What a primary care physician can do for CFS patients

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Last Updated: 30 August 2017 30 August 2017

Recommendations by James Oleske, M.D., M.P.H.

Dr. James Oleske, a Professor of Pediatrics at the University of Medicine and Dentistry, Newark, New Jersey, in his talk of October 17, 2010 explained his theory of the multi-causality of Chronic Fatigue Syndrome (CFS) and also described some specifics for what a primary care doctor working with a CFS patient can and should do. These recommendations cover the initial evaluation, specialized studies, treatments, and the structure of an overall care plan, and may be helpful as a starting point for discussion and planning between patients and their physicians. He spoke at the New Jersey Chronic Fatigue Syndrome Fall Conference, October 17, 2010.

Dr. Oleske emphasized that even if a physician has not had much experience evaluating and treating CFS patients, there is still much that s/he can do for the patient.

Initial evaluation of the patient

• Review previous medications, patient records, medical reports, and laboratory test results. Often the patient has taken great effort to assemble records from visits to other providers, and these records will often contain very useful information. Also, duplicate testing may often be avoided if results of earlier tests can be utilized.
• Take a detailed history, including past history of other fatigue-like illnesses, significant psychiatric illness if any, a detailed review of systems, and determine what pattern of illness the patient has been experiencing.
• Perform a thorough physical examination. A physical examination may reveal issues that explain some of the symptoms.
• Lab studies should include a CBC with SED rate, chemical profile, thyroid function test, ANA, UA, EKG, chest x-ray, intermediate strength PPD, and if the patient has a fever over 101 degrees, include blood cultures.
• Other studies may also be indicated, such as CT or MRI brain scans or psychological testing.

Further evaluation

Further evaluation should include:

• A follow-up of any abnormalities found on the initial workup to determine if there are other causes of chronic fatigue or other symptoms
• Appropriate referrals to specialists after the initial workup
• Immune Dysfunction testing (often available only through research centers and Immunology physicians) to look for infectious agents such as EBV, HHV-6, and other humeral immune evaluations (IgG, IgM, IgA, IgE, IgG subclass, T-cell subset evaluation), and innate immune responses (anti-inflammatory mediators, lymphokines). Finding a center to do this testing may be difficult because despite the recommendation coming repeatedly from the CFS Advisory Committee, Centers of Excellence for CFS still have not been created and funded.

Treatment plan

A treatment plan for CFS must first address treating the symptoms to improve the patient's quality of life.

Symptoms which can often be well-managed by standard approaches include:

• Pain
• Allergy
• Sleep disturbances
• Fatigue, by helping the patient achieve a balance of rest and activities

Specific investigational therapies (if available) may include:

• Anti-viral
• Immunoglobulin
• Anti-inflammatory
• Anti-cytokine

Finally, it is important to structure a Long-term Care Plan, based on a chronic illness model of care. Important items to include are:

• Reasoned laboratory evaluations
• Reassurance
• School or workplace accommodations such as
  • Individualized attendance and start times
  • Increased time for assignments and exams
  • Access to home study or work
  • Adjusted physical activities
  • Accommodation for physical limitations
  • Flexibility of course or work requirements
  • Sympathetic administration/educators/managers. Not sympathetic in the sense of feeling sorry for the patient, but in the sense of working toward effective means of improving the patient's quality of life and ability to function.

What is health-related quality of life?

Dr. Oleske asks physicians to consider "What is health-related quality of life?" He said it recognizes the multi-dimensional nature of health and brings together physical, psychological and social domains that influence health status. It reflects a transition from measuring mortality to understanding morbidity, but there is no one accepted definition. Quality of life domains include:

• Social
• Psychological
• Physical (including general health)
• Disease symptoms

Special issues in assessing quality of life in children include the following

• Changing developmental level
• Adjusting for age
• Sensitivity to changes in health status
• Use of proxy respondents (e.g. parent or other family member speaking for the child)
• Asking the child directly
• Comparison with normal population (scientific studies of "normal" are rare)

Why is assessing quality of life important?

