WHMC311. Session 18. Fatigue States. Naturopathic Medicine Department. Endeavour College of Natural Health endeavour.edu.au 1

Transcription

1 WHMC311 Session 18 Fatigue States Naturopathic Medicine Department Endeavour College of Natural Health endeavour.edu.au 1

2 Topic Overview o Management of complex and multi-system conditions through the use of specific herbal medicines and their specific biochemical and physiological applications in the management of chronic fatigue syndrome and fibromyalgia. o Focus on herbal support of these fatigue states drawing on relevant literature. o Discuss relevant drug interactions and potentiations through an understanding of mechanisms of action of interactions. Endeavour College of Natural Health endeavour.edu.au 2

3 Chronic Fatigue Syndrome Endeavour College of Natural Health endeavour.edu.au 3

4 Chronic Fatigue Syndrome o Characterised by expert consensus including: Persistent disabling fatigue lasting more than 6 months with other known medical conditions excluded by clinical diagnosis also four or more of the following symptoms: Substantial impairment in short-term memory or concentration Shore throat Tender lymph nodes Muscle pains Multi-joint pain without swelling or redness Headaches of a new type, pattern or severity Unrefreshing sleep Post-exertional malaise lasting more than 24hours (Sarris & Wardle, 2010, p.707) Endeavour College of Natural Health endeavour.edu.au 4

5 Aetiology Chronic Fatigue Syndrome o Infectious agents (e-barr, ross river, Coxiella burnetti) o Immunologic abnormalities (multiple infectious aetiological agents, persistent or relapsing infections = immunological disorders such as elevated pro-inflam cytokines) o Neuroendocrine abnormalities (hypoactive HPO axis + hyperactive serotonergic system, adrenal exhaustion) o Orthostatic intolerance (fatigue and elevated pulse rates when standing or sitting for long periods of time) o Nutritional causes (B vit, L-carnitine, Mg) (Sarris & Wardle, 2010, pp ) Endeavour College of Natural Health endeavour.edu.au 5

6 Chronic Fatigue Syndrome Risk Factors o Older age o 4 Female : 1 Male o Low or middle rather than high educational level o Presence of an anxiety disorder o Mood disorder o Personality trait emotional instability o Musculoskeletal pain o Low fitness 2 months post infection o Lower physical functioning at baseline assessment o Presence of fatigue at time of viral illness; Fatigue severity o Other family members with symptoms of CFS (Sarris & Wardle, 2010, p.710) Endeavour College of Natural Health endeavour.edu.au 6

7 Treatment Considerations Decrease suffering o Reduce pain and stiffness Curcuma longa Boswellia serrata Zingiber officinale Apium graveolens (Cox et al, 1991, cited in Sarris & Wardle, 2010, p.711) Endeavour College of Natural Health endeavour.edu.au 7

8 Treatment Considerations o Improve sleep Withania somnifera (Kulkarni et al, 2008, cited in Sarris & Wardle, 2010, p.711) Valeriana officinalis Ziziphus jujuba Passiflora incarnata (Burgoyne, 2002, cited in Sarris & Wardle, 2010, p.711) Endeavour College of Natural Health endeavour.edu.au 8

9 Treatment Considerations o Increase physical conditioning Graded physical activity Eleutherococcus senticosus Panax ginseng Withania somnifera Rhodiola rosea (Sarris & Wardle, 2010, p.712) Endeavour College of Natural Health endeavour.edu.au 9

10 Treatment Considerations o Improve immune function Astragalus membranaceus Hemidesmus indicus Echinacea spp. Rehmannia glutinosa Hypericum perforatum o Improve psychological symptoms Hypericum perforatum (Sarris & Wardle, 2010, pp ) Endeavour College of Natural Health endeavour.edu.au 10

11 Fibromyalgia Endeavour College of Natural Health endeavour.edu.au 11

12 Fibromyalgia o Fibromyalgia is a chronic disorder characterised by widespread musculoskeletal pain, fatigue, and multiple tender points. o Fibromyalgia mainly affects muscles and their attachments to bones. o Although it may feel like a joint disease, it is not a true form of arthritis and does not cause deformities or loss of function of the joints. Instead fibromyalgia is considered a form of soft tissue rheumatism. (NIAMSD, 2009) Endeavour College of Natural Health endeavour.edu.au 12

