Joint Aches without taking flagyl yet

Submitted by 4dogday on Mon, 2008-07-28 01:14

I increased my Biaxin again a few days ago, only by 62.5 mg twice a day.  I was ok for a few days, but then I had reactions of increased inflammation causing sinus discomfort and other problems.  I felt flu-like symptoms last night, but then instead of getting my usual fibromyalgia symptoms, I skipped that and went straight to very achy joints, fingers and knees especially, and some lower back.

This is weird, because the aching joints might occur a little if my fibro gets really bad (which now only seems to happen as a reaction, but used to be pretty standard for me at one time) but not without really bad symptoms of fibro (sore muscles) first.  Also it is weird because it is worse now than it usually is even with fibro symptoms. 

Others complain of joint aches after taking flagyl, but I am getting this before even starting flagyl.  I wonder if this happens to others or if most people have these reactions only after starting flagyl.  It puzzles me how such a little increase in Biaxin could cause this, but it is not my imagination.  I also wonder if the first two abx are helping me kill bugs (in my cells or outside my cells?) without flagyl?  

I wonder if this means flagyl will not be too terrible for me, because I've perhaps already killed some of these bugs?, or if it means flagyl will really give me a beating?  Only time will tell.

Anyway, the joint aches are very annoying, but I hate the inflammation the most. 

I see my doc tomorrow.  I'm asking for flagyl/Tini but don't have a clue if he'll give it to me as I'm having a hard time figuring out his take on all of this.  Anyway, I hope to increase my Biaxin to 500 mg x 2 in the next 2 or three weeks and start taking ONLY ONE starting dose of flagyl, and then waiting. 

If I ever in the past even considered having a devil-may-care attitude when it comes to increasing meds, I'm pretty sure I've lost it by now!  So no taking several days in a row for me and then getting knocked off my feet!!!  I've read enough here to know better, thanks to all of you who didn't know better, or did know better, didn't care, and did it anyway!  More power to you. 

Memphis,TN - FMS, IBS, rhinitis, depres (~20 yrs) CFS, intestine, bladder, pelvic inflam., red itchy skin, anxiety (~5 yrs). CPn titer 1:256.  CAP 6-07 Current NAC 2400 mg; doxy 100 mg x 2, Biaxin 375 mg x 2, supplements

For sure you do kill some of them with the bacteriostatic ABX but mostly it is a stopping of replication that happen, so don't count on an easier time with flagyl.... But this treatment is so difficult to predict and depends so much on the vulnerable parts of each individual body that it is difficult to predict what will happen.

You may have been killing other stuff though which is good.... 

Michèle (UK) GFA: Wheldon CAP 1st May 2006. Daily Doxy, Azi MWF, metro pulse.

Thanks Michele for giving me some idea of what is going on in terms of what I am killing now vs. when I (hopefully) start taking flagyl.  That is what I thought, and why these reactions are so weird.   I am really having strong reactions before even getting to flagyl.   I thought I was just putting the bugs into a cryptic state!  Fortunately, my reactions usually go away in a few days or so. 

Hopefully this reaction will go away soon too, because my joints are aching more than they ever had before.  I feel like I'm having an attack of arthritis or something (I do not have arthritis, fortunately) along with other flu-like symptoms that are more typical for me, like nausea, light headedness, and general yucky feelings. 

I do think now that it may not be just the recent slight increase in the abx that is causing the problem.  It may be the fact that I increased it somewhat about 3 weeks before that, also, or that the reactions are cyclical (perhaps CPn dying due to lack of nourishment?)  I've been doing only doxy and Biaxin for over a year now, so perhaps the bugs are also dying from hunger, or my body is just managing to find new spores better or something. 

I don't really know what it is, but I definitely believe it is a sign of the CAP working, because these are definitely "reactions" to something hitting my system.  The symptoms are related to my pre-CAP symptoms, but they present differently in many ways from my pre-CAP symptoms, and I have improvement afterwards. They come and go very dramatically, and my improvement is slow, but noticable.


Memphis,TN - FMS, IBS, rhinitis, depres (~20 yrs) CFS, intestine, bladder, pelvic inflam., red itchy skin, anxiety (~5 yrs). CPn titer 1:256.  CAP 6-07 Current NAC 2400mg; doxy 100mg x2, Biaxin 500mg x2, supplements, 1st pulse Flagy

Reve, Clarithromycin(Biaxin) is not a macrolide that has been discussed much in the past year that I have read here at CPnhelp site.  I is a macrolide that is widely used in the Bbcommunity to tx the bacteria responsible forLyme. 

