- Designing Your Chronic Fatigue Treatment Plan
- The Practice of Ranking Medicine
- Trying Antidepressant No. 2
- Sleep Problems
- More than a happiness boost: How mood medications help when you’re depressed
Designing Your Chronic Fatigue Treatment Plan
Chronic fatigue syndrome treatment is a very individual thing, based on each patient’s symptoms and response to different therapies.
How you describe your symptoms of chronic fatigue syndrome will often guide your treatment plan. “A lot of it has to do with how patients answer the questions,” explains Morris Papernik, MD, a doctor in private practice with ProHealth Physicians Group in Glastonbury, Conn., and a member of the U.S. Department of Health and Human Services Chronic Fatigue Syndrome Advisory Committee. “That’s what we tell residents and medical students all the time — it’s not a cookbook type of science here. We’re dealing with an illness that is somewhat nebulous. You need to practice the art of medicine.”
For example, how a patient describes her sleep and fatigue problems will help direct chronic fatigue treatment recommendations. “If a patient complains of fatigue and lack of energy, you say, ‘Tell me about your sleep.’ Maybe sleep is not the problem — it could be daytime energy,” says Dr. Papernik. Treatments for boosting daytime energy are different than those used to ease sleep disturbances.
Chronic Fatigue Treatment Options
Among treatments that may be helpful for patients with chronic fatigue symptoms are these classes of drugs:
- Antidepressants and benzodiazepines. Although not everyone with chronic fatigue syndrome is depressed, some antidepressants can help ease fatigue, pain, and disordered sleep. Cymbalta (duloxetine HCI) is one of the most commonly prescribed antidepressants, followed by Effexor (venlafaxine). The benzodiazepine Klonopin (clonazepam) may also be used to help people sleep at night.
- Anticonvulsants. For reasons that are not clear, medications typically used for prevention of seizures can sometimes help people with CFS. Lyrica (pregabalin) may be prescribed, especially for patients who also have fibromyalgia pain. Lyrica has been shown to reduce pain and physical discomfort in these patients.
- Thyroid medications. Thyroid treatments can complement other treatments for people who are not responding as expected, especially if thyroid hormone levels are borderline. “Lots of times we will add thyroid pills to the mix if patients are not getting the response that we look for,” says Papernik.
- Stimulants. Provigil (modafinil) or Nuvigil (armodafinil) may be prescribed to increase daytime alertness. “Some people go so far as to use amphetamines,” says Papernik, although he does not recommend this approach over a long period.
- Pain medication. For patients who experience severe headaches, joint pain, or other pain that is not managed with other treatments, pain medications may ease those symptoms.
The possibility of a link between a virus called XMRV and chronic fatigue syndrome may have patients seeking a type of treatment called antiretroviral therapy. XMRV is classified as a retrovirus, which means infection with it may allow other, previously dormant (inactive) viruses within the body to reactivate. The human immunodeficiency virus (HIV) is the best-known retrovirus, and the antiretroviral drugs on the market are aimed at treatment of HIV, not XMRV.
Papernik warns against the retroviral treatment approach because there is no test that can reliably tell you if you have XMRV and because its role in CFS is not clear. Current antiretroviral medications have many strong side effects that make them inadvisable for treatment of unproven XMRV infection.
Alternative Treatments for Chronic Fatigue Syndrome
You may hear a lot about vitamin therapy and other kinds of herbal supplements that are said to ease chronic fatigue symptoms. However, says Papernik, the only alternative therapies for chronic fatigue syndrome that have been shown to work better than placebos are:
- CoQ10 (coenzyme Q10), 100 milligrams (mg) three times a day
- NADH (nicotinamide adenine dinucleotide), 5 mg twice a day
- SAM-E, 200 to 400 mg twice a day
Many CFS patients try acupuncture, valerian root, aloe vera, and magnesium, Papernik says. While there is no data to support these treatments, Papernik points out that they probably don’t cause any harm.