• It provides descriptive information about health status
• It helps identify individuals with differing morbidity levels
• It offers patient and family perspectives on the impact of the illness and treatments

When multiple treatment regimens are available, quality of life assessment may be a factor in treatment choice. Understanding the relationships among disease, symptoms, treatments, and social factors is critical to providing optimum care.

Dr. Oleske closed his talk with a quote from Aesop: "No act of kindness, no matter how small, is ever wasted."

More Resources

For further information about diagnosis, see the 2003 Canadian Definition, Pediatric Case Definition, as well as the Differential Diagnoses articles.

For more information about ME/CFS symptoms and their frequency, see the list compiled by Paul Cheney MD (the Cheney Clinic, specializing in ME/CFS), Anthony Komaroff MD (the Harvard Medical School), Charles Lapp MD (Hunter-Hopkins Center, specializing in ME/CFS)) and Daniel Peterson MD (Whittemore-Peterson Institute for Neuro-Immune Disease), by clicking on the Symptoms Checklist.

For comments on the confusion concerning the role of psychological conditions in ME/CFS, see the article by psychiatrist Alan Gurwitt MD, "On the Morbid Fascination with Psychiatric Morbidity" and a summary of an article by Anthony Komaroff MD in The American Journal of Medicine, "Differences between CFS and Major Depression."

Other articles in the Differential Diagnoses section address differentiating between ME/CFS and various specific psychological conditions, such as depression.

Pharmacological therapies approved for FM

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Last Updated: 03 January 2016 03 January 2016

Fibromyalgia (FM) has received a lot more attention over the last couple of years through television and magazine advertisements promoting three new drugs indicated for use in FM. Lyrica (pregabalin), Cymbalta (duloxetine), and Savella (milnacipran) were approved by the Food Drug Administration (FDA) as effective treatments for FM based on their performance in clinical trials.

In order to meet the FDA criteria as "effective" treatments, these drugs had to show benefits or some measurable level of improvement in study participants as they compared to placebos (substances with no active ingredients) in each their own trials. These medications might provide considerable relief for some patients, but they do not work the same way for everyone with FM, for a number of reasons.

These particular drugs differ from each other in their chemical composition and modes of action (i.e., they target different brain chemicals). Therefore, how each patient responds to any one of these will greatly depend on his or her own body chemistry, variation in symptoms, and severity of illness. The majority of FM patients have pain and disrupted sleep, but some may find mood disturbances to be problematic, while others have digestive, intestinal or bowel sensitivities. It is not unusual for FM patients to be prescribed multiple medications, to manage multiple symptoms, which may put some patients at a greater risk of adverse drug interactions.

Whenever new treatments are being contemplated, the general rule is to select a drug where its benefits are thought to outweigh the potential risks, and anything else known about the patient's medical history that might negatively impact him or her. In addition, when starting out any new medication, it is usually recommended that individuals with FM begin with a very low dose (i.e. 25% of prescribed dose) and work their way up slowly to the full prescribed dose, watching for any adverse side effects. This particularly applies to these drugs.

Despite their limited "track records" there often tends to be an eagerness to try out the latest treatments. Decisions to initiate treatment are often based on favorable study results (i.e., the acceptance of study results at face value) and may not take into account other factors that influenced results (i.e., the severity of illness in the study participants or the placebo effect that produced favorable response). The result is the possibility of unrealistic expectations for the typical FM patient, who may have a more complicated history or combination of problems than study participants.

A group of German doctors conducted an extensive review of these three drugs on their overall efficacy, benefits and adverse effects, with one significant difference—they evaluated how they measured up to each other. Their comparative analysis was published in 2010 in the Journal of Pain, the official scientific journal of the American Pain Society. Their findings and excerpts from several other studies are examined later in this article. But first, we will review the basic properties of these medications and the developments since their release on the market.

Basics about medications approved for use in FM

Pregabalin (Lyrica)

The FDA approved Lyrica, made by Pfizer, Inc., in June 2007 as the first prescription medication for the treatment of FM. Very simply, Lyrica is thought to work by changing the effect of GABA (gamma amino butyric acid), often referred to as a "calming" neurotransmitter/brain chemical.

