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Cholestyramine (CSM) is a bile acid sequestrant, traditionally used to lower cholesterol. Now it is being used to help with other stubborn health issues. Cholestyramine does not get absorbed in the body and is a great option for helping you to bind and eliminate biotoxins.


Introduction to Cholestyramine

Cholestyramine (CSM) prevents bile from being reabsorbed into the body, this is what makes it a bile acid sequestrant. Cholestyramine has been used for years without complication for lowering cholesterol levels.

Now it is being used off-label to help with other stubborn health issues including treatment of CIRS and other biotoxin-related illness.

Cholestyramine Snapshot

Cholestyramine Snapshot



  • Potently binds to toxins and reduces toxic burden
  • Good if you’re dealing with chronic infections or toxins
  • Good for diarrhea
  • Good for reducing cholesterol


  • Decreases thyroid hormones
  • Doesn’t taste good and can cause a bit of nausea or stomach upset
  • Hard on the liver
  • Can cause constipation
  • Can cause nutrient deficiencies
  • Can bind to other drugs

The Benefits of Cholestyramine

1) Cholestyramine Helps CIRS and Biotoxin Issues

Cholestyramine is helpful in a few ways.  First, it can bind directly to a wide variety of toxins. Second, it can help flush bile and LDL cholesterol out of your system, both of which contain toxins.

a) Cholestyramine Binds Directly to Toxins

Cholestyramine (CSM) has been very successful at lowering inflammation and improving VCS scores (a test used to determine neurotoxicity) for patients with Chronic Inflammatory Response Syndrome (CIRS). There are other binders that have been used with success, but CSM is the only scientifically studied way to eliminate biotoxins from the body.

CSM binds ionophores from a wide variety of biotoxins produced by fungi, cyanobacteria, lyme, and other infections, and excrete them from the body. Some toxins include Psalmotoxin, a spider toxin (R), Caribbean ciguatoxin (R), responsible for Ciguatera fish poisoning (CFP) (R) and Brevetoxin, responsible for neurotoxic shellfish poisoning (NSP) (R).

You can see the polycyclic ethers, surrounded by several double bonds. The CSM fits between, the positive charges attracting the negative charge of the toxins.

However, the most common toxins that can be bound by CSM come from a multitude of toxins produced by mold.

Ochratoxin A, a mycotoxin fund in a wide variety of raw and processed foods such as coffee, dried fruits, wine, nuts, beans, bread and rice, is a potent neurotoxin that can cause chronic effects in kidneys. It is genotoxic (damages DNA) and teratogenic (damages the fetus), and is considered a probable carcinogen. (R) Ochratoxin is another toxin that is bound by taking CSM.

Cholestyramine is almost like a “glue” for biotoxins. It is a long polystyrene chain molecule with side groups of positively charged nitrogen called quaternary ammonium (1.43 Angstroms) (Shoemaker Conference, 2016). The shape and size of the positively charged molecules on the CSM are relatively the same size as many negatively charged biotoxins (at 1.41 Angstroms), making it easy for the CSM to bind to them. Once the biotoxins are bound within the gastrointestinal track, the CSM prevents them from being reabsorbed into the intestines, before finally being excreted in the stool.

Cholestyramine will not be able to bind to every toxin (for instance, the botulinum toxin are too large), but it can bind to a majority of toxins that are relatively similar to its size. Several of the toxins that it can bind to are in the chart below (in red).

b) Cholestyramine Helps Flush Bile

Cholestyramine is composed of positively charged resins that bind to bile acids in the intestine in order to be excreted from the body.

Cholestyramine forms insoluble complexes with the bile, which is then excreted from the body [R].

By lowering bile, which stores toxins, that can also help reduce the toxic burden in the body.

c) Cholestyramine Reduces LDL Cholesterol

Serious infections can trigger sepsis, an inflammatory response throughout the body in response to the presence of bacteria or the byproducts of bacteria (herxheimer reaction) that have been killed by antibiotics.