A Word of Caution About Chronic Fatigue Treatment
The lack of a standardized approach to chronic fatigue treatment means that patients may encounter advertisements from companies claiming to have a product to help with chronic fatigue symptoms, as well as practitioners who promise a quick cure. At the opposite end of the spectrum, CFS patients may encounter doctors who do not take their symptoms seriously. Papernik advises patients to be cautious when selecting a treatment approach. He warns patients to avoid doctors who:
- Do not appear to be listening to your description of your chronic fatigue symptoms — one size does not fit all in the CFS world
- Tell you that your experience is all in your head and want to refer you to a psychiatrist
- Are interested in selling you a line of vitamins offered in their office
- Push intravenous vitamin, antibiotic, or antifungal treatments, which have not been shown to work better than placebos
Remember, finding the right doctor and communication are the keys to successfully treating chronic fatigue syndrome — and that means communicating with your doctor openly and clearly about symptoms, side effects, and any traditional or alternative medicine options you’re using.
- CFS Basics
- See All Chronic Fatigue Syndrome Articles
Milnacipran HCl (Savella)
Pregabalin (Lyrica), duloxetine (Cymbalta), and milnacipran HCl (Savella)are medications approved by the FDA for the treatment of fibromyalgia. Fibromyalgia is a chronic disorder characterized by widespread pain and tenderness, general fatigue, and non-restful sleep. Doctors do not currently know the cause of fibromyalgia, but it is believed that people with this condition have experienced a rewiring of pain pathways in the brain due to repeated nerve stimulation. As a result, the central nervous system (your brain and spinal cord) experiences an increased sensitivity to pain signals. Many people with lupus have fibromyalgia; in fact, much of the pain that people with lupus feel is due to this condition. Both pregabalin and duloxetine were originally developed to treat other conditions (epilepsy and depression, respectively), but they have also proven successful in reducing some of the physical and emotional symptoms of fibromyalgia.
Pregabalin helps fibromyalgia by reducing pain by up to 25% and improving sleep and fatigue. Many people also report that this medication helps to improve their overall vitality. It is not known exactly how pregabalin works to combat symptoms of fibromyalgia, but some believe that it binds to a protein in nerve cells that is responsible for heightened pain sensitivity. Like other medications, pregabalin can have some side effects, including dizziness, drowsiness, dry mouth, edema, blurred vision, weight gain, swelling of the hands and feet, constipation, exaggerated feelings of happiness/wellness, balance disorder, increased appetite, and difficulty concentrating.
Duloxetine also helps to improve pain and promote an overall feeling of improvement in patients with fibromyalgia. It is not known exactly how duloxetine works in the body against the symptoms of fibromyalgia, but it is known that this medication increases the activity of two neurotransmitters in the brain, serotonin and norepinephrine. These neurotransmitters are known to be linked to emotion and mood, but research also suggests that they are involved in the brain’s natural pain-suppressing system. Duloxetine can have some side effects, including nausea, dry mouth, constipation, decreased appetite, drowsiness, increased sweating, and agitation. More information on duloxetine can be found under the information sheet, “Antidepressants.”
Like duloxetine, milnacipran also increases the activity of the neurotransmitters serotonin and norepinephrine and was first used as an antidepressant. However, the drug has been shown to significantly improve pain and physical function in people with fibromyalgia and was approved this year by the FDA for the treatment of this condition. Like pregabalin and duloxetine, it is not known precisely how milnacipran works to combat fibromyalgia.
While pregabalin, duloxetine, and milnacipran can help reduce discomfort, there are many things that you can do on your own to help ease and manage the symptoms of fibromyalgia. Some people believe that limiting their daily activities helps to reduce pain and fatigue. However, doctors recommend that people with fibromyalgia continue to engage in their regular daily activities. Scheduling daily rest times may help you to keep a normal schedule; spending too many hours resting may make your symptoms worse and prevent you from adjusting to life with fibromyalgia.
In addition, since responses to stress can cause physical symptoms such as headache, increased pain, and muscle tension, try to practice stress management skills. There are some stressors that you can control, and there are some that are simply out of your hands. Focus on what you can control, and direct your energy toward future growth. Practice stress management by identifying stressors, focusing on what you can control, using coping techniques when a stressor is beyond your control, practicing relaxation techniques, and sometimes, simply letting go.