Many abx have a range that tips bacteriostatic to bacteriocidal.  Doxy goes to that range at 200mgTwice a day for a total does of 400 mg per day.  I have been trying to find imformation regarding that shift for Clari because I have Rx's for the 250mgBID and 500mgBID.  I first got the 500 script then read about the potency of reaction with KK2 and got cold feet for the moment.  Then on a repeat call I asked to reduce to 250 and got another script.  Still I have enought Roxi to wait a little longer to shift or not even.    So I am intrigued by your incremental approach as I have decided that I want to go to the bacteriostatic level and hold there for a while and then perhaps surge on ward.  

If anyone knows the dosage that shifts clari from bacteriostatic to bacteriocidal please post.

I have found old info here at the site that talks about many of the abx but clari is not amongst them.  What I do understand it is effective. Any thoughts or references would be appreciated.  May also help Reve, afterall this is her blog.   Thanks Reve.


  • CAP(TiniOnly): 06/07-02/09 for CFS
  • MethylationProtocolSupplements: Started08/08
  • Intermtnt CAP: 02/09-02/10
  • Full MethylProtocol & LDN 02/09
  • Off CAP: 02/10, cont LDN & MethlyProtocol support

Louise et. al.,

If it helps, Louise, when I first took Biaxin as my first abx for CAP (and also arithromycin before, which I took for something else) I had a very strong reaction to my first 250 mg pill, and I stopped for a few days.  I've mentioned this in previous posts, but I'll repeat it here due to your concern about Biaxin.  My doc first thought I was having an allergic reaction, but I thought differently due to this site (the fact that it was a normal CAP reaction and not an allergic-like reaction.) Then I started on Doxy for a week and then restarted Biaxin 250 mg once a day, although I think it would have been better at 125 mg twice a day, or 250 mg twice a day if it didn't cause a big reaction.  I'm not sure if it is ok to do it once a day as it wasn't extended release.  I don't know that much about it, but there are two Biaxins.  I take the non-extended release and I assume that means it needs to be taken twice a day? 

The second time it was not nearly as bad.    But that's kind of why I have crept up on it (among other reasons) and this has worked ok, although I think I could have actually gone faster as I was going too slowly.  My reactions could also be related to my possibly having a heavy load of the bugs while someone with a light load may not react the same from what I gather from my doc.

I guess it reminds me a little of how people talk about flagyl in terms of knowing how to dose.  I just started with a low dose and waited to see what happened and adjusted as needed until I could work my way up.  I think that falls within the guidelines spelled out on this sight for abx, but if not, hopefully someone will point it out. I am not a doc or a microbiologist, so I just piece the puzzle together from what I read and what happens to me.  My suggestion would be to start at 125 mg BID and go up to 250 mg BID as fast as you can tolerate but without getting overdoing it, and then proceed in a similar fashion up to 500. 

I can't imagine why one wouldn't be able to take Biaxin anymore than azithromycin (unless one really does have a true allergy, if that is possible).  It is just a matter of figuring out where to start, how fast to go up, and where to end, since Biaxin isn't identical to Azithro and each person is different.  For a long time I didn't know if the final dose was supposed to be 250 BID or 500 BID until someone finally posted info from a doctor (I have forgotten which doctor right now, was it Stratton?) on this site in a post specifying 500 BID as the target dose, so I started increasing to get to that dosage.

Thanks for mentioning about the point at which an abx  tips from bacteriostatic to bacteriocidal.  I never knew anything about that.  It would be interesting to know about Biaxin, but it also brings up other questions in my mind.  For instance, do two different abx together become bacteriocidal at lower dosages whereas they would not be bacteriocidal separately?  Why is our doxy dose 100 mg bid instead of 200 mg bid?  Are we not trying to have a bacteriocidal effect with doxy and the macrolide, just bacteriostatic?  And if this is the case, what would happen if we did increase them to a bactericidal amount?  I'm assuming the flagyl dose is bacteriocidal?

Louise, are you saying you are going to go up to 200mg BID of doxy? 

 There is a lot to learn.  If anyone knows any of this stuff, please feel free to enlighten us/me.


