Chronic Fatigue Syndrome |
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DescriptionAn in-depth report on the causes, diagnosis, and treatment of chronic fatigue syndrome. |
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MedicationsNo medications are specifically approved for the treatment of CFS. However, some may be useful for specific symptoms or in cases where CFS may have a specific cause. Physicians generally use combinations of drugs to accomplish specific goals, such as medication at night to improve sleep and medication in the morning to improve cognition and energy. Treatment is very individualized, with no standard regimen applying to all patients. Mild Pain RelieversNonsteroidal Anti-Inflammatory Drugs (NSAIDs). Patients with CFS may find relief using nonsteroidal anti-inflammatory drugs (NSAIDs). They are common pain relievers that reduce inflammation and include, among many others, aspirin, ibuprofen (Motrin, Advil, Nuprin, Rufen), and naproxen (Aleve, Naprosyn, Naprelan, Anaprox). Although NSAIDs can work very effectively against symptoms, long term use can trigger gastrointestinal problems such as upset stomachs, ulcers, and internal bleeding. NSAIDs can also increase blood pressure, particularly among people already being treated for hypertension. About 12% to 15% of elderly people take both an NSAID and an antihypertensive drug. Piroxicam, naproxen, and indomethacin appear to pose the greatest risk of high blood pressure. Sulindac has the smallest effect. Other side effects of NSAIDs include dizziness, ringing in the ears, headaches, skin rashes, and possibly depression. Studies have appeared suggesting that high doses of NSAIDs can damage cartilage, and there have also been reports that NSAIDs can cause kidney damage (which, however, resolves once the patient stops using the drug). People with high blood pressure, severe circulation disorders, or kidney or liver problems, as well as people taking diuretics or oral hypoglycemics, must be closely monitored if they need to use NSAIDs on a long-term basis. Because NSAIDs reduce blood clotting, NSAID users scheduled for surgery should stop taking those drugs a week before the operation. COX-2 Inhibitors. Celecoxib (Celebrex), rofecoxib (Vioxx), and valdecoxib (Bextra) are known as COX-2 (cyclooxygenase-2) inhibitors. Meloxicam (Mobic) is a new drug known as a COX-2 preferential. These agents may prove to be as effective and less harmful to the GI tract than NSAIDs. Importantly, studies are reporting a lower incidence of ulcers in patients taking the COX-2 inhibitors than in those taking NSAIDs. One 1999 study even found the rate of GI problems with celecoxib was equal to that in people who do not take NSAIDs at all. COX-2 inhibitors are currently more expensive than traditional NSAIDs, however, and some insurers do not pay for them. Still, long-term side effects are unknown, and some researchers theorize that inhibiting COX-2 may have some negative as well as positive results. Of specific concern are reports of a higher incidence of heart attacks in patients taking Vioxx and Celebrex. As with standard NSAIDs, they may have adverse effects on kidney function and they can also increase blood pressure. AntidepressantsBecause of the association between depression and CFS, antidepressants are often tried with varying degrees of success, depending on the type. Common side effects of many antidepressants include dry mouth, restlessness, reduced sexual drive, a slightly increased heart rate, and constipation. Virtually all antidepressants have complicated interactions with other drugs, and some are very serious. Tricyclic Antidepressants. Antidepressants known as tricyclics may be particularly helpful for CFS patients. For example, the tricyclic amitriptyline (Elavil) is known to relieve many of the symptoms of CFS, including sleeplessness and low energy levels. They may provide benefits by promoting deep sleep and inhibiting pain pathways in the nervous system. Improvement in symptoms can take three to four weeks. Other tricyclics include doxepin (Sinequan), desipramine (Norpramin), nortriptyline (Pamelor), clomipramine (Anafranil), and imipramine (Tofranil, Janimine). These agents can have severe side effects, although patients with CFS normally respond to much lower doses than those used to treat people with depression. In fact, many CFS patients cannot tolerate the higher doses commonly used to treat the psychiatric disorder. Like all medications, tricyclics must be taken as directed; overdose can be life threatening. Monoamine Oxidase Inhibitors (MAOIs). Monoamine oxidase inhibitors (MAOIs) block the enzyme monoamine oxidase, which has negative effects on many of the neurotransmitters that are important for well being. In one study moclobemide, a newer MAOI, was associated with improved energy levels in CFS patients regardless of whether they are depressed or not. Other MAOIs are likely to have similar effects. The most serious side effect of MAOIs is severe hypertension, which can be brought on by eating certain foods having a high tyramine content. Such foods include aged cheeses, most red wines, sauerkraut, vermouth, chicken livers, dried meats and fish, canned figs, fava beans, and concentrated yeast products. They also have serious interactions with a number of medications and should not be taken by pregnant women. Designer Antidepressants. Newer, so-called designer SSRIs, including bupropion (Wellbutrin), nefazodone (Serzone), or mirtazapine (Remeron), affect