But the antichlamydial effect may be more important than it’s anti-inflammatory effect.

JIMK- How much Quercetin do you use a day—I tend to take three caps with the bromelain.
Dr. A- I tend to use 2 caps a day containing 500 mg of Quercetin along with vitamin C.

Differences in treating different diseasesi?
JIMK- Do you see differences in treatment based on disease entity, or more on the person.
Dr. A- That’s hard to say. My generalization is that: the longer the person’s been sick and the sicker the person has been, the more problematic the therapy is going to be. In addition, the older the person is, the more likely that they’ve had a Cpn load building for a long time without knowing it. Their ability to tolerate treatment can be low, both from the high Cpn load, and from an aging immune system. On the other hand, I know of a young patient who had a very strong family history of cardiac disease. For this reason, his doctor placed him on the regimen. He had very few reactions. He was in his early 30’s.

JIMK- He had some reactions, which let you know that he had some Cpn building.
Dr. A- Yes.
JIMK- I know in my family there’s both cardiac disease and Alzheimer’s, and another sibling has fibromyalgiai. So there may be a common link genetically that is more about the susceptibility to Cpn.
Dr. A- AOE4 probably has a place in Cardiac disease, Alzheimer’s and MS.
I’ve observed that the recent memory problems that come with brain fog for patients can really lift once the Chlamydia is gone, even in those 50 or more.

Porphyria
JIMK- On the porphyrin stuff- do you think the porphyrin testing is worthwhile, or do you just assume it and treat for it anyway when you are treating for Cpn?
Dr. A- The trouble is that you really have to test for the fat soluble porphyrins to get the best data, and that involves a 24-hour stool test, and you have to freeze that sample and so on. You need a 24-hour urine to look for water-soluble porphyrins.
There is a poor man’s way to check for porphyrins. It seems that if you have porphyrins, you will have an increased hemoglobin level, on the high end of normal on most CBC’s.

JIMK- when I was first treated I was very low on iron, which I understand is heavily used by chlamydial metabolism. Would that make a problem for using hemoglobin’s as an indicator of porphyrins?
Dr. A- Initially, low iron would mask the increased hemoglobin you would expect with porphyrins. Once your iron levels are normal, it would no longer mask the elevated hemoglobin. But in general, a high-normal hemoglobin and high-normal hematocrit are both good indicators of porphyrins.

JIMK- I can’t tell you how unusual it is to speak to a physician who sees it his or her job to actually investigate and reason out what’s going on in a patient, rather than look to see which already-known-box to put them in. I spoke to David Wheldon about that and he said, “Yes, I know, if I’d listened to those doctors I would be a widower now.” Kind of put home the point.