CISRA’s Synergy Health Newsletter

Issue 6. Speeding up the Guaifenesin Reversal Process: Variable Higher Doses (2000)

by J. C. Waterhouse, Ph.D. 

Summary of Key Points. A brief review of Dr. St. Amand’s use of guaifenesin to treat fibromyalgia is given. This is followed by the proposal of a possible method of speeding up the guaifenesin reversal process. Many patients progress rapidly, even at fairly low doses (600-1800 mg/day). Patients who progress more slowly, or who’s initial improvement slows considerably should first check for hidden salicylates, which can block the effect of the guaifenesin. If no hidden salicylates are identified as the source of the slow progress, they then may decide, along with their doctor, to raise the dose in stages, up to as many as 3, 4, 6 or even rarely 8 guaifenesin per day (4800 mg). In the minority of patients for whom improvement is very slow even at higher doses, an additional option is proposed here–variable higher doses (VHD). The idea on which VHD is based is that there appears to be a sort of habituation to the effects of guaifenesin in some patients over the long term. Due to this proposed habituation, the greatest increase in the reversal process tends to occur in the weeks just after the dose is first raised. To take advantage of this effect, after the patient has been at a higher dose for some time, he/she simply lowers the dose to the original baseline effective dose for 3-10 days and then raises it back to the higher level for several weeks. By varying the dose, the habituation effect is reduced, and the reversal process is enhanced each time the dose is raised back up to the higher level again. There are also some other advantages in flexibility and assurance of progress, which should be especially helpful for sicker patients and those who do not have a doctor who is trained in Dr. St. Amand’s lesion mapping technique to monitor their progress. The extent of the benefits of this approach is still being assessed and reader feedback is encouraged. However, patients must be cautioned to always stay at or above their original baseline effective dose and avoid salicylates, so as not to risk losing progress. [Editor’s Note: See note at end of article for Dr. St. Amand’s view of this approach, which differs from mine.]

To give a somewhat oversimplified overview, Dr. St. Amand’s approach to fibromyalgia is based on the theory that ATP is in short supply due to excess phosphate and calcium being stored in the cells. Dr. St. Amand developed this theory after discovering that taking certain drugs affecting the kidneys led to the disappearance of the hard and swollen muscle lesions (tender areas) observed in fibromyalgia, chronic fatigue syndrome and related conditions (St. Amand & Marek, Clin. Bull. of Myofascial Therapy, Oct. 1997; St. Amand, R. Paul, M.D. and Claudia Marek, M.A. 1999. What Your Doctor May Not Tell You About Fibromyalgia: The Revolutionary Treatment that Can Reverse the Disease. Warner Books, New York). Laboratory measurements of the urine of fibromyalgia patients using these drugs showed increases in phosphate excretion. From this, Dr. St. Amand hypothesized that fibromyalgia was due to a retention of phosphate by the kidney. The urine test results indicated that excess phosphate was being reduced by the uricosuric drugs he was using (used to treat gout by increasing uric acid excretion), since they also enhanced kidney excretion of excess phosphate. As in gout treatment with uricosuric drugs, salicylates from many sources, including cosmetics, some sunscreens, toothpastes, herbs, plant extracts and bioflavonoid supplements, can block the effects of the medication on the kidneys and must be carefully avoided (see, the above-mentioned book, or previous issues of this newsletter for more on salicylate sources and other aspects of this treatment approach; also see pages 7-9, this issue, for a review of another book that points to phosphate excess as a cause of disease). Guaifenesin is a weakly uricosuric drug usually used as a cough suppressant or mucolytic, which Dr. St. Amand has found to be the safest and most effective of the drugs that he has used to enhance phosphate excretion and thus reverse fibromyalgia.