Sepsis isn’t an active infection, it’s your body’s response to the toxic parts of an infection.

When your body responds aggressively to an infection you will see high temperatures, racing heart, and low blood pressure, which is the case in CIRS as well.

Even if you defeat the infection, your body has a memory that can trigger a response when it finds parts of the toxin in your blood stream (R).

The parts of the infection (LPS?) that your body recognizes as toxic ride around almost exclusively on LDL cholesterol (R).

Researchers found that the death rate from sepsis went down when they gave people a powerful drug to flush the LDL cholesterol out of their body (R).

Because Cholestyramine lowers bile levels in the body, to even out bile levels, cholesterol in the liver is converted to bile, thus lowering cholesterol levels [R].

Patients that had a daily treatment of cholestyramine had reported levels of 50-80% less cholesterol compared to average control levels [R]. 

By lowering LDL cholesterol, cholestyramine can lower the toxic burden in your blood.

2) Cholestyramine Can Stop Diarrhea

People who suffer from diarrhea can use cholestyramine to treat it.

Bile acid can stimulate the colon and cause diarrhea. However, after cholestyramine makes bile acid insoluble, the bile acid passes through the bowels and does not stimulate the colon, preventing diarrhea from happening [R].

Cholestyramine was found to be one of the most effective drugs to treat diarrhea, with a success rate of more than 70% [R].     

3) Cholestyramine Treats Bacterial Infection


Bacteria clostridium difficile can overgrow in the digestive tract and release toxins that attack the lining of the intestines. It can be treated using Cholestyramine and is used in conjunction with another drug called vancomycin to treat diarrhea and other symptoms related to this bacteria infection [R].

Lyme disease can also be treated by using cholestyramine and atovaquone. It reduces the symptoms of the disease [R].

Cholestyramine can also bind E.coli and its toxins to help prevent diarrhea [R].

4) Cholestyramine Improves Blood Sugar Control in Diabetes Patients


Cholestyramine reduced blood glucose levels in patients with type 2 diabetes [R].

5) Cholestyramine Combats Hyperthyroidism

Patients that do not respond well to conventional therapy for hyperthyroidism can take daily doses of cholestyramine to treat hyperthyroidism and its symptoms [R].

6) Cholestyramine Treats Digoxin Intoxication

Digoxin is a drug used to treat heart failures. Toxic levels of digoxin can cause health problems, and cholestyramine will reduce levels and decrease the performance of digoxin [R].

7) Cholestyramine Prevents Itching

Cholestyramine can be used to stop pruritus or severe itching of the skin, that occurs when someone has liver failure [R].

Cholestyramine used in ointments can be also used to heal diaper rashes in babies [R].

8) Cholestyramine Reduces Pain


When used on patients post-surgery (for patients with hemorrhoids), cholestyramine ointments helped reduce pain by 15%. They also took fewer painkillers than the average patient [R].

9) Cholestyramine Reduces Inflammation

Cholestyramine and mesalazine treatment can be used to treat collagenous colitis, a chronic inflammatory disease of the colon [R].

10) Cholestyramine Treats Anemia


Cholestyramine, coupled with flunarizine and pentoxifylline can help treat spur cell anemia, which is a lack of red blood cells due to alcoholism. This treatment of 3 drugs helped patients recover from anemia and also reduced the number of spur cells in the body [R].

11) Cholestyramine Promotes Gallbladder Health


Cholestyramine is shown to increase emptying of the gallbladder. This prevents gallstones from forming and is good for your health [R].

Cons of Cholestyramine

1) Common Side Effects of Cholestyramine

2) Cholestyramine Reduces Vitamin Absorption

Cholestyramine lowers the levels of Vitamin D and K. In some cases, patients were Vitamin K deficient after long term usage of cholestyramine [R, R].

You need to supplement with Vitamin K2 if you’re taking cholestyramine.