Structurally, it is related to Pfizer's first antiepileptic drug, gabapentin (Neurontin), which came on the market in 1983. Lyrica is found to be more potent and effective at lower doses than gabapentin (Neurontin). Its primary uses in FM are for pain relief and improvement of fatigue and sleep.

An "informal" review of several internet drug information sources show that patients' experiences with Lyrica varied widely, from stating that it caused many difficult side effects, rapid weight gain, and the drug was found to be very expensive, to praising it as the best treatment they've used to date. The average of the patient/user ratings placed Lyrica at slightly beyond the halfway point on the scale used. This information is meant to provide a general idea in how a random group of patients responded to this treatment—it is strictly subjective and not a medical interpretation.

Lyrica is also used to treat diabetic nerve pain, nerve pain after shingles and partial onset seizures in adults with epilepsy.

The most common side effects are weight gain, swelling of hands and feet, and may worsen "fibro fog" in some patients. In some clinical trials, dizziness and somnolence were the most frequently reported adverse events. Many of these side effects were echoed in the above-mentioned patient/user reviews.

It is important to report any unusual reactions to the prescribing physician, as some of these could be serious and warrant discontinuation of treatment—such as loss of coordination, uncontrolled movements, unusual fatigue, difficulty speaking or changes with vision.

Some patients have experienced depression, changes in their mood or have had suicidal thoughts. As a result, effective April 2009, Lyrica and Neurontin (along with other antiepileptic drugs) were required by the FDA to include a warning about the increased risk of suicidal thoughts or actions on their product labels.

Duloxetine (Cymbalta)

In June 2008, Cymbalta, manufactured by the Lilly Co., was approved by the FDA for use in FM, to help reduce pain and improve function. Cymbalta belongs to a class of medications called selective SNRIs (serotonin and norepinephrine reuptake inhibitors). It works by increasing the activity of these two neurotransmitters which are found to be deficient in FM.

By adjusting in how the brain and spinal cord respond to painful stimuli (which is part of the nociception system/how pain is sensed), is how it is thought to provide an analgesic effect.

Cymbalta is also indicated for the treatment of major depressive disorder, generalized anxiety disorder, management of diabetic peripheral neuropathic pain, and more recently, it was approved for the management of chronic musculoskeletal pain, including chronic osteoarthritis pain and chronic low back pain.

Though Cymbalta is suggested for a wide range of problems, it still should be approached as a potent treatment with a dual mechanism. A thorough assessment should be made of the patient's personal and/or family history of psychiatric problems (e.g. bipolar/manic-depressive disorders) as this drug may worsen or uncover these.

It is also very important to review all medications used by the patients (including over-the-counter products and supplements) in order to prevent serious interactions since one-fourth of all prescribed medications are metabolized by the same enzyme (CYP2D6).

These medications include other selective serotonin reuptake inhibitors (SSRI's), tricylic antidepressants (TCA's), beta-blockers, opiates, antiarrhythmics, migraine headache treatments, and various plant substances.

For their own safety, patients need to communicate with their doctors in an honest, open manner, and not withhold any information about what else they might be using on their own (including alcohol), and use medications exactly as prescribed.

In the event of adverse effects, patients need to inform their doctors about these problems and not make changes on their own.

NCBI warning for medication-induced suicidal tendencies. The National Center for Biotechnology Information (NCBI, a branch of the National Institutes of Health (NIH)) has posted an important warning about the potential risk of suicidal tendencies in some patients while using certain antidepressants, including, but not limited to, duloxetine (Cymbalta).

The NCBI advises that "all" patients should be informed about this risk and the early signs/symptoms associated with this risk. Family members or caregivers should know the same, so they can recognize warning signs. The reason for extra precautions, according to NCBI, is because people's mental health can change unexpectedly, even in individuals who do not have mental illness, but are using duloxetine to treat other conditions. This appears to happen, more often, at the beginning of treatment and/or when the dose is increased or decreased; therefore, their recommendation is that patients be closely monitored during these times. NCBI lists the following symptoms as potential warning signs of suicidal tendencies which need to be immediately reported to the doctor: "new or worsening depression; thinking about harming or killing yourself, or planning or trying to do so; extreme worry; agitation; panic attacks; difficulty falling asleep or staying asleep; aggressive or hostile behavior; irritability; acting without thinking; severe restlessness; frenzied abnormal excitement; or any other unusual changes in behavior."

