Steps of the Shoemaker Protocol

Once the diagnosis of Chronic Inflammatory Response Syndrome (CIRS) from water damaged buildings has been established by history, physical, and labs, the Shoemaker protocol is the only peer reviewed published protocol shown to reverse the symptoms and laboratory findings. The steps are as follows:

Remove exposure from water damaged buildings

For many people, this is the most critical, yet most difficult step. Dr. Shoemaker has shown that the best test for determining the safety of a building is an ERMI test from Mycometrics. The ERMI stands for the Environmental Relative Moldiness Index. It is a quantitative PCR analysis that looks at spore equivalents of 36 species of mold. Shoemaker has determined from his database of thousands of patients that the cutoff for safety is an ERMI score of 2 if the MSH is < 35 and C4a is less than 20,000 and 0 if the C4a is greater than 20,000. He later developed a derivative of the ERMI score looking at 5 species, which he calls HERTSMI-2. This test is also done at Mycometrics and the cutoff for safety is a HERTSMI-2 of 10 for someone previously sickened by a water damaged building . More information can be found at http://www.survivingmold.com/diagnosis/hertsmi-2

I recommend that my patients test buildings that they spend a great deal of time at which usually includes their homes and workplaces. If the ERMI or HERTSMI-2 is over the safety cutoffs, I recommend that they remediate or move out of the building. Briefly, remediation involves identifying and correcting all sources of water entry, removing water damaged construction materials, and thorough cleaning of all contents of the building. After remediation, a HERTSMI-2 should be performed. The criteria for a successful remediation is a HERTMI-2 of 10 or less.

If patients choose to move, I recommend that they run an ERMI or HERTSMI-2 before moving into any new buildings.

The industry standard of sampling the air for spores is not an acceptable substitute for many reasons. One of the main limitations is that over 99% of the particles that carry the inflammagens from water damaged buildings are smaller than 3 microns. Spore traps can only detect particles that are larger than 3 microns and therefore miss over 99% of the inflammagens. Studies have shown that for every spore, there can be 100-500 inflammagen carrying fragments. The World Health Organization has stated that if one wants to do air sampling, it should be done in multiple locations per room, at multiple times of the day, multiple days per week. In other words, air sampling done properly is too time consuming and cost prohibitive. Finally, only the ERMI and HERTSMI have been associated with sequential activation of innate immune responses, not air testing. I have seen numerous patients who have been told that their air tests were “normal” yet they had high ERMI or HERTSMI scores and their bloodwork shows persistent inflammation.

Cholestyramine or Welchol

The next step is to interrupt enterohepatic recirculation of biotoxins using either cholestyramine or Welchol for at least a month. The dose of cholestyramine is 4 grams ½ hour before eating 4 times a day. If cholestyramine cannot be tolerated, a less effective alternative is Welchol 2 tablets three times a day with food. A number of people are sensitive to the fillers in cholestyramine so using compounded cholestyramine without fillers is a good alternative. The success of this step can be monitored by seeing improvements in the VCS (Visual Contrast Sensitivity) Test. If there is no improvement, the most common cause is persistent exposure to a water damaged building.

Treatment of MARCONS

MARCONS stands for Multiple Antibiotic Resistant Coagulase Negative Staphylococcus. It colonizes the deep nasal aerobic spaces of the majority of people with CIRS. This bacteria forms biofilms and releases biotoxins that can cleave MSH (melanocyte stimulating hormone), an anti-inflammatory neuropeptide. It is diagnosed by a deep nasal swab, which is sent to DLM labs in Massachusetts. If it is present and there are at least 2 classes of antibiotic resistance, the treatment is the use of compounded BEG spray (bactroban, edta, and gentamicin) 2 sprays three times a day for 1 month. Earlier versions of the protocol involved using Rifampin, but this is no longer necessary.

Correct anti-gliadin antibodies

If these antibodies are found on blood testing, the patient needs to avoid gluten containing foods for at least 3 months. I do find in my practice that most patients feel better avoiding gluten indefinitely.

Correct androgens

Many people with CIRS will have low androgens due to excessive activity of the aromatase enzyme. Dr. Shoemaker has shown that this will correct with VIP. In cases of those with low DHEA levels, supplemental DHEA may help correct androgen levels.