Memphis,TN - FMS, IBS, rhinitis, depres (~20 yrs) CFS, intestine, bladder, pelvic inflam., red itchy skin, anxiety (~5 yrs). CPn titer 1:256.  CAP 6-07 Current NAC 2400mg; doxy 100mg x2, Biaxin 500mg x2, supplements, 1st pulse Flagy

On the other hand, Louise, after looking at your signature, you are already taking a lot more abx than I am, so perhaps you will not have as strong a reaction just changing from one macrolide to Biaxin as I did when I was just starting Biaxin as my first abx.  Good luck on that.  I feel very comfortable using it at this point, and I'm pretty sensitive about this stuff.  If I can use it, I don't know why anyone else couldn't, as long as they didn't go hog wild and start with too high of a dosage.  It may just be normal for it to whack you a little when you first start, especially when someone is dealing with a heavy load of the critters.

Hope that helps.


Memphis,TN - FMS, IBS, rhinitis, depres (~20 yrs) CFS, intestine, bladder, pelvic inflam., red itchy skin, anxiety (~5 yrs). CPn titer 1:256.  CAP 6-07 Current NAC 2400mg; doxy 100mg x2, Biaxin 500mg x2, supplements, 1st pulse Flagy

Reve, I started per Rx at the 200 BID dose Doxy and did not decrease until 14 weeks. Then I backed down to the Wheldon 100 BID starting Roxi 150 BIDtwo weeks later.  It is a story and Doxi  was bacteriocidal for me at the 400 per day level.   It was a very challenging experience for me, much like many folks with Bb that I have talked to report and they thought it was at least an "effective" dose of Lyme treatment standards.

So my interest in  knowing the minimum bactriostatic level of Clari as a minimum starting dose is based on my past experience of bacteriocidal dosing from my doxy rx from the the start of my treatment. Returning to the 100 BID recommended on the Wheldon Protocol allowed me to begin to function cognitavely and physically.

Roxi 150 BID is equal to _____mg of Clari BID?  Assuming that Roxi 150 BID is bacteriostatic,  at what point does it come bacteriocidal?

Reve I realize that you don't have a take on the answer. 

Perhaps someone else does. From time to time I ask this question, sometime there will be some response from someone based on some research or pharmacalogical data. 

Roxi was easy for me to add and easy for me to take.   Just not so easy to come by.  And doesn't allow my MD to really learn from my situation to apply to other patients and clari is covered by my insurance and roxi is self pay.  

Still to attempt to quote Sarah, "Roxi is a dream to take" or something close to that choice of words and I agree completely.

Reve, I see from your signature that you started CAP the same month that I did, congradulations on completing your first year!


  • CAP(TiniOnly): 06/07-02/09 for CFS
  • MethylationProtocolSupplements: Started08/08
  • Intermtnt CAP: 02/09-02/10
  • Full MethylProtocol & LDN 02/09
  • Off CAP: 02/10, cont LDN & MethlyProtocol support

Rieve- in addition to the dual abx and increase in dose, you may have a strain of Cpn more sensitive to Biaxin. We simply don't know much about differences in strains, except to know there are. At any rate, bacteriostatic affects in the joints are not suprising to me. I got them from switching to Biaxin for a month (250mg BID) with pyruvate even after a number of years on the CAP. I got them again when I was using pyruvate and 300mg BID of roxithromycin, although I don't get this with the 150mg BID dosage. There is clearly some threshold for some tissues in terms of tissue saturation or penetration. I wish I knew more about the chemistry and mechanics of this. But even without the more scientific explanation the symptoms you report are familiar here.

Louise- I share your questions about equivalence, but I expect it's more complicated than any of us realize. Equal in what ways? What tissues? Tetracycline probably has more antichlamydial impact than doxy, but only reaches the BBB in very high doses. So it may be bacteriocidal at those doses in non CNS tissues but not in the brain. My own experience is that Roxy is not bacteriocidal until I got to the 300mg twice a day. I may go back to that if I can affort it, as I otherwise tolerate it really well and feel it's more effective than azithromycin. I'm hoping that Daisy or someone more pharmacologically wise will help us understand all this better.


CAP for Cpn 11/04. Dx: 25+yrs CFS & FMS. Currently: 250 aithromycin mwf, doxycycline 100mg BID, restarted Tini pulses; Vit D2000 units, T4 & T3, 6mg Iodoral

Don't know if this helps...

Yes - many antibiotics can be both bacteriocidal or bacteriostatic depending on the dosage.  They are generally classified as 'cidal or 'static depending on their antimicrobial activity against a broad number of pathogens at an average "safe" dose. 

Quinolones for example are generally categorized as 'cidal because they are bacteriocidal against a broad number of pathogens at a "standard" dosage.

It's also true that antibiotics can be 'cidal or 'static depending on the pathogen at the same dose.