Guaifenesin Dosage and “Mapping”

The appropriate dose of guaifenesin needed to reverse the fibromyalgia lesions varies among individuals from 600 mg/day to 4800 mg/ day. There appears to be a threshold dose needed for progress to occur. If the dose is below this individually determined threshold dose (baseline effective dose), no benefit will be achieved and previous benefit will probably be lost. A definite increase of symptoms (called reversal symptoms) is usually a sign that one has crossed the threshold and achieved an adequate dose, which will be referred to as the “baseline effective dose.” These reversal symptoms decline over time, but may return periodically in “cycles,” during which the guaifenesin is most actively reversing fibromyalgia lesions. “Mapping” of changes in lesion size is the most accurate way to determine whether the dose has been adequate (see Issue 4 of this newsletter for a more thorough description of the technique, or the web site: about how to obtain an instructional video for doctors on the mapping technique). The mapping technique requires a special technique of physical examination developed by Dr. St. Amand, involving detecting the areas of swelling through palpation. If mapping is unavailable, one may start with 300 mg twice a day for 2 weeks to see if that initiates reversal symptoms. If it does not, then one raises the dose to 600 mg twice daily for 2 weeks (70% find 1200 mg or less adequate). The dose at which a noticeable increase of symptoms occurs (reversal symptoms), which signals lesion reversal has begun, is the dose usually considered adequate. If there is still no symptom exacerbation using 1200 mg/day, one can raise the dose in 300 mg increments every 2 weeks, until either a change in the map of the lesions or reversal symptoms are observed. Occasionally, a patient will not experience reversal symptoms. In these cases, mapping of changes in lesions, or definite changes in the appearance of their urine (see below) might be used to determine if they have achieved their baseline effective dose of guaifenesin. [Note: Specify plain prescription guaifenesin tablets. Do not use over-the-counter syrups or pills containing other drugs. If you feel you must resort to non prescription guaifenesin, it may be ordered in a form free from other drugs from a mail order pharmacy: Dave Ributsky, R. Ph. 800-846-5525. In Australia, it is available from Dalkieth Village Pharmacy, phone (08) 9386 3625. In countries where guaifenesin is unavailable, mail order prescription guaifenesin may be obtained from College Pharmacy, 800-888-9358, FAX: 800-556-5893.]

Many people experience cycles of reversal symptoms which tend to decrease in severity with each month on the treatment. Then, after being on the treatment for 6 months or a year, sometimes patients choose to increase the dose by 300 or 600 mg or more, if they and their doctor decide they want to speed up the process. Although this approach works well for a majority of patients, it has been observed that there is a marked tendency in many of the patients to have a considerable slowing of lesion disappearance after the first 6 months. Even at higher doses, sometimes a plateau is reached where the changes in the lesions are barely visible on the map from one 6 month check up to the next. One can keep increasing the dose, in fact some increase to as high as 8 per day, but even then, for a subset of patients, the progress can still be quite slow. I have done some experimentation in my own case, when my progress slowed to a crawl, and found that what seemed to be most successful in overcoming this problem is what I am calling variable higher doses (VHD). I believe that in some patients, the body becomes somewhat habituated to a certain level of guaifenesin and thus the rate of response declines, leading to a slowing of progress. My experience and that of a few others suggests that VHD can overcome this problem, and that it provides an important option that deserves further study.

Variable Higher Doses (VHD) Method

What I am suggesting here, is that after you progress using Dr. St. Amand’s approach for 6 months to a year or more, if you believe your progress is slowing and you want to speed it up, you can try the following variable higher doses method (Note: always first reexamine the products you are using and the list of hidden salicylates to make sure blockage of progress due to salicylates is not occurring and remember to stay at or above your originally determined baseline effective dose):

Proposed VHD Steps:

1. After you have been on guaifenesin for 6 months to a year, increase the dose by 300-1200 mg per day above your baseline effective dose for 1 or more months (see above on how to determine the baseline effective dose). This dose increase will tend to increase reversal symptoms, and you can stay at this dose for several months or until you feel your progress at this level is slowing. The amount you increase the dose can be determined by the level of increased reversal symptoms you feel you can tolerate. (Note: Some people may already be at a dose that is above their baseline. They can either increase it more, or if they choose to, they can proceed directly to step 2, without a further increase.)

2. If and when you feel your progress is slowing (as evidenced by a lack of clearly distinguishable reversal symptoms), you can decrease your dose back to your original baseline dose for about a week.

3. After being at the lower dose for a week, raise the dose again to the previous higher dose. This will often start another reversal cycle with increased reversal symptoms within the next week or so.

4. Whenever you feel that the reversal process may be slowing again, lower the dose to the baseline dose for another 3-10 days. You may do this once a month or once every few months, whatever seems to work best for you. According to my theory regarding habituation, each time you raise the dose back again to the higher level, the reversal process will tend to be intensified once again. This may increase symptoms (reversal symptoms), but this is regarded as evidence that you are progressing. If you don’t have an increase in progress as evidenced by reversal symptoms, mapping or urine changes, you might consider raising both the baseline and the higher dose by another 600-1200 mg per day (but not above 4800 mg/day).