Correct ADH / osmolality

Most people with CIRS will have ADH (antidiuretic hormone) and osmolality levels that are out of proportion to each other. The most common pattern is a relative or absolute deficiency of ADH. Typically, one will see an ADH level either low or low normal with osmolality mid or high normal. ADH causes the kidneys to retain free water. Therefore, when levels are relatively low, patients will commonly experience excessive thirst and urination. In more severe cases, people will experience frequent static shocks.

The treatment is to use desmopressin 0.2 mg every other night. Sodium levels must be checked in 5 days then again in 10 days as hyponatremia can sometimes occur. If hyponatremia occurs, patients may experience poor appetite and nausea.

Correct MMP 9 (Matrix Metalloproteinase 9)

MMP is an enzyme that breaks down extracellular tissue. If MMP 9 is over 332 ng/mL, then this is treated with a low amylose diet and high dose fish oil (2.4 g of EPA, 1.8 g of DHA).

Correct VEGF (Vascular Endothelial Growth Factor)

This substance stimulates the growth of new blood vessels in response to Hypoxia Inducible Factor (HIF). In many people with CIRS, VEGF is suppressed to less than 31 pg/mL. The treatment is a high dose fish oil and a low amylose diet as listed in step 7.

Correct Complement C3a

This can be elevated if there is the presence of bacterial membranes such as those with acute Borreliosis. If high, the Borrelia needs to be treated first with antibiotics. If the levels remain high, a statin can be used to lower the level.

Correct Complement C4a if levels are greater than 2830 ng/ml

In earlier versions of Dr. Shoemaker’s protocol, erythropoietin (Procrit) injections were given. Now that VIP is available, VIP is the current treatment of choice. Note that this lab test needs to be run at National Jewish Hospital in Denver.

Correct TGF-B (Transforming Growth Facter Beta)

If elevated (over 2380 pg/mL), the treatment is losartan up to 25 mg bid. A metabolite of losartan called exp3179 lowers TGF beta.

VIP (Vasoactive Intestinal Polypeptide)

If the patient remains symptomatic after following all of the above steps, then the use of VIP is needed. It is a nasal spray that is dosed at 50 mcg/mL, 1 spray 4 times a day. The first dose should be given in the office. A TGF B and C4a should be drawn before the first spray and again in 15 minutes. If the levels rise, there is a hidden mold exposure.

According to Dr. Shoemaker’s paper published in 2013, administration of VIP will correct C4a, TGF beta, VEGF, MMP-9, estradiol, testosterone, vitamin D3, and PASP. More importantly, it improves the quality of life.

It is critical that there be no continued mold exposure before starting VIP otherwise it will be ineffective. VCS must also be normal and MARCONS must not be present to ensure that VIP will be effective.

Ou, Dave. MD Steps of the Shoemaker Protocol. Atlanta: 2014. Surviving Mold - Steps of the Shoemaker Protocol. Web. 10 Aug 2014. http://www.survivingmold.com

Allergen Avoidance Recommendations

Allergen Avoidance Recommendations

The following recommendations will help you minimize your exposure to toxic molds:

Eliminate Dampness In Your Home

Suggestion 1: Eliminate dampness in your home – check walls and roof for leaks. Waterproof walls and ceilings before painting.

Reason: Mold thrives in damp conditions

Do Not Wallpaper Walls

Suggestion 2: Do not wallpaper walls – paint instead.

Reason: Mold grows on wallpaper and in wallpaper paste.

Avoid Carpets As Floor Covering

Suggestion 3: Avoid carpets as floor covering. Replace with wood floors, vinyl or ceramic tile or terrazzo.

Reason: Mold grow sin carpet pile. Carpets also trap dust which can cause allergic reactions.

Allow Good Air Circulation In Closets

Suggestion 4: Allow good air circulation in closets. Leave space between hanging clothes and check leather clothing, belts, shoes and luggage for signs of mold growth.

Reason: Mold grows in damp, enclosed environments, especially on leather items.

Keep Bathrooms And Laundry Rooms Well Aired

Suggestion 5: Keep bathrooms and laundry rooms well aired. Spread out towels and washcloths for fast drying. Dry clothes as soon as they are taken from washer.

Reason: Mold grows rapidly in damp conditions and on damp fabrics.