combinations of different neurotransmitters, and some may have moderate benefits for CFS patients. For example, in one study, nefazodone improved mood, fatigue, and sleep disturbances. SSRIs. The popular antidepressants known as selective serotonin-reuptake inhibitors (SSRIs may be helpful for the subgroup of CFS patients who experience significant depression. They include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). A new SSRI called Cymbalta (duloxetine) will be available as of June 2004. Physicians are hopeful that this will be more effective than other SSRIs, potentially because the drug targets two key neurotransmitters, serotonin and norepinephrine, in contrast to the other SSRIs, which target only serotonin. The popular antidepressants known as selective serotonin-reuptake inhibitors (SSRIs) appear to have little value for CFS beyond treating any accompanying depression. They include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). Treatment of Neurally Mediated HypotensionTreating NMH may be appropriate in the subgroup of CFS patients with this condition. In one study, 76% of patients diagnosed with and specifically treated for neurally mediated hypotension (NMH) experienced improvement within a month, and in 40% of these patients, chronic fatigue symptoms completely or nearly completely resolved. It should be stressed that increasing blood pressure can be very dangerous in individuals with existing normal or high blood pressure. No one should take measures to raise blood pressure without a clear diagnosis of NMH or without a physician's approval. Life Style Changes. For treating NHM, the physician might first recommend nonmedicinal measures:
Medications. If NMH does not improve with lifestyle measures, certain medications may be tried in combination or alone. A wide range of drugs normally used for other disorders have been used to treat NMH, but physicians have had difficulty adjusting them so that they would be effective for NMH without causing distressing side effects. Such medications include the following:
Other Drugs Being Investigated for CFSCorticosteroids. Some evidence exists that patients with CFS may be deficient in cortisol, a steroid hormone. Studies testing the steroid drug hydrocortisone have reported increased energy and less fatigue in patients taking it. However, side effects, including insomnia, increased appetite, weight gain, and, more seriously, suppression of the adrenal gland, make this therapy unacceptable. One study reporting improvement with very low doses (5 mg to 10 mg daily) with only minor side effects may make this therapy feasible for some patients, but longer-term and larger studies are needed. Fludrocortisone (Florinef) is an oral steroid used for low blood pressure. This has been tested specifically on CFS subjects with NMH, but studies reported no benefits and side effects may be serious. Psychostimulants. Psychostimulants may be helpful for a subgroup of patients with CFS who have cognitive problems such as difficulty concentrating, memory problems, and other attention deficit disorder (ADD)-like characteristics. Imbalances in neuroepinephrine and dopamine have been demonstrated in imaging studies of CFS patients, and are thought to be responsible for such symptoms. Although such imaging tests are not available to most patients, experts postulate that the benefit of psychostimulants offers proof that some CFS patients in fact have measurable chemical imbalances. It is not clear whether such imbalances may contribute to causing CFS, or whether the disease underlying CFS causes such changes in neurochemical structures in the brain. Traditional psychostimulants have included Dexamphetamine, Adderal, Ritalin and Ritalin-like drugs such as Focalin, Concerta, Ritalin LA, and Metadate. Newer agents include Strattera and Provigil. Ampligen. The drug polyl:polyC12U (Ampligen) is a form of genetic material called dsRNA. It inhibits viral replication. While early studies yielded questionable results, more carefully designed, larger studies are now showing clear benefits to CFS patients. The largest study to date, presented in 2004, found that compared to placebo, Ampligen considerably increased exercise ability and caused no serious adverse effects. At this time Ampligen must be administered by intravenous injection and is extremely expensive. If it becomes available in pill form, it may gain insurance reimbursement and wider use among patients. Atypical Antipsychotics. Antipsychotic medications including Zyprexa and risperdal are gaining use for their benefits in improving sleep among CFS patients. Although formal study is lacking, anecdotal evidence suggests benefits in fatigue and pain for some patients. Among other atypicals under investigation is Xyrem, or GHB. Because of its notoriety as the date rape drug in the 1990s, it is being approached with great caution. Xyrem is currently approved for the treatment of narcolepsy. Alternative RemediesBecause of the difficulties in treating chronic fatigue syndrome, many patients seek alternative therapies. Some, such as acupuncture and relaxation techniques, may be helpful and are not dangerous. No scientific evidence exists that vitamin and mineral supplements will relieve CFS, but taken in moderation, they are usually not harmful. Herbal or Natural Medicines. A number of herbal medicines have been used for chronic fatigue syndrome. Most have not proven to be effective and some may even be harmful.
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