Pharmacologic therapy is directed toward the relief of specific symptoms experienced by the individual patient. Patients with CFS appear particularly sensitive to drugs, especially those that affect the central nervous system. Thus, the usual treatment strategy is to begin with very low doses and to escalate the dosage gradually as necessary.
Low-dose Tricyclic Agents: Tricyclic agents are sometimes prescribed for CFS patients to improve sleep and to relieve mild, generalized pain. Examples include doxepin (Adapin, Sinequan), amitriptyline (Elavil, Etrafon, Limbitrol, Triavil), desipramine (Norpramin), and nortriptyline (Pamelor). Some adverse reactions include dry mouth, drowsiness, weight gain, and elevated heart rate.
Antidepressants: Antidepressants have been used to treat depression in CFS patients, although non-depressed CFS patients receiving treatment with serotonin reuptake inhibitors have been found by some physicians to benefit from this treatment as well or better than depressed patients. Examples of antidepressants used to treat CFS include serotonin reuptake inhibitors such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil); venlafaxine (Effexor); trazodone (Desyrel); and bupropion (Wellbutrin). A number of mild adverse reactions, varying with the specific drug, may be experienced.
Anxiety or anxiolytic agents: Anxiolytic agents are used to treat panic disorder in CFS patients. Examples include alprazolam (Xanax), clonazepam ( Klonopin), and lorazepam (Ativan). Common adverse reactions include sedation, amnesia, and withdrawal symptoms (insomnia, abdominal and muscle cramps, vomiting, sweating, tremors, and convulsions).
Nonsteroidal Antiinflammatory Drugs: These drugs may be used to relieve pain and fever in CFS patients. Some are available as over-the-counter medications. Examples include naproxen (Aleve, Anaprox, Naprosen), ibuprofen (Advil, Bayer Select, Motrin, Nuprin), and piroxicam (Feldene). These medications are generally safe when used as directed, but can cause a variety of adverse effects, including kidney damage, gastrointestinal bleeding, abdominal pain, nausea, and vomiting.
Antimicrobials: An infectious cause for CFS has not been identified, and antimicrobial agents are not commonly prescribed for CFS, unless of course the patient has been diagnosed with a concurrent infection.. A controlled trial of the antiviral drug acyclovir found no benefit for the treatment of patients with CFS.
Antiallergy Therapy: Some CFS patients have histories of allergy, and these symptoms may flare periodically. Non-sedating antihistamines may be helpful for CFS patients. Examples include astemizole (Hismanal) and loratadine (Claritin). Some of the more common adverse reactions associated with their use include drowsiness, fatigue, and headache. Sedating antihistimines can also be of benefit to patients at bedtime.
Antihypotensive Therapy: Fludrocortisone (Florinef) has sometimes been prescribed for CFS patients who have had a positive tilt table test. Florinef is currently being tested in controlled studies for its efficacy in the treatment of CFS patients.
Antihypertensive Therapy: Beta blockers such as atenolol (Tenormin) have also been prescribed for patients with a positive tilt table test. Increased salt and water intake is also recommended for these patients. Adverse reactions include low blood pressure.
Experimental drugs and treatments
Ampligen is a synthetic nucleic acid product that stimulates the production of interferons, a family of immune response modifiers that are also known to have anti-viral activity. One report of a double-blinded, placebo-controlled study of CFS patients documented modest improvements in cognition and performance among Ampligen recipients compared with the placebo group.
These preliminary results will need to be confirmed by further study. Ampligen is not approved by the Food and Drug Administration (FDA) for widespread use, and the administration of this drug in CFS patients should be considered experimental. Although the recipients of Ampligen in this study tolerated the drug well, the adverse reactions of this material are still incompletely characterized, and some participants did experience reactions that might be attributable to Ampligen.
Dehydroepiandrosterone (DHEA) was reported in preliminary studies to improve symptoms in some patients; however, this finding has not been confirmed and the use of DHEA in patients should be regarded as experimental. Gamma globulin (Gammar) is pooled human immune globulin. It contains antibody molecules directed against a broad range of common infectious agents and is ordinarily used as a means for passively immunizing persons whose immune system has been compromised, or who have been exposed to an agent that might cause more serious disease in the absence of immune globulin. Its use with CFS patients is experimental and based on the unsubstantiated hypothesis that CFS is characterized by an underlying immune disorder. Serious adverse reactions are uncommon, although in rare instances gamma globulin may initiate anaphylactic shock. High colonic enemas have no demonstrated value in the treatment of CFS. The procedure can promote intestinal disease. Kutapressin is a crude extract from pig’s liver. Its use should be regarded as experimental in any clinical circumstance, and there is no scientific evidence that it has any value in the treatment of CFS patients. Kutapressin can elicit allergic reactions.
Center for Disease Control, 1998\