3) Cholestyramine May Decrease Mineral Levels

Magnesium, Iron, and Zinc levels were found to decrease in rats that underwent cholestyramine diets. They also had increased urinary excretion of calcium and magnesium; however, calcium levels remained normal [R].

4) Cholestyramine Might Cause Liver Damage


High levels of alanine aminotransferase in the blood can lead to liver damage. In a study done on healthy adults, they were given a daily dose of 8g of cholestyramine and their levels of alanine aminotransferase increased by more than three times. This huge increase was also coupled with cell death in the liver, which means that cholestyramine plays a part in liver damage [R].

5) Cholestyramine Can Lower Thyroid Hormones

Bile activates receptors that increase thyroid hormones (TGR5).

By binding to bile, your thyroid hormones will go down, which is why it’s good for hyperthyroidism.

6) Drug Interactions

Cholestyramine can decrease the absorption and prevent full performance of the following drugs [R]:

  • Digoxin [R]
  • Diclofenac [R]
  • Warfarin [R]
  • Hydrochlorothiazide [R]
  • Leflunomide [R]
  • Cerivastatin [R]
  • Glipizide [R]
  • Troglitazone [R]

Because these drugs help treat heart diseases, rheumatoid arthritis, high blood pressure, and diabetes, taking cholestyramine might cause more health problems.

Using Cholestyramine

Adults usually take 4g of the pure CSM on an empty stomach (1 hour after food) 3-4x a day. It’s best to eat something with fat 30 minutes after taking CSM in order to help stimulate bile. You may also take CSM 30 minutes before a meal.

Make sure to take CSM 3-4 hours away from medication to avoid binding of the medication. For this reason take vitamins first thing in the morning is most efficient.

It’s a good idea to check VCS before taking CSM so that you can monitor its decrease as you continue taking CSM. Some will also test MMP9 before taking CSM. You’ll see why in the “What to Expect” section.

Generally, it’s best to mix several binders in water for the best results, such as a scoop of Activated charcoal, Clay, a few caps of Chitosan-micro, 4g of CSM and Magnesium (taking this mixture with magnesium calm at night helps cover the taste of CSM).

You must be able to go to the restroom in order for the binders to have an effect, and the magnesium helps to offset any constipation effect. If you have major gastrointestinal problems, work up your dosage slowly, or as tolerated. For these people, it’s best to take a break after 3 months.

Dr. Shoemaker recommends someone with CIRS take Cholestyramine until their VCS test is normalized. This can sometimes take longer than 3-6 months.

However, because long-term use can occasionally cause slight problems with your liver, it’s usually best to stop at the 3 or 4 mark and continue taking other binders in order to help your liver recover if need be. But toxins in the body can cause a lot of damage to the liver in general, so it’s best to get them OUT as soon as possible.

What to Expect

Some people can begin to see improvement in their VCS tests (a test used to determine neurotoxicity) within a month of taking Cholestyramine. There are also cases of people with CIRS taking CSM and immediately having their symptoms disappear. This is rarer and usually requires a longer length of treatment.

Others may experience what Dr. Shoemaker describes as an “intensification,” meaning a short-term rise in symptoms after taking CSM, which then usually dies down over the next day or few days. If the intensification takes a long time to resolve, it’s best to temporarily stop CSM, then add it back in at a reduced dose of 4g 2x a day.

If the intensification occurs again and lasts awhile, you can take an MMP9 test to see if it has increased. If so, this is another clue that treating infections is a good next step before adding CSM back into the picture again.

There is no real data on why this happens, but the theory is that perhaps this is due to an already increased MMP9, or a current lyme infection (I believe it could also be due to other infections which cannot be targeted directly by CSM and may require treatment in addition to the CSM). In this case, CSM is potentially increasing the release of toxins, causing a temporary spike in cytokines before they are then excreted from the body.

