R. Paul St. Amand, M.D. on Guaifenesin Treatment
October 12, 2004
R. Paul St. Amand MD, is a graduate of Tufts University School of Medicine. He has been on the teaching staff at the Los Angeles County Harbor-UCLA Medical Center Department of Endocrinology for over forty-three years. He is currently an assistant clinical professor at the UCLA School of Medicine.
Fibromyalgia (once called “Fibrositis”) was first described in 1843 as a type of rheumatism “with painful hard places.” Today, Fibromyalgia is accepted as a distinct illness. Patients present with fatigue, insomnia, non-restorative sleep and generalized pain.
Over thirty-seven years ago, a patient taking gout medication found he could easily break tartar off his teeth with his fingernail. Dental calculus is a calcium phosphate deposit in the form we recognize as “apatite.” It seemed probable a serum derived abnormality existed in saliva that allowed such deposition. Total body calcium and phosphate might attain excessive, critical levels.
Cellular accumulation would interfere with energy formation and cause malfunction of susceptible systems. This would explain not only tenderness, palpable swelling and spasm but also the generalized complaints. We began using “gout drugs” for patients with the above symptoms and findings. We stress, uric acid and gout have no relationship to Fibromyalgia. To be effective, a medication must act on nearly the same area of the kidney that malfunctions in most cases of gout. Allopurinol, which blocks formation of uric acid does not affect renal excretion and is useless for Fibromyalgia. We feel an inherited defect permits some type of excessive, kidney retention that leads to an abnormality in the metabolism of phosphate and calcium.
We now rarely use the two gout medications, probenecid (BenemidTM) and sulfinpyrazone (AnturaneTM) for Fibromyalgia. Another medication, guaifenesin, is normally prescribed to loosen mucus (mucolytic effect) in patients with chronic sinusitis, bronchitis and various lung diseases. Unlike the previous drugs, it only weakly increases excretion of uric acid and would be useless for gout. It has no listed side-effects though we have learned of nausea, heartburn, itching or rash in rare instances. We usually begin with one half tablet (300 mg) twice a day for one week, an adequate dosage for twenty percent of individuals. If needed, we increase to 600 mg (full tablet) twice daily according to changes we and patients note. For about 70 percent, one of these two dosages suffices. Obviously, 30 percent will need larger amounts. Adjustment is made as suggested by our subsequent mapping.
Observations suggest a primary defect in phosphate, not calcium metabolism. Calcium with or without magnesium tablets taken with meals have allowed lower dosages of medication possibly because they bind phosphates from food, increase fecal excretion and thereby lessen absorption. Some patients have fingernail changes that suggest an abnormal calcium phosphate deposition at the root. Similar to concentric tree rings, they grow and eventually break or peel at the tip. Primarily phosphate, some calcium and oxalate, increased in the urine as we initiated treatment in the few patients we tested.
Our hypothesis is that an inherited, abnormal renal retention of phosphate and secondarily, calcium, leads to an intracellular excess of both. Cells and their power stations, the mitochondria, malfunction and produce inadequate ATP, the currency of energy. An energy deprivation syndrome develops and affects susceptible, widespread, bodily functions. We realize this is simplistic and the chemistry far more involved.
Aspirin completely blocks the benefit of all medications we have used, including guaifenesin. The greatest source of patient error comes from taking aspirin-related agents, salicylate or salicylic acid, which interfere with guaifenesin at the kidney level. Skin readily absorbs these compounds. Almost all plants manufacture salicylates, often in large quantities. Parts from leaves, roots and seeds concentrate salicylate in herbal medicines. Patients can neither take these nor use any skin creams that contain plant products. This includes products such as nasal sprays or suppositories. Our warnings do not apply to foods, cooking herbs and spices though they do harbor salicylates. The content is insufficient to block benefits if cumulative, extraneous sources are not added.
This is deliberately repetitious because it is important. We cannot detect how easily or completely one's genetic make-up allows blocking. Assume you are very sensitive. Be meticulous in conducting your search of current or replacement products. Manufacturers make sudden changes and often list only “active” ingredients. If you must use the product contact the manufacturer to learn of “inactive” ones, which might include aloe, mentholatum etc.
Many pain medications contain aspirin or have “salicylate” or “salicylic acid” as part of their contents. You cannot use these. Tylenol, Advil, Darvocet-N and anti-inflammatory drugs are acceptable.
Heed the warning: all plants make salicylates. “Natural” refers to something made in nature. Poison ivy, oleander and hemlock are all natural but that does not make them safe. You must avoid products with that word including such things as aloe, ginseng, menthol, mentholatum, almond, grape seed oils etc. in creams, lotions and herbal medications.
Castor oil and camphor have recently appeared in many lotions, lipsticks and underarm deodorants–they are high in salicylates.
Ingredients with plant names butchers' broom, rosemary, geranium, St. John's Wort must be avoided. Oils made from plant parts must not be applied to the skin.
Avoid vitamin E derived from rose hips and vitamins from “natural” sources such as vitamin C with bioflavonoids, which may contain quercetin, a source of salicylates.
Avoid all lip balms with the exception of plain Vaseline. Tubes of this product are available. All creams and lotions for muscle and rheumatic pains such as Ben Gay contain salicylates and cannot be used. All sunscreens or sunless tanning products with plant derivatives, including oxylsalicylate readily block. Cleansing lotions, astringents, exfoliants, lotions for oily skin and acne compounds, such as Stridex, often contain salicylates.
It is best to avoid herbal shampoos and hair conditioners though they are not on the scalp long. Herbal hair sprays will land on the skin and deliver salicylates. Avoid shaving creams or soaps with menthol or aloe; microscopic cuts produced by razors with aloe-coated, white or colored strips provide direct access into the bloodstream.
Use no herbal bubble baths. Wart and callus removal products almost all contain salicylates. Pepto-Bismol is bismuth subsalicylate. Certain mouthwashes such as Listerine, contain salicylate as do toothpaste's with “gum care ingredients.”
These offending substances will be absorbed and partially or totally block the effect of guaifenesin. No adverse reaction ensues but no benefit is attained. Patients should obtain plain “guaifenesin,” not a tablet containing decongestants or anti-cough preparations.
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