Dr. Paul Cheney, M.D., is one of the leading medical experts on Chronic Fatigue Syndrome. He first started working on the disease in 1984 when patients at Incline Village, Nevada, started coming down with a mysterious illness. Cheney attempts to treat the whole syndrome, not just the symptoms of the disease. In the following interview, Cheney discusses symptomatic treatment of the disease.
The four best drugs for sleep disorder in CFIDS are low-dose tricyclic antidepressants, especially Doxepin or amitripyline; benzodiazepines, especially Klonopin; magnesium due to its ability to block the NMDA receptor and raise neuronal threshold firing potential; and melatonin. Melatonin is a brain hormone that sets the biochemical stage for sleep. There is reason to believe that this hormone is deficient in CFIDS patients. Sleep resistance to the first three drugs suggest the use of melatonin, at least on a trial basis.
Addressing sleep disturbance can yield impressive symptom relief in the areas of fatigue, cognition and pain. Failure to address sleep disturbance substantially reduces the potential benefits of other therapies.
The approach to pain relief in certain very ill patients with severe pain can easily be the most challenging problem in CFIDS management. Failure to address pain adequately can lead to high risk of suicide and can exacerbate the underlying symptoms.
The rational approach to pain in this disorder includes first addressing the issue of sleep disorder. Patients who have sleep disturbance successfully treated often see significant reduction in pain. Pain can also be managed by centrally acting drugs such as calcium channel blockers, Diamox and the selective serotonin reuptake inhibitors (SSRIs). Analgesics ranging from acetaminophen to some of the non-steroidal anti-inflammatory drugs (NSAIDs) to narcotic analgesics can be used effectively in CYIDS patients. Narcotics deserve special mention in the overall center of CFIDS since INF- injury to the hypothalamus is mediated in part by a narcotic (m opioid) receptor. Because of this, narcotics may actually defend against cytokine brain injury.
NSAIDs need to be used with care in CFIDS patients because they can gut permeability and exacerbate liver-gut dysfunction. Adjutant therapy including Vistaril and Phenergan as well as muscle relaxants such as Flexeril have also been helpful. Relaxation techniques, biofeedback, acupuncture, massage and other alternative therapies have also been helpful in managing pain.
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Fatigue, in my view, is one of the most difficult single symptoms to treat since it is so central to the disorder. As a matter of fact, it is possible that in the sicker patients, fatigue represents a defense response. In this instance, excessive attention to the treatment of fatigue may actually worsen the patient’s condition.
I’ve found that fatigue is best treated in the context of the entire syndrome and by addressing sleep disturbance, neurotoxicity and pain. I’ve found B-12 injections to be particularly effective in the treatment of fatigue. I’ve also found low- dose (5-10 mg) Prozac elixir to be helpful. Some patients will respond to low-level CNS stimulants such as Ionamin or Symmetrel. Lifestyle adjustment and limiting excessive exertion, overactivity or stress also has a major impact on fatigue.
I think depression is best treated by nutritional intervention, particularly amino acid therapies based on objective nutritional assessments; Inositol; and addressing sleep disturbance. Failing this, I will use the SSRIC particularly Zoloft.
Of significant importance on this issue is to give the patient some sense of control over their disorder. As they understand the disorder better and gain some sense of control over the symptoms, I’ve found that as function improves, depression appears to improve significantly.
Cognitive complaints are common and debilitating in this disorder. The most important treatment is to block neurotoxicity by using Klonopin (low doses in the daytime and higher doses at night), magnesium and Nimotop which block the NMDA receptor and its effects. Occasionally a patient will respond to low-level stimulants such as Ionamin or low-dose Prozac. As mentioned above, cognitive complaints in all patients will improve as sleep improves.
Reprinted by permission from The CFIDS Chronicle, published quarterly by The CFIDS Association of America, Spring 1995, page 41. For more information, please call 1-800-40 CFIDS or write: The CFIDS Association America, PO Box 220398, Charlotte, NC 28222-0398.