Usually, if MMP9 has increased after an intensification, it is a good idea to take a high dose of fish oil, and stay on an anti-inflammatory, low-lectin, low-tannin diet (you should be on this diet anyway throughout treatment). After 30 days your inflammation levels should be reduced and you may begin taking CSM at the regular dose of 4g, 3-4x a day (as tolerated) dose.

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  • Hypnogal

    Hi. I take cholestyramine dry raw powder (very very $$$) because I cannot have food colorings (orange in the name brand Questran.) I take it because I have bile salt diahrrea ever since I had my gallbladder out. This binds to excess bile and stops horrific diahrrea. My question is… I’ve been taking 4gms, 30 minutes before a meal 3x a day. What I understand is, when I eat a meal (that has fat in it), my liver (now) dumps bile directly into my small intestine…and so I need to get the medication in the small intestine well before I eat any meal that would trigger this bile release (in the small intestine.) I find, for me, that if I take it WITH a meal, it doesn’t work (as well) at all. So it’s the 30 minute rule for me… is this making sense to all y’all who take it to bind bile? If you take it for the same reasons please tell me how you take it. Thank you.

  • Jackie

    I have been taking 4mg of Cholestyramine daily for 18 years for bile binding. I have had no side affects except I have a hard time losing weight and often questioned my thyroid. This article has helped with possible thyroid hormone issue which I will talk to my doctor about. Other than that, using Cholestyramine has given me back freedom.

  • Pat

    I have taken cholestyramine for a month for high LDL. I cannot take statins because of severe muscle pain. Now I am experiencing muscle and leg cramps that are not as bad as previous muscle pain, but wake me up at night. Is this common?

  • Kathleen G Babcock

    I can’t thank you enough about the warm water. My husband takes it for his illiostomy output. Helps it not run so fast thru his system. But he kept gagging and throwing it up. Warm water did the trick along with an ice water chaser.

  • Smalm4444

    I am scared for my sanity and well being when my Cholestyramine is out of refills. Ever since I had the diagnosis of a fatty liver and a bad gallbladder I had horrible, liquid lava diarrhea. I have had my gallbladder removed and even a low fat diet was not helpful at all. I was very happy when my surgeon put me on this, my only side effects are gas and constipation. I only got told to stay away from carbs to help my liver and stat away from data to not have diarrhea after my gallbladder removal. Even with these changes it was happening still. This medication is the only one I can take for OTC Immodium causes constipation with even a 4th of a 2 mg pill. This is amazing though.


    I thank you so much the useful information you presented about the product.

  • Lynne McCarty

    I have tried several times to take CSM for CIRS but have found that even at miniscule doses I tolerate it for about two weeks and increasingly become really unwell with an extreme intensification of all symptoms including re-introducing symptoms I no longer suffered from. It became unbearable each time and the next time I would start from an even smaller dose. I eat a high fat diet and have vastly improved gut issues that I once had to the point my guts can feel almost normal. I have been taking Vit D, fish oils, magnesium and other balanced minerals for some years and am under the supervision of a Shoemaker doctor. I still don’t understand though why I, and some others, just cannot tolerate CSM.

  • Barry Trute

    Anyone have a source for pure cholestryamine? I want to use cholestryamine without the fillers.

  • Jeannie

    That’s exactly how I felt after I just drank a cup of the Cholestryamine! I was panicking so much that I began to look up side effects of the medication; when I stumbled upon this page. I have drank it before without any side effects, but this time my heart started racing and my head was pounding. I honestly don’t even know why my doctor put me on this medication. Do you think that I may have just drank the mixture too fast, in an attempt to get the horrible taste over with?

  • David

    Cholestyramine is non-systemic so these symptoms you describe are exceptionally strange.

  • Justin

    After having had an emergency open right hemicolectomy after my appendix perforated my colon, (the inflammation also caused an umbilical hernia) followed less than two months later by a cholecystectomy (and the gallbladder was found to be gangrenous), I can say that Cholestyramine has been a life changer for me. Although I don’t – and probably never will – feel completely normal again, at least I am able to go about my day without the fear of sudden, intense urgency and pain associated with bile acid diarrhea.