In addition, try to practice a healthy lifestyle. Research has shown that light stretching activities such as Tai chi and yoga can help to relax muscles and improve some of the pain associated with fibromyalgia. In addition, molecules released by your brain after exercise—usually about 30 minutes of moderate or intense activity—help you to achieve a ‘natural high,’ and many people report that exercise simply makes them feel better overall. Other lifestyle elements, such as a supportive social network and a healthy diet, can also help to ease feelings of emotional and physical discomfort and promote an overall sense of well being. Remember that you play the most important role in maintaining your own personal health. Your doctor can help you to devise strategies if you feel you need more help in managing your fibromyalgia.
Lyrica (pregabalin), when used on its own for fibromyalgia, is superior to opioids in reducing pain and improving pain interference in daily life, finds a study sponsored by Pfizer. The analysis, which included 1,421 fibromyalgia patients, showed that those using Lyrica doses recommended for fibromyalgia treatment had the best outcomes, suggesting that many patients should increase their doses to reach recommended levels. Pfizer and ProCare Systems conducted the study, “Interpreting the Effectiveness of Opioids and Pregabalin for Pain Severity, Pain Interference, and Fatigue in Fibromyalgia Patients,” which took aim at the notion that — despite little evidence of their effectivity — opioids are the most commonly prescribed drugs for fibromyalgia. To examine how different treatments affect pain and related outcomes in fibromyalgia patients, the research team turned to information from the ProCare Systems network of chronic pain clinics in Michigan. All patients received Lyrica or opioids alone or in combination, and had been through several pain health assessments, including pain characteristics, physical function and psychosocial function. The team divided the patients into different groups based on their average morphine equivalent dose or average Lyrica dose. Patients were followed between 56 and 365 days. Nearly 78 percent of them were women — typical of fibromyalgia in the real world. Findings, published in the journal Pain Practice, showed that only 3.4 percent of patien Subscribe or log in to access all post and page content.
Jan. 29, 2009 — When someone swallows his or her first antidepressant, it may come as a surprise how the psychiatrist chose that particular pill to prescribe: It’s a best guess out of dozens of antidepressants on the market.
Now, a few psychiatrists have set out to bring some order to this educated guessing game. By looking at 117 studies of the 12 most popular antidepressants, researchers ranked the top 12 drugs in the journal The Lancet.
To view their results, click here.
Zoloft and Lexapro came in first for a combination of effectiveness and fewer side effects, followed by Prozac (fluoxetine), Paxil (paroxetine), Cymbalta, and Luvox among others.
“We were surprised because we found a difference among antidepressants,” said Dr. Andrea Cipriani of the University of Verona, Italy, and a co-author on the study.
“What we usually said was that all antidepressants worked the same,” said Cipriani, who explained that doctors often compare different side effects while choosing an antidepressant.
“So, is there a rationale, is there a hierarchy?” Cipriani asked.
Now, he hopes the ranking will offer more guidance for doctors choosing the first antidepressant for a patient.
Although many psychiatrists are leery of the list, patients who’ve gone through years of distressing trial and error might find it comforting.
“When I first was diagnosed with depression, they tried all sorts of medication,” said Paul Letourneau, 67. “It was terrible.”
Letourneau of Worcester, Mass., lived antidepressant-free until 2004, when his parents died, his dog died and he lost his house. Then his life-long mild depression took a serious turn. Drug after drug, Letourneau found the side effects worse than the depression itself.
His rollercoaster emotions landed Letourneau in the hospital on suicide watch four times in two years.
“I was really over-medicated and he ended up taking me off a lot of the medication and we settled on the two that I take now, and I feel great,” Letourneau said. “I’ve been stable for a year.
“When your medication starts to work and you get involved in a positive thing in life, it does help you tremendously,” he said.
Cipriani said issues like Letourneau’s motivated him to try and narrow down the best drugs for a patient in need of antidepressants to try the first time. Indeed, Cipriani added, the idea and the method for ranking treatments is not new in medicine.
The Practice of Ranking Medicine
“This has been used in oncology but this is the first time it’s been used in psychiatry,” he said.