So far, I find that the reversal process is reinvigorated by the higher dose after a temporary return to the baseline effective dose. For example, you may find that 1200 mg (2 pills/day) is your baseline. After 6 months (Step 1), you might increase the dose to 1800 mg (3 pills/day) for 3 months. Then your progress may slow some as shown by decreased reversal symptoms. At this point you might lower the dose to 1200 mg for a week (Step 2) and then return to 1800 mg for the rest of the month (Step 3). You might find that once every one or two months, you can lower it temporarily and then go back to 1800 mg/day and have faster progress (Step 4). If you have trouble remembering to do this, you could write it on your calendar each month as something to do at the beginning of the month, when you change your calendar to the next page.

Additional Advantages of VHD:

1. Increases flexibility and control. Using this method, you may be able to choose when to go through periods of cycling, with their exacerbations of symptoms. This may be important in helping fibromyalgics to complete the reversal process using guaifenesin when trying to work or go to school or fulfill other obligations. You can choose when to lower the dose and when to raise the dose. You may decide that reducing your symptoms on one particular day, week or even month will be of great help. For example, if you are a menstruating female or on hormone replacement therapy, you might decide to lower the guaifenesin dose during menstruation (this method may also help you remember to do it or you can mark your calendar each month as a reminder). You won’t need to feel guilty for lowering the dose for a brief time, because you will also be helping to increase the effectiveness of the guaifenesin when you raise it again. Naturally, however, if you spend too much time at the lower doses, your progress will slow, and if you go below your baseline dose, you will probably lose your previously gained progress achieved through taking guaifenesin. In my own case, my initial effective baseline dose was 2 per day, but now I vary it between 3, 4 and 6 guaifenesin per day. Using the variable higher dose method I have had more progress in the last 4 months than in the last 1½ previous years. It appears that the progress was even faster than a 4 month period when I stayed at 6 guaifenesin per day almost all the time.

2. Increases assurance and provides evidence that the guaifenesin is still working. For people who do not have access to mapping by a trained physician, they may not know where they stand. Some may be tempted to quit if they seem to have reached a plateau in their improvement. Using this method, where you stimulate reversal cycles with the dose increases, it becomes very clear that you still have lesions and the guaifenesin is still working on them, since you can feel the reversal symptoms when you increase the dose. You also can experience more clearly the difference between the ongoing symptoms due to the existence of your lesions (much of what you experience at the lower dose or before going on guaifenesin) and the true reversal symptoms (what you experience at the higher dose, during the cycles of exacerbation in which the excess phosphate and calcium are leaving the lesions, see Issue 2 of this newsletter for some examples of reversal symptoms). I found that after a while I had started to assume certain symptoms were reversal symptoms, when they were probably not, since my map had changed very little during the time the symptoms were occurring. Some may also choose to seek evidence for guaifenesin’s effects by observing changes in the urine before, during and after raising the dose. In this way, you can see exactly what changes in the urine are most correlated with the increased levels of the guaifenesin and the reversal symptoms. I find in my own case, that very fine bubbles, specks and cloudiness of the urine are the characteristics that seem to most closely correlate with raising the dose and experiencing reversal symptoms [Note: Try to examine the urine immediately, since some of the bubbles and cloudiness rapidly disappear.] Making these observations may allow you to, in a sense, watch your illness disappear down the drain. It gives you another way to gauge your progress when mapping is not available to you. In my case, I have found that the observed urinary changes provide support for the VHD approach, since the greatest changes in the urine generally occurs after the dose of guaifenesin has been increased and reversal symptoms are at their maximum. It should be noted, however, that there are other factors that influence the strength of the reversal symptoms and the urinary changes. Not all the factors are known, and there can even be bubbles and cloudiness in the urine without guaifenesin or the reversal process. In some cases, there is a predictable increase in reversal symptoms and urinary change for about 2 days during menstruation or after exercise. In my case, there is also an increase in reversal symptoms and bubbles in the urine for a few days during allergy/sensitivity withdrawal reactions occurring 1-7 days after allergen exposure or after stopping a food allergen that has been consumed chronically (see Issue 5 of the newsletter for more on allergies/sensitivities). It should be remembered that the best way of monitoring progress is by changes in your map of lesions done by a doctor or physical therapist trained by Dr. St. Amand (see for a list of over a hundred doctors who use Dr. St. Amand’s approach, with information on their mapping background, if they have any).