Regularly Inspect Bathrooms And Laundry Rooms For Mold Growth

Suggestion 6: Regularly inspect bathrooms and laundry rooms for mold growth. Look for evidence of discoloration in tile grout and caulking. Do not forget to check under sinks, around the commode, shower curtains and shower door runners.

Reason: Mold thrives in damp environments.

Use a Dehumidifier in Humid Environments

Suggestion 7: In humid conditions, use air conditioning or a dehumidifier.

Reason: Mold does not grow well in dry environments.

Avoid Foods Which Contain Molds

Suggestion 8: Avoid foods which contain molds or are related to molds such as Mushrooms, yeast containing foods, fermented meats and pickles, smoked fish and meats, and blue cheese.

Reason: Inhalant allergy symptoms may be aggravated by consumption of these foods.

This list was originally written by the Longevity Medical Centre.

Frequently Asked Mold Questions

Frequently Asked Mold Questions

Q: Do I literally have to clean everything in my house (i.e. plastic storage containers, books, toiletries, candles, knickknacks, canned food etc.) or just the major things like clothing and furniture?
A: Yes, everything.

Q: Is it possible to clean electronic devices that may have mold spores inside of them, seeing as I have no way to clean the inside of these devices (i.e., DVD players, computers)? Is it good enough to simply clean the outside of them?
A: Clean the outside and vacuum the openings.

Q: Do pictures and documents have to be scanned/copied or can the originals be kept? Photos can be washed.
A: Porous frames are trash. Documents need to be copied.

Q: What about books, journals? How do you clean them? Or do they have to be thrown out?
A: Books are difficult. If the books are on a shelf and not opened, HEPA vacuum each one. Opened books are trash.

Q: Do I need to use a new cloth for every item that I clean (one clean cloth per moldy item) or can I use the same cloth for several items?
A: One cloth can be reused. You will be vacuuming, then wiping and vacuuming again anyway.

Q: Can leather furniture be cleaned since it is not porous like cloth?
A: Use quaternary cleaners on leather. Vacuum the nooks and crannies of the piece of furniture and do the same thing again. I know some people will say throw away the leather, but I have seen good results if the leather has a finished (not rough) surface.

Q: Is it likely that I have cross contaminated my car seeing as I drive in it, in my moldy clothes and with other items from my home on a daily basis? If that is the case, do I need to sell my car as well or can it be cleaned?
A: The trouble with cleaning for mold is where do you stop? There are many chemically sensitive people who have to get new cars. For most people the car isn’t the problem. Be careful about the antifreeze system in a car as that system’s glycol ethers are a real problem.

Q: Is it likely that I have contaminated my friends’ homes just by being there as well? If so, is that going to be problematic for me when I go to visit with them? I plan to move in with one of my friends for several months while I look for a new place to buy. I have slept at this person’s house already with my moldy clothes and suitcase quite a few times. Will I need to clean her floors and table tops etc., or is any possible cross contamination from my simply having slept there too minimal to worry about? Have I cross contaminated this person’s bed by sleeping in it?
A: Clothes are much less of a problem if they are laundered before wearing to someone else’s home. I get mold hits from families that come from moldy homes, but the risk of illness and cross contamination from clothes is less if the clothes are removed from the home, cleaned or dry-cleaned.

Q: I plan to purchase a HEPA vacuum cleaner. After I clean things with it will it need to be thrown out, or is replacing the filter sufficient?
A: Replace the filter. A good HEPA will last a long time. Better yet, invest in a central vacuum.

Q: I assume that plates, dishes, silverware etc. can simply be run through the dishwasher. If so, where do I clean them? My current moldy dishwasher before I move out or the dishwasher in my new place?
A: I have not seen people made ill by a cleaned dishwasher. Rub down the outside and vacuum it but the wash cycle is enough to safeguard your silver and china.

Q: I am a little worried that work could be moldy too. None of my coworkers are sick and I have asked about water damage. I am told there has not been any. But I have noticed tiles that you can tell have been wet. Any way to determine if the building is moldy short of doing a test?
A: ERMI is the key concept here. I don’t trust any building to be safe just because a landlord said so. Spend the $300 to know for sure.

Q: Would it be better to clean everything myself or to hire a mold expert?
A: As far as abatement and removal of materials, you need to learn the tricks of the trade. But there is no reason you can’t do the work yourself if you have carpentry skills. The cleaning you probably should do.

Re-posted from the Surviving Mold website, https://www.survivingmold.com/