Yet, the ranking did little to sway the thinking of some psychiatrists.
“This rating would not change the way that I prescribe at all,” said Dr. Mark I. Levy, a distinguished life fellow of the American Psychiatric Association and an assistant clinical professor of psychiatry at the University of California, San Francisco.
Levy said he largely agrees with the rating because he has found that, on average, Zoloft and Lexapro come with fewer side effects, such as agitation, insomnia or weight gain.
“However, ‘on average’ doesn’t take into account the individual patient who is sitting in front of me in my office,” Levy said.
When patients come to Levy, he tries to match their unique emotional profile to the drug with the most compatible side effects, he said.
“For example, an agitation patient with severe insomnia may do best on Paxil, not Zoloft … a patient with marked symptoms of psychomotor retardation may do best on Prozac. A patient with great concern about their libido may do best starting on Wellbutrin,” Levy said.
But, in many cases, the first person to prescribe an antidepressant isn’t a psychiatrist, it’s a family physician. In that case, Levy might see use for such a ranking.
“It may greatly affect prescribing practices by non-psychiatric physicians, primary-care doctors in particular, who do most of the antidepressant prescribing, so it is good news for the generic makers of sertraline and for Forest Pharmaceuticals, who still have the patent on Lexapro,” Levy said.
Other psychiatrists believed the rankings reflected their usual prescription decisions for patients trying antidepressants for the first time, anyway.
Trying Antidepressant No. 2
“I would be likely to start patients on either Zoloft or Lexapro …,” said Dr. Harold G. Koenig, a professor of psychiatry and behavioral sciences at Duke University Medical Center in Durham, N.C.
“Unfortunately, that is almost none of my patients. By the time they get to me , the primary-care doctors have tried Zoloft and other antidepressants, so my patient are not the “new to medication” kind of patients,” he said.
Still, Cipriani hopes the rankings will have an impact on depression treatment, even if psychiatrists use other ways to choose an antidepressant for their patients.
He hopes the ranking could be used as a measuring stick for all the new antidepressants coming to the market.
“When developing new drugs for treating depression, usually we have placebo controlled trials … but before new treatments that are going to be on the market, we need an active comparable list,” Cipriani said. “Perhaps the new drugs have to be better than the active standard.”
As for Letourneau, he thinks beating depression requires the right drugs, but also a change in thinking.
“When people suffer from mental illness, they very often isolate themselves in life,” Letourneau said. “The best thing is to get active. When you sit on your butt doing nothing, all you do is think about your problems.
“I volunteer every day in a place called the Genesis Club in Worcester, Mass,” Letourneau said. “I feel great.”
Many people with ME/CFS have some kind of sleep disorder. Getting a good (or at least better) night’s sleep could help you feel less tired during the day.
First, your doctor will probably make sure you have good sleep habits. These include sticking to a regular bedtime and wake time and keeping your bedroom quiet, dark, and cool.
If this doesn’t improve your sleep, she might suggest an over-the-counter sleep aid, such as an over-the-counter antihistamine. While these can help you sleep soundly through the night, the downside is that the effects can last more than 8 hours. This means you could feel drowsy throughout the day, which is exactly what you’re trying to avoid. But not all sleep aids affect everyone in the same way. Talk to your doctor about which type would be best for you and how to take it.
If over-the-counter sleeping pills don’t do the trick, your doctor might try you on a prescription sleeping pill. The goal with these drugs is to get your sleep on track at the lowest possible dose in the shortest amount of time. You aren’t supposed to take them long term.
Some prescription sleep medications help you get to sleep, such as:
- Eszopiclone (Lunesta)
- Ramelteon (Rozerem)
- Zolpidem (Ambien)
Others that your doctor may prescribe help you stay asleep. For example:
- Trazodone (Desyrel)
- Muscle relaxants
All prescription sleep medications cause side effects. But some of them — daytime sleepiness, dizziness, unsteadiness, and memory lapse — are also symptoms of chronic fatigue syndrome. You and your doctor should weigh the pros and cons. The beneficial effects of many of these medicines wear off in a few weeks, so they are not useful for long-term treatment.
