CHRONIC FATIGUE SYNDROME. Rosamund Vallings MNZM, MB BS
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1 CHRONIC FATIGUE SYNDROME Rosamund Vallings MNZM, MB BS
2 Tired all the time
3 CFS/ME etc etc UNDERSTANDING OF ILLNESS DIAGNOSTIC CRITERIA EXCLUSION CRITERIA MANAGEMENT STRATEGIES TREATMENT FOLLOW UP
4 UNDERLYING PATHOLOGY ABNORMAL IMMUNE SYSTEM NEURO-INFLAMMATION PROBABLE AUTO-IMMUNITY A VERY PROLONGED POST-VIRAL ILLNESS A CONTINUUM OF SEVERITY
5 PREDISPOSING FACTORS GENETIC PREDISPOSITION MENTAL or PHYSICAL DISTRESS SLEEP DEFICIT VIRAL PRIMING
6 Other onset triggers Viral illness Other infection Bodily onslaught Overexercise Toxins Accident Surgery Immunisation etc etc
7 Who gets CFS/FM
8 EPIDEMIOLOGY of CFS 4 per million sufferers in USA sufferers in NZ in Australia All age groups and ethnicity SEX: FEMALE 3:2
9
10 CARDINAL SYMPTOMS FATIGUE++ (unresolved by rest) POST-EXERTIONAL MALAISE COGNITIVE PROBLEMS ORTHOSTATIC INTOLERANCE FLU-LIKE SYMPTOMS PAIN/FIBROMYALGIA/HEADACHE GASTRO-INTESTINAL DISTURBANCE SLEEP DISTURBANCE
11 FIBROMYALGIA Most with CFS have FM Most with FM have CFS Central sensitsation syndrome (M Butler)? Genetic vulnerability?early life effects (M Fitzgerald) Mitochondrial abnormalities (J Newton)
12 Making a diagnosis: CDC Criteria (Fukuda et al) Unexplained persistent or relapsing fatigue, of new or definite onset, not due to ongoing exertion, not relieved by rest, and results in substantial reduction in previous levels of activity 4 or more of defined symptoms concurrently present for 6 months or longer:
13 CDC Criteria defined symptoms 1. impaired memory/concentration 2. sore throat 3. tender cervical or axillary nodes 4. muscle pain 5. multi joint pain (no redness/tenderness) 6. new headache 7. unrefreshing sleep 8. post-exertional malaise
14 INTERNATIONAL CRITERIA (2012) Include: NO 6 MONTH WAIT P.E.N.E (P.E.M) ORTHOSTATIC INTOLERANCE ALCOHOL/DRUG INTOLERANCE NEUROLOGICAL SYMPTOMS GASTROINTESTINAL SYMPTOMS PAEDIATRIC ISSUES
15 LABORATORY TESTING Process of exclusion/differential diagnosis Full blood screen Specific symptom testing
16 WE NEED A BIOMARKER!
17 DESPITE SYMPTOMS SUGGESTIVE OF INFECTION (eg sore throat) NOTHING IN BLOOD PICTURE SUGGESTS ACTIVE INFECTION. ESR usually low ANA may be +ve??autoimmune disease
18 TESTS OF LITTLE USE (Shepherd) HAIR ANALYSIS SALIVARY TESTS MERCURY AMALGAM Electro-acupuncture (Voll) CANDIDA MUSCLE TESTING
19 DIFFERENTIAL DIAGNOSES CHRONIC PAIN/FIBROMYALGIA LUPUS POLYMYALGIA POST POLIO SYNDROME DEPRESSION/ANXIETY BIPOLAR DISORDER LYME DISEASE IBS SLEEP DISORDERS HYPERVENTILATION EHLERS-DANLOS SYNDROME etc etc
20 PSYCH ASSESSMENT NECESSARY DIAGNOSIS of CFS CANNOT BE MADE IN PRESENCE OF UNTREATED DEPRESSION Other psychological conditions need to be treated before we can make a diagnosis eg anxiety, anorexia,bipolar
21 DIAGNOSIS A DIAGNOSIS OF EXCLUSION SUB-CATEGORIZATION ONGOING SURVEILLANCE 30% EVENTUAL ALTERNATIVE DIAGNOSES Symptoms tend to mimic initial illness PEM 2 day exercise test
22 MANAGEMENT CORRECT DIAGNOSIS ACKNOWLEDGEMENT/SUPPORT EDUCATION LIFESTYLE Stress (Friedberg, Sharpe) Exercise/rest (Fulcher&White, Lapp) Nutrition (Burnet) Supplements Sleep management Pain management
23 PACED EXERCISE NONE LEADS TO POOR OUTCOME TOO MUCH LEADS TO RELAPSE NEEDS TO BE REGULAR/OUTSIDE START AT LOW LEVEL (?lie down) LITTLE and OFTEN (pacing) PREPARATION and REST BUILD SLOWLY AVOID CRASH and BURN