Milnacipran (Savella) 

Savella was approved by the FDA in January 2009 as yet another FM-appropriate treatment. It is made by Forest Laboratories Inc., and falls into the same class of medications as Cymbalta.

However, its mechanism focuses on boosting norepinephrine levels more so than serotonin ones.

Its overall ability to reduce pain has been reported by several sources as being only "marginal."

Two of its more frequent side effects are increase in blood pressure and nausea.

According to the NCBI, milnacipran is currently not used in the U.S. to treat depression. The NCBI has issued the same warnings for milnacipran as for duloxetine regarding potential changes in mood and/or risk of suicidal thoughts and tendencies.

How do these medications compare to each other?

A group of German doctors retrieved and reviewed data from previous studies conducted for all three pharmacological therapies, totaling 17 studies and 7,739 patients who met the inclusion criteria. (Such a study is called a meta-analysis.)

Some of their sources included MEDLINE, SCOPUS, Cochrane Central Register of Controlled Trials, as well as unpublished data from FDA and NIH databases and others. Even though these studies may have some variations in how they were conducted, the amount of data reviewed was quite substantial.

(See our editorial note at the end of this article concerning the validity of meta-analyses such as this one.)

The article is written by Häuser W, et al, titled "Comparative efficacy and harms of duloxetine, milnacipran, and pregabalin in fibromyalgia syndrome", and was published in the Journal of Pain, 11 (2010): 505-521.

One of the most remarkable findings in their analysis of these medications and their ability to reduce pain was that "adjusted indirect comparisons indicated no significant differences for 30% pain relief." This suggests that none of these were found to be highly effective against pain and they all seemed to be about the same, when evaluating degree of pain relief.

When combining pain and sleep disturbances, duloxetine (Cymbalta) and pregabalin (Lyrica) were found to be considerably more effective than milnacipran (Savella).

Milnacipran (Savella) and pregabalin (Lyrica) were more beneficial in reducing fatigue than duloxetine (Cymbalta), while duloxetine had a stronger impact on mood.

Both SNRI's caused more headaches and nausea/digestive symptoms and also raised blood pressure.

This comparison of specific features of these medications may be very helpful in a clinical setting as physicians try to select the most suitable treatment for each individual patient.

Though the level of pain relief or other noted improvements can be modest, or even minimal in some cases, drugs can still meet approval by the FDA. As mentioned above, pharmaceutical companies only need to show that a drug performs better than a placebo.

For example, Medical News Today reports the following data on clinical trials testing Cymbalta's effectiveness for FM: "Lilly established the efficacy of Cymbalta in two pivotal three-month clinical trials involving 874 patients with fibromyalgia. In both studies, Cymbalta reduced pain at study endpoint compared with placebo as measured by the Brief Pain Inventory (BPI) ... improvement in pain for Cymbalta vs. placebo was observed in the first week of each study. Fifty-one percent and 55 percent of patients on Cymbalta had a 30 percent improvement on the BPI at endpoint (clinically meaningful relief is considered at least 30 percent pain reduction)."

Some physicians are not convinced that all new drugs are better just because they are new, generally speaking, since this applies to treatments indicated for other conditions. The reason for their doubts is that the effectiveness/benefits of new drugs are not often compared to existing drugs.

In one unusual case, clinical trials for a new drug that was supposed to be promoted as another treatment for FM were abruptly terminated by Pfizer in February 2009. The "Musculoskeletal Report" (a source for Biopharm business news) announced that Pfizer had re-evaluated this drug, esreboxetine, and concluded its potential benefits to FM patients would not be too substantial.

The President and General Manager of Pfizer's Primary Care Business Unit, Pedro Lichtinger issued this statement, "While confident in the safety of these compounds, we don't believe that they provide significant benefit over other therapies."

