Transcript

Lee Tetreault:

Welcome to Frequently Asked Questions from the session, Chronic Fatigue Syndrome. We are joined by Dr. Fan? Before we begin with these questions, Doctor, would you be able to reiterate a few key pointers from today's session to our audience?

Dr. Fan:  

Thank you, Lee. So what I talked about today is a baffling condition called chronic fatigue syndrome, both as a pure entity, and also a strong association with a much more common condition called fibromyalgia. The way we define chronic fatigue syndrome is to have the following criteria as a bare minimum: The patient has to have chronically fatigue for about, at least six months, and the degree of fatigue has to be great enough to reduce her activities of daily living, her function, her work by at least 50% of the normal premorbid ability. So with that in mind, then we would also need to do a very careful history and physical examination to look for much more common reasons why people are chronically tired, and that unfortunately embraces pretty much all of medicine. So we need to look into, for example, the general health of the patient. Is there underlying cardiovascular disease, poorly compensated? Congestive heart failure could be a prominent cause of fatigue, so could chronic obstructive lung disease, for example.

Do they have endocrine problems that are not well-managed, low thyroid, adrenal insufficiency by history, or by clinical features? We also keep in mind whether there is significant general anxiety disorder or depression, because some of the somatic complaints there could simply reflect underlying depression and anxiety. We also want to get a history about drug use, both drug addiction, which can suddenly be linked to fatigue, or even the drugs that are legitimately prescribed to some of them provoke fatigue. So a careful history is important. And then a careful physical examination would also be important in giving you pointers on what may be causing fatigue in that context. Someone that we call chronic fatigue syndrome or fibromyalgia should really have a normal physical examination, where despite the litany of complaints, we do not find objective clinical evidence causing those conditions. For example, they claim that they are very weak and their muscles are weak, but when we examine muscle strength, it would be normal. So in summary, the talk really was to concentrate on giving you a clear idea of how a patient with chronic fatigue syndrome, with or without fibromyalgia, would present.

Lee Tetreault:

Thank you, Doctor. Are Provigil and Nuvigil effective for treating CFS?

Dr. Fan:  

Yeah, that was one of the questions that was asked, and aroused interest. Some of the drugs that we use to treat narcolepsy or ADD, mainly some of the brain stimulants, would they be beneficial? And the answer is a provisional yes. In patients who are really fatigued, we have used small doses of these drugs, as well as Ritalin or even dextroamphetamine. The concern is that some patients with chronic fatigue and fibromyalgia have a lot of symptoms of palpitation and tachycardia, shortness of breath; and some of those cardiac symptoms can be aggravated by these stimulants. So you have to use very small doses to begin with, and not try to push them up to the levels that we used to treat ADD, for example, or narcolepsy, but smaller doses, in addition to other medicines, or even a few cups of coffee to see if that would help the fatigue.

Lee Tetreault:

What is the most reliable way to test for adrenal insufficiency as a cause of CFS?

Dr. Fan:  

Adrenal insufficiency as a cause of CFS is actually uncommon. Clinically, they may bear some of the findings of it. In evaluating my patients, I don't really recommend tests for adrenal axis as part of the routine workup; but in select patients, you could do a early morning plasma cortisol, to see if it's low. If there were evidence, then you could do an ACTH stimulation test, to see if the axis is normal; but I must say that this occurs in a very small minority of fibromyalgia and chronic fatigue patients because low adrenal function is just not very common in this context.

Lee Tetreault:

What is the relationship between CFS and depression?

Dr. Fan:  

Very strong relationship. Most people who are depressed do feel tired, as you know. The problem, of course, is chicken and the egg. If you have chronic fatigue syndrome without depression, but it is now a year now since you were able to work full-time, you have to take time out from work very frequently because you're so tired, don't you get depressed? So very often, we are treating depression or general anxiety, but not claiming that the entire cause of the depression... I mean, of the fatigue is the depression. We need to understand that. So every time I treat chronic fatigue syndrome and fibromyalgia, I'm very aware of looking for signs of depression and anxiety, and I may even consult one of my psychiatric colleagues to secure that diagnosis, and make sure that those conditions are well-treated, but I warn the patient that that doesn't necessarily mean that all their fatigue, or all their muscle pains will go away. So yes, the relationship is complex, but not a direct cause and effect.