13 Fibromyalgia Widespread pain for three months with all of the following pain areas: (Destined for 150, 2010) Endeavour College of Natural Health endeavour.edu.au 13

14 Fibromyalgia Statistics o Fibromyalgia syndrome is believed to affect approximately 3.7 million people. o It occurs seven times more frequently in women than in men. o It occurs most frequently in women of childbearing age. (NIAMSD, 2009) Endeavour College of Natural Health endeavour.edu.au 14

15 Fibromyalgia v s Chronic Fatigue o While the constellation of symptoms can be similar, the primary complaint in chronic fatigue syndrome is the unrelenting fatigue. o With fibromyalgia, an arthritis-related condition, the primary complaint is a round-the-clock pain that rarely goes away. (NIAMSD, 2009) Endeavour College of Natural Health endeavour.edu.au 15

16 Treatment Considerations o Reduce pain o Improve sleep o Address mood and cognitive changes o Address any digestive dysfunction o Improve daily functioning (Sarris & Wardle, 2010, p.446) Endeavour College of Natural Health endeavour.edu.au 16

17 Treatment Considerations o Neurotransmitter effects Rhodiola rosea (increase 5-HT levels) Hypericum perforatum (increase 5-HT levels) Scutellaria baicalensis (increase 5-HT levels) o Adaptogens/tonics Withania somnifera Panax ginseng Rhodiola rosea Eleutherococcus senticosus (Sarris & Wardle, 2010, p.449) Endeavour College of Natural Health endeavour.edu.au 17

18 Treatment Considerations o Anti-spasmodics Viburnum opulus, Piper methysticum, Piscidia erythrina, Scutellaria lateriflora o Nervines Scutellaria lateriflora, Passiflora incarnata, Matricaria recutita, Melissa officinalis (Sarris & Wardle, 2010, p.449) Endeavour College of Natural Health endeavour.edu.au 18

19 Treatment Considerations o Thymoleptics Hypericum perforatum, Avena sativum, Lavandula angustifolia, Turnera diffusa o Hypnotic Humulus lupulus, Passiflora incarnata, Valeriana spp. o Analgesics Corydalis ambigua, Eschscholzia californica (Sarris & Wardle, 2010, p.449) Endeavour College of Natural Health endeavour.edu.au 19

20 Treatment Considerations o Digestives Zingiber officinale, Taraxacum officinale, Ulmus fulva o Circulatory stimulants Zingiber officinale, Gingko biloba, Cinnamomum zeylanicum, Zanthoxylum spp. (Sarris & Wardle, 2010, p.449) Endeavour College of Natural Health endeavour.edu.au 20

21 Treatment Considerations Improve sleep o Modify circadian rhythm As appropriate: hypnotics, nervines etc. o Modify HPA-axis Eleutherococcus senticosus, Schisandra chinensis, Rhodiola rosea, Panax ginseng (Sarris & Wardle, 2010, pp.450) Endeavour College of Natural Health endeavour.edu.au 21

22 Treatment Considerations Address digestive issues as appropriate o IBS o Dysbiosis o Food allergies Immune alterations o Significantly raised IgG, mast cells Endeavour College of Natural Health endeavour.edu.au 22

23 Rhodiola rosea o Adaptogen o Improves serotonin levels, fatigue, sleep patterns and mental performance (Kelly, 2001 and Fintelmann et al, 2007, cited in Sarris & Wardle, 2010, p. 456) o Positively affects neurotransmitters with normalisation of stress-induced elevation of serotonin, corticosterone, norepinephrine and dopamine (Spasov et al, 2000, cited in Sarris & Wardle, 2010, p. 456) Endeavour College of Natural Health endeavour.edu.au 23