24 NUTRITION BALANCED DIET/VARIETY SMALL REGULAR MEALS MINIMISE ALCOHOL, CAFFEINE AVOID RICH FATTY FOODS PLENTIFUL FLUIDS (not excess) EXTRA SALT/potassium BEDTIME SNACK SUNSHINE
25 SUPPLEMENTS BETTER ABSORBED VIA FOOD DEFICIENCIES IN BLOOD DEFICIENCIES IN DIET TREATMENT OF CONDITION
26 POSSIBLE SUPPLEMENTS OMEGA 3/OMEGA 6 OILS (2:1) (Puri) B VITAMINS (B12 INJECTIONS) (Regland,Lapp) MAGNESIUM 300mg at night (MALIC ACID) COENZYME Q-10 (up to 200mg) D-RIBOSE (Japan) VITAMIN D AVOID VIT C EXCESS or IMMUNE BOOSTERS
27 MEDICATION SLEEP DEFICIT (Moldofsky) INCREASE BLOOD VOLUME (Bell) PAIN CONTROL DEPRESSION and ANXIETY CENTRAL ACTIVATION ANTIMICROBIALS HRT (Studd, Evengard)) AMPLIGEN (de Meirlier)/ISOPRINOSINE (Hyde) AUTO-IMMUNE DRUGS
28
29 SLEEP MANAGEMENT GOOD ROUTINE/sleep hygiene/magnesium TRICYCLICS FIRST CHOICE MELATONIN ANTIHISTAMINES MUSCLE RELAXANTS BENZODIAZEPINES QUETIAPINE PREGABILIN, GABAPENTIN ROPINAROLE (RLS)
30 AUTONOMIC DYSFUNCTION POSTURAL CHANGE SUPPORT HOSE CARE WITH SHOWERING etc INCREASE BLOOD VOLUME (salt, fludrocortisone 0.1mg) REGULATE PUMP (β blockers)
31 PAIN CONTROL WARMTH, MASSAGE, RELAXATION ACUPUNCTURE, HYPNOSIS SIMPLE ANALGESICS ANTI-INFLAMMATORY DRUGS STRONG ANALGESICS OPIOIDS RELAXANTS (BZDs, orphenadrine) ANTI-EPILEPTICS (GABAPENTIN,PREGABALIN) LOW DOSE NALTREXONE ( mg)
32 DEPRESSION/ANXIETY etc Counselling,CBT ANXIOLYTICS MOOD STABILISERS (eg bipolar) CENTRAL ACTIVATION (Ritalin/Modafinil) ANTIDEPRESSANTS: TRICYCLICS (timing) SSRIs SRNIs
33 ANTIMICROBIALS?ANTIBIOTICS (Lyme,mycoplasma) ANTIFUNGALS?? (side effect!) ANTIPARASITICS (Tapanui) ANTIVIRALS: (eg persistent herpes) ACICLOVIR VALGANCICLOVIR?OXYMATRINE (Equilibrant) (J Chia)
34 OESTROGEN (Evengard) KEY REGULATOR of GROWTH REDUCED GENETIC EXPRESSION INCREASED BLOOD VOLUME INCREASED CEREBRAL BLOOD FLOW HIGH OESTROGEN IMMUNE MODULATION RELIEF OF MUSCLE/JOINT PAIN?HRT USEFUL/OCs PREGNANCY EFFECTS Risk factors
35 IMMUNE MODULATORS AMPLIGEN (Rintatotolimod) ISOPRINOSINE ANTI-VIRALS (Montoya) IMMUNISATIONS
36 Latest research Is CFS/ME an auto-immune condition? Norwegian findings (B cell lymphoma) Treatment possibility B cell depletion Rituximab (Fluge &Mella) Marshall-Gradisnik et al Goldcoast Gene studies J.Kerr
37 ONGOING ISSUES AVOIDANCE OF RELAPSE REGULAR REVIEW MULTIDISCIPLINARY TEAM RECOVERY RATES adults/children
38 LONG TERM RISKS LOW NK CELLS: INCREASE IN CANCERS INCREASE IN INFECTIONS INCREASE IN LYMPHOMA AGING OF TELOMERES
39 LEPTIN From fat cells Increased in stress Primes microglia (primary defence in CNS) Microglia make one feel ill Gut/brain connection More microglia in brain than neural cells
40 To reduce Leptin Weight loss Stress management Diet: tumeric, reservatrol Drugs: Antihypertensives Naltrexone Minomycin
41 Likely Biomarkers Cytokine activity NK cells decreased late in disease NPY elevated (stress mediator) Leptin elevated VO2 max (X2) (98% reliable) Biomarker must be specific to the disease.
42 All CFS patients can experience a better quality of life with compassionate care and a multidisciplinary approach. Patient needs to feel in control of health rather than being controlled by the disease
43 Rehabilitation
44 Physicians Primer IACFS/ME:
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