3. Makes it feasible to raise the dose, at least part of the time in some patients who are sicker or who have heavy demands on their energy. Some people may feel they are unable to raise the dose in order to speed their progress, because they can not always function at the level they feel they need to when on the higher dose. But if they use the VHD approach, they have a greater ability to choose when to raise the dose and deal with more reversal symptoms (e.g., during vacations, weekends etc…). Conversely, they can choose to lower the dose when they catch a flu or go through their menstrual cycle, or have a stressful period at work. These people may find that the only way in which they can manage to raise the dose above their baseline effective dose at all is by using the VHD approach. However, they may also want to consider other factors, like the low carbohydrate diet for hypoglycemia or reducing allergens (Issue 5 of this newsletter), or other factors discussed in issues of this newsletter (magnesium, treating parasitic infections). Anything that can improve their health may be helpful by itself, as well as allowing them to tolerate a higher dose of guaifenesin, which can further speed their progress.

I regard this variable higher dose approach as preliminary and experimental, requiring further verification (see note at end of article for Dr. St. Amand’s view of this approach). I know of 2 other people besides myself who seem to be having faster progress with this VHD approach, but would like to obtain much more data. Any readers of this newsletter who have been on guaifenesin for 6-12 months or more and want to try this variable higher dose (VHD) method could write a brief account of their experiences with this method and send it to me. I will try to gather more data on VHD and present it in future issues of this newsletter. It may prove to be a particularly important option for the few patients who are already at 8 pills per day and are making very slow progress. Others still have the option of increasing the dose of guaifenesin a little more, but those on 8/day are already at the maximum dose and no longer have that option.

Caution: I repeat once again, that the main thing to remember is that you should always stay at or above your initial effective baseline dose, which you determined at the beginning was adequate for your progress and be sure to keep checking and rechecking for hidden salicylates (e.g., see, the book by St. Amand & Marek, or Issue 3 of this newsletter). It should always be remembered that a dose below the individually determined effective baseline dose may lead to a reversal of progress, not just a slowing. In other words, lesions you got rid of may rapidly return if the dose is too low or salicylates are causing a problem.

[Editor’s Note: Dr. St. Amand does not believe habituation to guaifenesin occurs. However, at present, he can neither confirm nor refute the VHD approach. He does not think that VHD should do any harm, as long as the above caution (in bold print) is attended to. He believes the apparent slowing of progress in some patients after the first few months is due to the guaifenesin working on deeper and harder to reach places. He also believes that in many cases, apparent slowing or failure to progress is due to inadequate elimination of hidden salicylates, sometimes due to a change in products being used or the manufacturer’s changing the ingredients of a product being used. If faster progress is desired, he recommends simply increasing the dose of guaifenesin (but not above 4800 mg/day). The main problem he sees in varying dosages is that the patient may confuse the doctor who is doing the mapping or prescribing the guaifenesin, when there is no set amount being given. He also currently feels that the addition of the VHD option may make it too complicated for some people and prefers to keep things as simple as possible.]

Editorial Note (August 12, 2006): For my current views on the best approach to fibromyalgia and chronic fatigue syndrome, see the transcript of a talk I gave before a Support Group in 2005. I give an overview of what has helped me most, with an emphasis on a new approach, called the Marshall Protocol (MP).  For more information, see and other articles on this site. 

Editorial Note (2008): I still do not have enough data to say that the above VHD approach using guaifenesin works.  As for myself, I stopped progressing on guaifenesin and had much greater success with the Marshall Protocol ( and  I now consider the evidence to be very strong that hard-to-detect bacterial pathogens are responsible for fibromyalgia and many other chronic inflammatory and Autoimmune Diseases (

Disclaimer: All articles provided on the SynergyHN website are for information only and are not intended as medical advice. An effort is made to be accurate, however readers are advised to verify what is presented here and check with their own doctors. No guarantee of accuracy is expressed or implied. Neither CISRA nor the author receives any funding or income from any organization or manufacturer connected with the topics discussed.

Written by synergyhn

October 29, 2008 at 11:36 pm

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