    It does have a gritty texture, but mixing it with warm water helps. It tastes like a less-sweetened Tang mixture. Just be sure to thoroughly clean your teeth after taking it to prevent damage to your enamel.

  • Miki

    I take this to absorb the bile from needed digestion due to my stomach remove from cancer. It helps a lot. I’ve been taking it… not daily… but 75% of the time. I’ve had no side effects yet that l know of. The gritty texture is my friend as l know the excess bile is being absorbed. This works immediately. I don’t always need it but if l eat high protein without fiber included, my esophagus gets burned. I keep it on my night stand at night in case l get bile reflex in the middle of the night, Just a sip or two does the trick. I prefer the orange flavor but it’s disappeared? Also they seem to have smoothed it out for those who don’t like the grit. However…. the grit is what does the trick…does the absorbing. I wonder if my pharmacy has switched manufacturers? Hard to know because clearly they don’t.

  • Oskar

    In theory should one achieve similar results doing liver flushes regularly? Mechanism at least looks similar – dump the bile out, synthesize new bile from cholesterol, dump it out again and repeat until feeling better.

  • Cara

    I was taking it to treat CIRS and developed serious panic attacks, heart palpitations and ended up in the ER twice. I am getting off of it today as I almost went to the ER at midnight when I woke in sweats and trouble controlling my breath.

  • Jill Heshka

    Very informative article. Thank you so much for sharing! You mentioned Cholestyramine can’t bind Botox as the molecular structure is too big. Do you have any suggestions for a Botox binder? I had an injection for headaches and then had a facial procedure at the spa and felt deathly ill after. Now months later I still feel very sick. I need to get this toxin out of my body as it keeps circulating. Thank you for any advice. I’m desperate to feel better!!!

  • Becky

    I took Colestid for 18 years and then switched to cholestyramine a couple of years ago. I find that I often, nearly daily, have red palms. Sometimes they are very red and they feel a bit swollen but don’t look swollen. Is this caused by the medication and what does it mean?

  • ritchie Shoemaker MD

    Mr. Cohen, your use of my slides is not authorized. Please remove them from this blog until you have obtained proper releases. Please also correct your error re Pacific ciguatoxin. The moleclue depcited is not aspider toxin.

    1. Joseph M. Cohen


  • The Walking Dead (literally)

    One of the most comprehensive articles I’ve seen about Cholestyramine, thanks. There is only so much time in a day, and Shoemaker and Co. have not looked into the damage Cholestyramine does to the body. Since it’s benefits are imperative for improvement.

    It likely binds to an array of Amino Acids and Minerals, since they all have charges in one direction or another. It maybe a good idea to use a Trace mineral supplement too, and iodine? It would likely help to use Taurine at least, since it facilitates bile production.

    I have long theorized Cholestyramine lacerates your delicate villi as it moves through your intestines. Since Glutamine is a major healer for your intestinal lining. I find it helps to take Glutamine while using it. Grass Fed Gelatin likely helps too. Magnesium like Calm irritates your intestines and tends to cause inflammation. Indeed, that’s why your intestines speed up to move it out. But I find I have to use forms of magnesium too, just to keep flowing while using Cholestyramine. Maybe MCT or coconut oil? We need to search for better ways to help the body without harming it, since it’s struggling to heal anyway. But as yet, I haven’t figured that out? I use Magnesium/Potassium Aspartate, but I don’t know if that’s an improvement.

    Anyway, you do have a good start on a list that needs serious attention, especailly on the Con side. like what does it do to any oil based vitamin, like A? or a highly charged vitamin like C, which is necessary to make the collagen to heal the damage of Cholestyramine and Magnesium ripping through your intestines?

    Vitamin D is actually a Hormone and I think Cholestyramine sucks up all of those? Like DHEA, Testosterone, Progesterone, Estrogen and especially Pregnenolone. Which is necessary to make all the others.

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