Esreboxetine was a selective norepinephrine reuptake inhibitor that Pfizer, Inc. was working on for use in FM. It is thought to be essentially the same drug as reboxetine (Edronax), also made by Pfizer, but currently approved as a treatment for depression.

Though one can only speculate about the potential value this drug might have had for FM (or not), it becomes all the more evident that "head to head" trials (i.e., studies in which one drug is directly compared to another drug or drugs from the same class or group) might be the best way to demonstrate the advantage of one treatment over another.

Reference

Häuser W et al, "Comparative efficacy and harms of duloxetine, milnacipran, and pregabalin in fibromyalgia syndrom," Journal of Pain 11, no. 6 (2010): 505-521. 

Editorial comment on Statistical Meta-analysis

The Massachusetts CFIDS/ME and FM Association would like to bring to the attention of our readers that the type of study conducted by the group of German doctors discussed in this article is referred to as a "meta-analysis." This term refers to the statistical analysis of a group of individual studies.

The authors of a meta-analysis re-analyze the results of many smaller studies (with only the limited information available in each published report of a study, not the original data from each) pooled as if a larger study had been done with all of the patients in the smaller studies.

Thus a meta-analysis will take results from 10 studies of 10 patients each and claim to have valid results from 100 patients, but without having access to the original data for each of the 100 patients.

Thus a meta-analysis, in itself, is not an actual scientific study, but a type of averaging of averages from many different studies.

Therefore, from a mathematical and also a medical standpoint, trying to get "effectiveness" data comparing drugs from varying studies that only compared a single drug to placebo is not really valid. There are too many factors that can throw one's conclusions off such as variations in study length, severity of FM in patients of different studies, numbers of dropouts in a study due to severity of side-effects, etc.

So the German meta-analysis is similar to comparing apples to oranges (placebo), persimmons to oranges and redwood trees to oranges, and then coming up with conclusions about how apples, persimmons and redwood trees compare to each other.

On the other hand, the German meta-analysis provides a broad review of a large number of studies. It is worth considering its conclusions, but they really shouldn't be taken as "gospel."

To put things even more into perspective, some time ago a meta-analysis of treatments for CFS found that Cognitive Behavioral Therapy (CBT) was the "best" treatment for CFS.

The facts that most of the studies analyzed used the Oxford definition of CFS and compared CBT to placebo, and only a few of the analyzed studies looked at other treatments and patients identified by the 1988 or 1994 definitions of CFS, were ignored.

Thus, the conclusion of a meta-analysis can be heavily influenced by the number of studies of a certain treatment outweighing the number of studies looked at in the analysis that used a different treatment. We don't know if that is the case in this German study, but it could be.

Ambien may leave older patients at greater risk of nighttime falls and injuries

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Last Updated: 20 November 2015 20 November 2015

Zolpidem (Ambien) is often used in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) or Fibromyalgia (FM) to help patients fall asleep or stay asleep. It belongs to a class of medications called sedative-hypnotics and works by adjusting the neurotransmitter GABA (gamma-aminobutyric acid). Some patients experience nocturnal awakenings when using this sleep medication.

The University of Colorado at Boulder evaluated the level of cognitive impairment and walking difficulties during these episodes in a study, "Influence of zolpidem and sleep inertia on balance and cognition during nighttime awakening: A randomized placebo-controlled trial", published in the Journal of the American Geriatrics Society, 2011.

Study participants consisted of both young and elderly healthy adults, some of whom were given 5 milligrams of zolpidem and others received a placebo. After sleeping for two hours, they were awakened and tested for balance and cognitive changes.

Unsteady walking, difficulties in maintaining balance, and cognitive impairments were found in 27% of the young adults, but in as much as 58% of the older participants who had taken is zolpidem. This study further shows how older adults may be at a greater risk of injury and accidental falls while under the effects of zolpidem.

An article reviewing study results, including potential health and safety issues, is available at the ProHealth library, Widely Used Sleep Drug Significantly Impairs Waking Balance, Coordination, Cognition.

Full Catastrophe Living --Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness

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Last Updated: 25 November 2015 25 November 2015

Full Catastrophe Living—Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness by Jon Kabat-Zinn, Ph.D. ISBN: 0385303122.

