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Treating a Herxheimer Reaction With Integrative Medicine

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Treating a Herxheimer Reaction With Integrative Medicine

A Herxheimer Reaction, or die-off, is relatively common when you start implementing therapeutic protocols to address bacterial, fungal, parasitic, and viral infections. Die-off can cause many unpleasant symptoms that make it challenging to stick with a treatment protocol, but these are typically temporary and signal that you're on the right path to healing. Given this, you don't need to suffer through your antimicrobial treatment plan. Read on to learn about a functional medicine approach to easing Herxheimer symptoms.


What is a Herxheimer Reaction?

A Herxheimer Reaction, also known as Jarisch-Herheimer Reaction (JHR) or die-off, is an acute febrile illness that can occur in patients undergoing antimicrobial therapy for infection. JHR was first described by Austrian dermatologist Adolf Jarisch in the late 1800s when he noticed increased skin lesions in a patient after starting antimicrobial syphilis treatment. A similar reaction was reported later by German dermatologist Karl Herxheimer. (1)

How Long Does a Herxheimer Reaction Last?

Not everyone undergoing antimicrobial therapy will experience a die-off reaction. For those that do, symptoms generally appear within 24-72 hours of starting antimicrobial treatment. Symptom duration varies, but symptoms are usually self-resolving within 3-7 days. Sometimes, a patient may experience Herxheimer symptoms throughout the course of antimicrobial therapy. (2)

Herxheimer Reaction Symptoms

The most common die-off reactions appear flu-like in nature, including (1):

  • Fatigue
  • Brain fog
  • Headache
  • Body aches and pain
  • Skin rashes
  • Gastrointestinal symptoms: bloating, diarrhea, constipation, abdominal pain, nausea
  • Fever and chills
  • Changes in mood and increased irritability

Patients experiencing a Herx Reaction often note that the symptoms present prior to starting treatment are exacerbated, making it seem as though the Herx symptoms are simply signs of the underlying infection.

Additionally, patients often stop treatment due to fear that Herx symptoms are signs of allergy to the antimicrobial agents. Providers must distinguish between die-off and allergic symptoms, which usually occur minutes to hours after initiating treatment and include nausea, diarrhea, hives, itching and tingling, swelling of the airways, and difficulty breathing (2).

What Can Cause a Herxheimer Reaction?

A Herxheimer Reaction is caused by the death of a pathogen (e.g., bacteria, virus, yeast) and the inciting inflammatory immune reaction that triggers. When a pathogen dies, it releases toxins and cellular products ("bug guts") into the host, inducing a pro-inflammatory immune response to clear the infection and increased toxic load. The human body is equipped with detoxification elimination pathways, including the gastrointestinal tract, liver, lymphatic system, kidneys, and skin. However, these pathways can become sluggish for people with chronic infection, contributing to a buildup of pathogenic and inflammatory byproducts and intense Herxheimer symptoms. (3, 4)

Three common reasons for the onset of Herxheimer symptoms are starting an elimination diet, introducing probiotics, and starting antimicrobial supplements or prescriptions. Elimination diets, such as the low-FODMAP or anti-Candida diets, limit foods from the diet known to feed opportunistic and pathogenic microorganisms colonizing the gastrointestinal tract, thereby cutting off the bad bugs' food supply. Beneficial probiotics can inhibit the growth of pathogenic organisms and colonize the large intestine with beneficial bacteria, essentially overcrowding and pushing out unwanted pathogens. Finally, the most common and effective way to treat pathogenic infections is with prescription or herbal antimicrobials, which act through various mechanisms to inhibit the growth of and kill pathogens.

Herxheimer Reaction can occur with the initiation of an antimicrobial protocol for virtually any type of infection. Chronic infections are more likely to cause die-off symptoms, given the increased total pathogenic load and their tendency to decrease host vitality. Commonly treated infections by functional medicine doctors that are likely to cause die-off symptoms include chronic Lyme disease, SIBO and intestinal methanogen overgrowth (IMO), chronic Epstein-Barr Virus (EBV), Candidal overgrowth, and intestinal parasites.

Functional Medicine Labs to Test for Root Cause of Herxheimer Reaction

Below are labs to consider ordering for patients before initiating an antimicrobial protocol to assess the status and function of elimination and detoxification pathways. Identifying imbalances in detoxification pathways and supporting the organs of elimination prior to starting antimicrobial therapy can help prevent and reduce the severity of potential die-off reactions.

Liver Function

The liver is the primary organ of detoxification through phase 1 and phase 2 biochemical pathways. A liver panel measures markers of liver function and inflammation. If liver function is impaired and inflammation is present, Herx reactions are more likely to occur due to the inability to detoxify and eliminate toxins through the liver efficiently.

Kidney Function

Once toxins have been converted to water-soluble compounds by the liver, the kidneys are responsible for eliminating waste products through urine. Kidney function can be measured with a kidney panel.

Comprehensive Stool Test

Many toxic and waste products are eliminated from the body through stool. Patients with digestive dysfunction, especially constipation, may be more prone to Herx symptoms if toxins cannot be eliminated through stool and are instead reabsorbed into circulation, contributing to systemic inflammation. A comprehensive stool test measures various markers related to digestive health and function, providing information that helps guide recommendations to normalize gut health and bowel movements.


Genetic variations (SNPs) can change the function of enzymes involved in phase 1 and phase 2 detoxification pathways, increasing the risk of impaired detoxification capacity. Understanding SNPs can help predict an individual's response to certain medications and supplements and assist in making specific treatment recommendations to support detox pathways.