Lee Tetreault:

Can you please discuss treatment of chronic fatigue syndrome?

Dr. Fan:  

Treatment of chronic fatigue syndrome is first of all, to recognize the condition, secondly, to educate the patient that at present, we still don't know the cause of the chronic fatigue, but then we're quite sure that it is not caused by a virus or other infection. We try to dispel a lot of the myths around chronic fatigue syndrome being part of an undiscovered virus, or chronic Epstein-Barr virus, or chronic Lyme disease. Because they go through fruitless treatments for viruses that really doesn't help the fatigue. We educate them that it is a benign disorder, that as bad as they feel, their body is not deteriorating. Other than being deconditioned, they're not really getting muscle breakdown, or joint inflammation, or their brain is deteriorating, or that they have an autoimmune disease like lupus that is attacking the body.

So the symptoms may be present chronically, but they don't lead to objective evidence of tissue damage, so it's a benign condition. And the most important aspect of treating chronic fatigue syndrome is to use non-pharmacologic modalities, such as a daily exercise program. I find swimming, aquatic exercise, tai chi, yoga all to be beneficial, daily stretching. Inactivity begets more inactivity, and it begets more fatigue. And when you try to exercise, you get delayed onset muscle soreness, so that the joint symptoms get worse, so you need to break this cycle of inactivity, and that is very important.

And the third avenue is to make sure that sleep is properly protected. They need to set aside a quiet environment, and a time for proper sleep. They should avoid taking naps during the day, which further disrupts their regular sleep pattern, and maybe use drugs to enhance sleep, which I use very low doses of tricyclics. I use liquid doxepin in small doses, like 3 milligrams a night, to enhance sleep. Or maybe one of the muscle relaxants because proper sleep is very important. After having gone through all the different non-pharmacologic approaches, then we judiciously use medications. And the medicines are really directed at whether we're dealing with pure chronic fatigue, or chronic fatigue in the context of fibromyalgia, where there's a lot of muscle pain and joint pain. So if fatigue is the dominant issue, then I tend to use the so-called SNRIs, the dual serotonin-norepinephrine release inhibitors, such as the duloxetine, milnacipran, in small doses and build them up because that helps not only the fatigue, but relieves some underlying depression.

If, on the other hand, the problem is lack of sleep, poor sleep and muscle soreness, I add the anti-seizure drugs such as gabapentin or pregabalin typically at night, again, in small doses, and gradually build them up. But they are not mutually exclusive. Patients do well with combinations of an SNRI together with a sleep-promoting drug, together with an anti-seizure drug for the pain. And you can use permutations and combinations. Recently, there's been a push to use cannabis in various forms to treat chronic fatigue and fibromyalgia, but I must warn you that this is still very new, and we don't really know in the long run what it is like to have someone chronically on a cannabinoid.

But that is being used now to treat the pain of fibromyalgia, as well as narcotic antagonists like naltrexone. What you really want to avoid in this context are the opioids. So we do not use narcotics to treat chronic pain in the context of fibromyalgia and chronic fatigue syndrome because we think that the underlying problem with both chronic fatigue and fibromyalgia is central sensitivity, where the brain becomes overly sensitive to signals from the environment, causing the discomfort and the pain and signals within the body affecting the autonomic system, causing the fatigue, the dizziness, the orthostatic imbalance. And the problem with opioids is that it induces hyperalgesia and hypersensitivity in the brain, and taken long-term, can actually make the symptoms worse.

Lee Tetreault:

Final question, Doctor. Can you contrast a FM tender point versus a MFPS trigger point?

Dr. Fan:  

Very nice question. So there are two conditions, one is fibromyalgia, the other is myofascial pain syndrome. And both have tender points or trigger points. Myofascial pain syndrome is the older terminology. We use it when people have a lot of soreness and tenderness in one region of the body, typically the neck and shoulder girdle after, let's say, an automobile accident. We call this chronic whiplash syndrome, and they are very tender in these tender areas. And to be honest, they're actually the same tender points as fibromyalgia. But in the older MFPS literature, the myofascial pain literature, there is a contention that these are trigger points. When you press them, the pain triggers along a certain pathway; whereas fibromyalgia, they are tender, but they don't trigger. The truth is that they're probably the same.

Lee Tetreault:

Great. Thank you so much for your time today, Doctor.

Dr. Fan:  

Thank you, Lee.

 

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