Jon Kabat-Zinn, Ph.D., is one of the most recognizable names in the field of mindfulness meditation and its clinical applications. Dr. Kabat-Zinn is the Executive Director of the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School, Worcester, MA. The Stress Reduction Clinic, founded by Kabat-Zinn in 1979, has drawn thousands of participants. Patients seek help to cope with health problems or stressful life situations.

This review focuses on Dr. Kabat-Zinn's first book, Full Catastrophe Living—Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. This book was designed to give the reader full access to the training program offered at the stress clinic. Our goal is to introduce this type of alternative material for your general information.  

In the title, the word catastrophe refers the enormity or magnitude of one’s life experiences (i.e., stressful situations at work, home, or in relationships; the high-paced activity and busyness of daily life; and all the emotional activity that will result from these events). 

At the core of Dr. Kabat-Zinn's program is the practice of mindfulness, a form of meditation originating from an ancient Buddhist tradition. Another term for mindfulness is “moment-to-moment awareness”, or paying attention to what is going on in one’s life, to what is going on in one’s body, and getting to know oneself.

In the book, we find that mindful breathing is the first fundamental technique used in meditation (i.e., focusing the breath moving in and out of the body).

We then learn to pay attention to sensations within the body though a technique called the “body-scan”. According to Dr. Kabat-Zinn, this technique is often used for patients who have chronic pain. A “body-scan” involves lying down in a comfortable, quiet setting, and using the mind to focus through the body, section by section (feet, legs, thighs, abdomen and so on). Within each section, we notice how it feels (including areas which may be very painful), and then redirect the focus back to breathing (letting the body soften and relax). This continues with each body part until the entire body is relaxed.

The book separates information into five main categories, delving into extensive detail about the philosophy of health, the relationship of the mind to body, stressors people might face, types of health problems that might develop, and ways to react to all of the above.

The first section provides the foundation for mindful meditation and includes many exercises to aid in meditation. Instructions and illustrations for specific techniques such as the “body-scan”, mentioned above, and a sequence of yoga postures are well described and easy to follow. The book not only explains how to do these postures (with appropriate cautionary notes on things which may not be suitable for some individuals) but it also explains what happens in the mind and body when engaging in “mindful hatha” yoga (the style used in the stress clinic). Yoga “is” meditation, according to Kabat-Zinn, and this particular style consists of gentle stretching and strengthening movements, done mindfully and purposefully, and within one’s own limits. The type of yoga he prescribes should never be competitive or focus on doing, pushing, or progressing.

The downside of this book is that there is quite a lot to read and learn about mindfulness meditation, therefore the book is quite wordy. Dr. Kabat-Zinn also incorporates numerous examples and situations from the Stress Reduction Clinic throughout the book. He describes extensively patients' medical backgrounds and feelings about their illnesses. This may appeal to some readers, especially those who seek to relate to other people’s experience.

But others may find this style too wordy and detailed, making it tiring to read and absorb. Nevertheless, the benefits of the information, insights, and skills that can be gained from this book will outweigh the negative aspects for most people. Dr. Kabat-Zinn’s readers can find this book and other material in a CD version as well as video presentations.

[Editor’s note: Since yoga has become very popular, classes in various styles are widely offered at the YMCA, wellness centers, and/or senior centers, just to name a few. This book can be very helpful when evaluating programs suitable for ME/CFS and fibromyalgia and other serious chronic health conditions. Some styles of yoga can be very intense, requiring one to maintain precise poses for long periods of time. Bickram yoga is practiced in a very hot environment (95 to 100 degree room), enabling profuse sweating thought to produce cleansing. These may be suitable for advanced yoga enthusiasts or young and healthy participants, but these are not compatible with the Kabat-Zinn program. Be sure to get a clear description and understanding about any class that you are considering, and ask if instructors offer the type of yoga practice prescribed by Kabat-Zinn.] 

Massachusetts Premiere of INVISIBLE draws supportive and appreciative audience

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Last Updated: 09 November 2015 09 November 2015

 Michael Thurston and Rik Carlson    

INVISIBLE

A film by Rik Carlson and Michael Thurston