Functional Medicine Approach to Treatment for Herxheimer Reaction

Effectively managing die-off symptoms requires understanding the variables that impact die-off symptom etiology and severity. While it is important to remember that a Herx reaction is usually self-limited and self-resolving, initiating a protocol to manage and alleviate symptoms can ease patient symptoms and increase compliance to treatment. Slowly titrating dietary and antimicrobial interventions, reducing systemic inflammation, and supporting the body's natural detox pathways are critical in minimizing Herx symptoms successfully.

Nutrition and Dietary Considerations for Herxheimer Reaction

Extreme elimination diets can cause die-off symptoms and restrict essential nutrients to fight infection and support detoxification. While minor dietary eliminations can be beneficial to supporting a healthy gut, such as limiting refined sugar and glyphosate-containing foods, emphasis should instead be incorporating nutrient-dense, anti-inflammatory foods into the diet.

An anti-inflammatory diet, such as the Mediterranean diet, emphasizes eating a wide variety of fresh, whole fruits and vegetables, unsaturated fats, whole grains, fatty fish, tea, herbs, and spices. Fermented and live-cultured foods (i.e., yogurt) also support a healthy microbiome and intestinal health and reduce inflammation. (5)

In addition, how you prepare and cook food can matter just as much as the food you eat. Avoid deep frying and grilling at high heat to avoid intake of saturated and trans fats and advanced glycation end-products (AGEs) created by high-heat cooking. Instead, cook your foods by steaming, baking, or stir-frying over lower temperatures. (5, 6)

Supplements and Herbs That Help With Herxheimer Reaction

Adding dietary and herbal supplements can provide additional antioxidant and detox support to help reduce die-off-related inflammation and clear pathogens and their toxins more quickly from the body.

Activated Charcoal

Activated charcoal is a broad-spectrum gastrointestinal binder that acts like a mop in the digestive tract to soak up and clear toxins from the body in stool. Binding and eliminating toxins prevents them from irritating the gastrointestinal lining and from being reabsorbed into circulation, perpetuating inflammation and die-off symptoms.

Vitamin C

Vitamin C is a potent antioxidant that quenches free radicals to limit their damaging effects and reduce inflammation. Along with supplemental oral vitamin C, you can increase vitamin C intake through diet by increasing your intake of citrus fruits, tomatoes, bell peppers, strawberries, and cruciferous vegetables.


Magnesium plays many essential roles in the body. Regarding the Herxheimer Reaction, oral magnesium can support regular bowel movements, preventing slow elimination through the bowels.

Liver Support

The liver is the primary organ that removes pathogenic toxins from the bloodstream. There are many natural supplements and herbs that can support phase 1 and phase 2 liver detoxification pathways, including N-acetylcysteine (NAC), glutathione, milk thistle, turmeric, and dandelion root.

Additional Complementary and Integrative Medicine for Herxheimer Reaction

Additional strategies to support detoxification pathways and reduce Herxheimer symptoms include the following:


Infrared sauna therapy is an evidence-based method for inducing detoxification through sweating (7). Staying well hydrated and replacing electrolytes after sauna therapy or any other activity that stimulates sweating is important.  

Epsom Salt Baths

Epsom salt is rich in magnesium and sulfate. Soaking in an Epsom salt bath can increase systemic magnesium and sulfate levels, both important for detoxification pathways. Additionally, hot baths can ease aches and pains, stimulate sweating, and promote relaxation.



A Herxheimer Reaction is a set of symptoms caused by a natural immune response to initiating an antimicrobial protocol. Although die-off is uncomfortable, it can tell you you're on the right path to treating an infection. Working closely with a functional medicine provider can be beneficial to distinguish Herx symptoms from a symptom flare or an allergic reaction to the treatment protocol. Many interventions can be implemented before and during an antimicrobial treatment protocol, focusing on reducing inflammation and supporting detoxification pathways. Doing so can prevent and ease symptoms of a Herxheimer Reaction.

The information provided is not intended to be a substitute for professional medical advice. Always consult with your doctor or other qualified healthcare provider before taking any dietary supplement or making any changes to your diet or exercise routine.
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Lab Tests in This Article

1. Dhakal, A., & Sbar, E.. (2022). Jarisch Herxheimer Reaction. StatPearls Publishing.

2. Marcum, L. (2017, July 31). LYME SCI: The dreaded Jarisch-Herxheimer reaction.

3. Butler, T. (2017). The Jarisch–Herxheimer Reaction After Antibiotic Treatment of Spirochetal Infections: A Review of Recent Cases and Our Understanding of Pathogenesis. American Journal of Tropical Medicine and Hygiene, 96(1), 46–52.

4. Hodges, R., & Minich, D.M. (2015). Modulation of Metabolic Detoxification Pathways Using Foods and Food-Derived Components: A Scientific Review with Clinical Application. Journal of Nutrition and Metabolism, 2015, 1–23.

5. Anti Inflammatory Diet. Johns Hopkins Medicine.

6. Does cooking at high temperatures increase your risk of heart disease? British Heart Foundation.

7. Genuis, S. J., Birkholz, D., Rodushkin, I., & Beesoon, S. (2011). Blood, Urine, and Sweat (BUS) Study: Monitoring and Elimination of Bioaccumulated Toxic Elements. Archives of Environmental Contamination and Toxicology, 61(2), 344–357.

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