24 Rhodiola rosea Endeavour College of Natural Health endeavour.edu.au 24

25 CFS & Fibromyalgia Drug Therapy Analgesics & NSAIDs o Short-term intermittent use for symptomatic treatment of pain. Antidepressants (Tricyclics, SSRI, SNRI) o Dose dependent. Low dose these drugs are utilized to have an anesthetic type effect, higher dose they are utilized to support co-morbid anxiety and depression. o Reduce the breakdown of serotonin and / or noradrenalin (Bryant & Knight, 2011) o Refer to session 5.3 for the drug monograph. Endeavour College of Natural Health endeavour.edu.au 25

26 CFS & Fibromyalgia Drug Therapy Benzodiazepines o Bind to GABA receptors enhancing the effect of GABA. This has the effect of causing muscle relaxation, sedation and anaesthesia. o Dependence is high with this class of drugs- a maximum treatment period of 2-3 weeks is generally recommended. o Refer to session 5.3 for the drug monograph. (Bryant & Knight, 2011) Endeavour College of Natural Health endeavour.edu.au 26

27 CFS & Fibromyalgia Drug-Herb Antidepressants All classes Albizia lebbeck Interactions o Increased risk of serotonergic syndrome as herb increases serotonin levels. Theoretical additive effect. Ginkgo biloba o Ginkgo may reduce the sexual dysfunction side effects associated with some antidepressants. May improve sleep continuity. Possible beneficial effect. Hypericum perforatum o Additive effects with antidepressants due to increasing the risk of serotonergic syndrome. Concurrent use is not recommended. (Braun & Cohen, 2010) Endeavour College of Natural Health endeavour.edu.au 27

28 CFS & Fibromyalgia Drug-Herb Tricyclic Antidepressants Interactions Andrographis paniculata & Silybum marianum o Hepatoprotective against damage caused by TCA s to liver. Reduced side effects. (Braun & Cohen, 2010) Endeavour College of Natural Health endeavour.edu.au 28

29 MAOI CFS & Fibromyalgia Drug-Herb Panax ginseng Interactions o A case report of headache, tremor and mania with concurrent usage. Combination contraindicated. Ephedra (Shader 1987) o Concurrent usage may cause potentially dangerous changes to blood pressure (ephedrine content) Rhodiola rosea o Theoretical interaction as rhodiola may inhibit MAO A receptors. Use with caution (Braun & Cohen, 2010) (Threlkeld 1997) Endeavour College of Natural Health endeavour.edu.au 29

30 CFS & Fibromyalgia Drug-Herb Benzodiazepines Interactions Passiflora incarnata, Piper methysticum, Valeriana officinalis o May aid symptoms of benzodiazepine withdrawal under medical supervision. May have an additive beneficial effect. Humulus lupulus, Lavandula officinalis, Matricaria recutita, Withania somnifera o Theoretical beneficial additive effect but only under professional supervision. Hypericum perforatum o May increase drug metabolism Paullinia cupana, Caffeine o Reduced drug effect. (Braun & Cohen 2010) Endeavour College of Natural Health endeavour.edu.au 30

31 Pre-reading for next session o Reading 1: Lister, RE 2002, An Open, Pilot Study to Evaluate the Potential Benefits of Coenzyme Q10 Combined with Ginkgo Biloba extract in Fibromyalgia Syndrome The Journal of International Medical Research, vol. 30, no. 2, pp v30n2/s13.pdf?expires= &id= &titleid= &accname=Guest+User&checksum=A82DFA9596BFE92CC7EB8 00F59B15F29 o Reading 2: Olsson, EMG Von Scheele, B Panossian, AG 2009, A Randomised, Double-Blind, Placebo-Controlled, Parallel-Group Study of the Standardised Extract SHR-5 of the Roots of Rhodiola rosea in the Treatment of Subjects with Stress-Related Fatigue Planta Med, vol. 75, no. 2, pp Endeavour College of Natural Health endeavour.edu.au 31

32 References Pictures Destined for 150, 2010, viewed Text National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2009, Fibromyalgia, viewed Sarris, J & Wardle, J 2010, Clinical Naturopathy: An Evidence-based Guide to Practice, Churchill Livingstone, Sydney Endeavour College of Natural Health endeavour.edu.au 32