For example -

Antibiotic XYZ 100mg BID vs Pathogen A = 'static response

Antibiotic XYZ 100mg BID vs Pathogen B = 'cidal response

No food, yes food, amount and type of food plus concommitant medications can also influence the antibiotics "kill" ability by effecting CMax/peak concentrations/kill levels. 

No antibiotic is generally considered to be 100% efficacious against a pathogen in 100% of all people.  Other body and genetic composition issues come into play.

Not to even consider "first pass" metabolites of drugs that are formed as the parent/orginal compound undergoes first pass metabolism thru the liver.  Often the metabolites of drugs can be even more active than the parent compound.

Also - with a drug such as say clarithromycin - 250mg BID is effective for a number of pathogens in the throat- pharyngitis or lungs - pneumoniae, etc... it however takes 500mg BID to penetrate well into the sinus tissues. 

Let's look at the macrolides as an example.  The macrolides are believed to work via binding at the 50s ribosomal unit interfering with protein synthesis. 

But each macrolide compound is chemically different - substitute a ring or molecule here or there.  This can in part account for varying degrees of efficacy with the same bacteria - different strains or even different body tissue locations.

For example - clarithromycin is only one single molecule different than erythromycin.  A single attached chemcial ring.  Otherwise the chemical structure of clarithromycin and erythromycin is identical. 

Yet that single molecule allows clarithromycin to be generally better tolerated and to have adequate Hflu and other pathogen activity than erythromycin.  Amazing the diff in one single chemical molecule in the composition of a drug.

Perhaps check out and really read this one single antibiotic PI to truly understand the complexity of the issues

As a purely personal opinion, I am coming to the school of thought of antibiotic rotation within class - about every 90 to 180 days or until die off reactions diminish or until plateau of improvements is reached. 

A plausible strategy for antibiotic rotation might be

Use Roxyithromycin 150mg BID until tolerated maybe 2 to 4 weeks.  Then bump to 300mg BID.    Take about 90 to 180 days.  You can even test out efficacy by going to 300mg TID for a couple of weeks to test reaction.

Next - use clarithromycin 250mg BID until tolerated. maybe 2 to 6 weeks  Then bump to 500mg BID.  Take about 90 days to 180. You can even go to 1 gram BID.

Next use azithromycin 250mg QD until tolerated.  Then bump to 500 mg QD.  Take about 90 days to 180 days. Watch closely for tinnitis at 500mg QD.

Same could be said of tetracycline class.  Each agent in the same class of drug be it cephalosporins, macrolides, quinolones, tetracyclines, etc... will have varying degrees of efficacy on the same pathogen and will even vary in different patient populations. 

Generally, you might find that,  say for H. influenza induced bronchitis, you might find an efficacy rate of 92% for macrolide A, 94% for macrolide B and 90% for macrolide C, etc... Nothing statistically significant.  You then might consider tissue and serum levels which can quiet frankly vary widely between antibiotics in the same class. 

 In every day garden variety infections, it generally doesn't matter whether you use Omnicef or Ceftin or Ceclor etc...  On the other hand, in long term antibiotic treatment if very likely may make a difference.

Also - there are no clear cut dosing equivalent studies of which I am aware.  This again is why I say, start with the lower dose for a few days, when tolerated, scour with the higher dose of the drug and then rotate. 

As I grow more and more to understand who in the lyme treating MD community are having what appears to be the very best results - this the strategy they seem to employ. 

Rotate antibiotics 2 to 4 times per year, start with lower doses and then bump to higher doses, when tolerated, move on to next agent and repeat.  Logically and with what I know of drugs - this makes sense to me.

This also makes sense to me sense as very rarely are you treating one single bacterial infection.

There are no clear cut dosing equivalent studies that I am aware within classes of antibiotics.  Pharmaceutical manufactures will rarely do head to head clinical comparisons between agents.  They might for example compare a new agent against ampicillin or amoxicillin or erythromycin but you aren't likely to see many head to head clinical trials of Rulid, Biaxin and Zithromax.  There's a reason for that but I won't go into it here.

Attached is a review of macrolides from Marne Gaynor (a well known macrolide guru).  This is one of the most excellent reviews of the differences in macrolides, mechanisms of actions, mechanisms of resistance.  If you dig science, I highly recommend this article. LINK

As a disclaimer - I am not a doctor - all of the above is just my own personal opinion.

Daisy - Husband on CAP 5/07.  Husband died from Acute Myelogenous Leukemia Secondary to the Infusion of Novantrone.  Ie - the treatment with the conventional MS drugs killed him.

Daisy on her own CAP 11/2012.