More than a happiness boost: How mood medications help when you’re depressed
Published: August, 2016
Antidepressants can help reduce insomnia, loss of appetite, and fatigue associated with depression.
When your doctor recommends an antidepressant to fight depression—such as selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs)—it’s about more than just boosting your mood. Depression has many potential physical effects. “Most people aren’t aware that depression can lead to other health problems,” says Dr. Amanda Hernandez, a geriatrician at Harvard-affiliated Massachusetts General Hospital.
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The most recent Monitoring the Future survey shows a disturbing fact: Prescription stimulants such as Adderall® and Ritalin® are two of the drugs most frequently abused by high school seniors, with 6.5 percent reporting nonmedical use of Adderall® in the past year.1 Doctors prescribe stimulants to treat attention deficit hyperactivity disorder (ADHD), narcolepsy (a sleep disorder), and, occasionally, depression.
When taken as prescribed, these medications help a lot of people. Unfortunately, they are too often abused by being taken in doses and/or in ways other than intended, or by being used by someone for whom they were not prescribed. Prescription stimulants are powerful drugs, and when they are abused there can be serious health consequences, including addiction. Read on to get the facts about prescription stimulants and why abusing them is dangerous.
What Are Prescription Stimulants?
Prescription stimulants include medications such as methylphenidate (Ritalin® and Concerta®) and amphetamines (Dexedrine® and Adderall®). These medications, which are in the same class of drugs as cocaine and methamphetamine (“meth”), increase alertness, energy, and attention. Like all stimulant drugs, prescription stimulants increase levels of dopamine in the brain. Dopamine is a neurotransmitter associated with pleasure, movement, and attention.
How Do Prescription Stimulants Treat ADHD?
People with ADHD have problems maintaining attention (e.g., fidgeting or trouble concentrating), and may be more hyperactive and impulsive than others of the same age. For teens, this can result in difficulty with completing schoolwork or other tasks. Doctors prescribe stimulants such as Concerta® and Adderall®, sometimes in combination with counseling, to treat these symptoms. These stimulants can have a calming effect on people with ADHD that helps them focus, dramatically improving their ability to stay organized and complete tasks.
When prescribed, stimulant medications are usually started at a low dose and gradually increased until symptoms subside, or until side effects become problematic. When taken as directed, prescription stimulants produce slow, steady increases of dopamine in the brain. Scientists think that these gradual increases may help to correct abnormal dopamine signaling that may occur in the brains of people with ADHD.
Why Do They Require a Prescription?
Prescription stimulants are strong medications, and their proper use needs a doctor’s supervision. The first step is an accurate diagnosis of a physical or mental disorder, such as ADHD, by a qualified doctor. Then, if appropriate, stimulants may be prescribed. A doctor should monitor both the positive and possibly negative effects of the medication to make sure it’s treating symptoms as intended.
Why Are Prescription Stimulants Abused?
Many teens report abusing prescription stimulants to get high because they mistakenly believe that prescription drugs are a “safer” alternative to illicit drugs. Teens also report abusing prescription stimulants to try to lose weight or increase wakefulness and attention. Some even abuse them to get better grades. Research, however, shows that stimulant abuse is actually linked to poorer academic performance. Why? Because people who abuse stimulants often take other drugs and engage in behavior that puts their academic performance at risk (e.g., skipping classes).
Is Abusing Prescription Stimulants Dangerous?
Yes. In fact, taking prescription stimulants in high doses, or by injection, smoking, or snorting, can affect the brain in ways similar to cocaine or other drugs of abuse (see below). Prescription stimulant abuse can result in abnormally high levels of dopamine, producing euphoria, an intense feeling of happiness. This increases the risk for abusing again, and ultimately for becoming addicted.
Abusing prescription stimulants can also result in increased blood pressure, heart rate, and body temperature, as well as nausea, headaches, anxiety, psychosis, seizures, stroke, and heart failure. Individuals who chronically abuse prescription stimulants may experience withdrawal symptoms when they stop using them. These symptoms can include fatigue, depression, and disturbed sleep patterns. Although not life threatening, these symptoms often prompt a return to drug use.