WHMC311 Session 18 Fatigue States Naturopathic Medicine Department Endeavour College of Natural Health endeavour.edu.au 1
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
Chronic Fatigue Syndrome Endeavour College of Natural Health endeavour.edu.au 3
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
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.708-709) Endeavour College of Natural Health endeavour.edu.au 5
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
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
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
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
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.713-714) Endeavour College of Natural Health endeavour.edu.au 10
Fibromyalgia Endeavour College of Natural Health endeavour.edu.au 11
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
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
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
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
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
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
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
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
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
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
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
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
Rhodiola rosea Endeavour College of Natural Health endeavour.edu.au 24
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
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
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
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
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
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
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. 195-199. http://docserver.ingentaconnect.com/deliver/connect/field/03000605/ v30n2/s13.pdf?expires=1298876017&id=61449593&titleid=7500144 2&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. 105-112. http://www.scicompdf.se/adaptogener/olsson2_2009.pdf Endeavour College of Natural Health endeavour.edu.au 31
References Pictures Destined for 150, 2010, viewed 28-01-11 http://destinedfor150.blogspot.com/2010/07/five-bags-offlour.html Text National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2009, Fibromyalgia, viewed 28-01-11 http://www.niams.nih.gov/health_info/fibromyalgia/default.asp 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