Your doctor can also prescribe a combination supplement of these herbs (also called the Revitalizing Sleep Formula) made by Integrative Therapeutics. See Appendix E: Resources for more information.
You may find, however, that the above sleep aids are not adequate by themselves. Other natural remedies include:
D-ribose (see Chapter 2). Helps sleep while increasing energy.16
Magnesium and calcium. Taking at least 75 to 150 milligrams of magnesium at night is a good idea because it can help you sleep. Lower the dose if it causes diarrhea. Taking 600 milligrams of calcium at bedtime also may improve the quality of your sleep, and you may wish to take the two supplements together.
Lemon balm. A double-blind research study showed that taking 80 to 160 milligrams of lemon balm (also known as melissa) in combination with 180 to 360 milligrams of valerian a night improved deep-stage sleep,17 without being sedating.
5 -Hydroxy-L-Tryptophan ( 5 -HTP). Your body uses 5-HTP to make serotonin, a neurotransmitter that helps improve the quality of sleep. A double-blind, placebo-controlled study looked at the effectiveness of 5-HTP or placebo in fifty people with fibromyalgia. After four weeks, there was improvement in pain, stiffness, anxiety, fatigue, and sleep.18 In addition, it often helps people lose weight. Take 100 to 400 milligrams at night.
The one caution I would note with 5-HTP is that if you are taking a number of treatments that increase serotonin (these include antidepressants like Prozac, Saint John’s wort, Ultram, Desyrel, and the like), taking doses higher than 200 milligrams of 5-HTP can result in serotonergic syndrome, a life-threatening reaction caused by a too-high level of serotonin. Because of this, discuss the use of 5-HTP with your holistic doctor. This is a rare problem, however, and I have never seen a serious reaction myself. Mild serotonergic syndrome can more often be associated with a constant fast heart rate. But when it gets more severe and potentially dangerous, it can be associated with a fever and feels like “the panic attack from hell.” Common in CFS/FMS, most panic attacks are not caused by excessive serotonin. However, if a reaction does happen, you should be checked out in a hospital emergency room to be safe. If you are taking any of the serotonin-raising treatments, it is reasonable to limit the 5-HTP to 200 milligrams at night. For anyone whose heart rate is constantly above 90, even if you are not taking 5-HTP, it is worth considering whether you are on too many treatments that raise serotonin and discussing lowering these with your doctor. If the rapid heart rate is coming from these treatments, it should come down within a few days of lowering treatments.
Melatonin. This is a hormone made by the pineal gland. Although it is natural and available over the counter, this does not mean that it is without risk. My concern with any hormone is that although it might be quite safe when used within the body’s normal range, I worry about toxicity when people take more than the body would normally make. For most people, all it takes to restore melatonin to normal levels is? milligram. The usual dose you find in stores, however, is 3 milligrams, which is ten times the level I recommend. Except for a small subset of people, who likely have trouble absorbing it properly, 0.5 milligram is every bit as effective for sleep as higher doses. Moreover, high levels of melatonin may raise the level of another hormone, prolactin, which is often already high in people with CFS/FMS, aggravating the risk of depression or infertility. Although I don’t know of any danger yet from using melatonin in higher doses—and it may even have immune-stimulating and antioxidant effects that could well be beneficial—I would only use a dose higher than 0.5 milligram under the supervision of your holistic doctor.
Delta-wave sleep-inducing compact discs or cassettes (www.vitality101.com). To fall asleep and stay in deep sleep, you can play the tapes or CDs and they will help your brain waves attune to and stay in the delta-wave frequency of deep sleep. If you wake up during the night, you can push your sound system’s replay button. Better yet, get a CD or tape player that can replay continuously throughout the night.
Cuddle Ewe mattress pad. Lying on this cushioning sheepskin pad can help relieve pain when it interferes with sleep (800-328-9493).
Prescription Medications
Although I prescribe medications in different orders for different people, depending on their symptoms, the most common order I use is the one below. If something is mentioned as especially good for a certain condition, you may want to try that medication first. A physician specializing in CFS can help you find the best combination. Do not drive or operate hazardous equipment if you are sedated from the medications. Also, as with almost any medication and most herbs, do not get pregnant during treatment.
As we’ve discussed, CFS/FMS patients usually do better with combining low doses of several medications than with a high dose of just one. If you had to use only one medication at a high enough dose to keep you out all night, you’d likely be hungover until two the next afternoon. If you use several different medications, however, each of them is cleared out of your body individually, so by morning you are not hungover. Fortunately, the positive effects of the multiple treatments are combined during the night. Most people find they may need a mix of anywhere from three to seven different natural and prescription sleep aids to get the eight hours of solid sleep that they need each night. Although in my experience it is quite uncommon, even for CFS/FMS patients, it is possible to get unusual reactions from combining these medications. If a medication causes recurring nightmares, change the dose or medication.
With hypothalamic sleep-center dysfunction, it is inappropriate to stop taking your sleep medications prematurely. Just as with high blood pressure, it is reasonable to stay on your sleep medications for years, if needed. Fortunately, after people are feeling better for six months they usually find that they can lower the dose of sleep medication as the sleep center (in the hypothalamus) recovers. Keep in mind that if you use adequate medication to get eight to nine hours of solid sleep a night for six to nine months, you will likely need less sleep medication in the long run.
Let’s look at the prescription sleep medications that work best in CFS/FMS:
Zolpidem (Ambien). This is my first choice of sleep medication for treatment in CFS/FMS because it is usually effective and well tolerated. Because Ambien is short acting (that is, it is out of your body after six hours), it is less likely to cause side effects than many other medications, but it also may not keep you asleep all the way through the night. Five to 15 milligrams will likely give you at least four to six hours of good, solid sleep as a foundation.
If you wake up in the middle of the night with the Ambien, switch to the newer Ambien CR (sustained release) 6.25 to 12.5 milligrams at bedtime. Around half of our patients prefer the sustained-release form over the original form of Ambien. However, the older form is now available as a generic, and is much less expensive. If you use the older, short-acting form, you can take an extra one half to one tablet (leave it by your bedside) and chew it if you wake during the night. Any sedation has usually worn off by the time you are ready to wake up in the morning. If you find that taking an additional dose in the middle of the night leaves you hungover, try Sonata (see zaleplon, Chapter 3) when you wake instead.
Do not take more than 15 milligrams of Ambien at one time. I usually don’t see improved sleep with the higher doses, and I have seen a case of sleepwalking that occurred when a patient took 20 milligrams as a single dose. Rarely, some people even eat while sleepwalking. Despite media attention, these are both unusual occurrences. Studies have not shown a wearing-off effect with Ambien or Sonata in most people, nor have they found addiction with long-term Ambien use.19 What does occur, though, is rebound insomnia when you stop using this medication—that is, the need to use something else to assist your sleep for about a week. Because of this need for sleep assistance, if you have taken Ambien for more than two months, when you stop it, use one of the other medications or natural sleep remedies discussed in this chapter for a week or so to assist sleep during the adjustment period. In my experience, Ambien ca
n also be helpful for restless leg syndrome.
Trazodone (Desyrel). Desyrel is marketed as an antidepressant, but its main use in CFS/FMS is to treat disordered sleep. It has the added benefit of being helpful for anxiety, and can be used during the day for this as well. Desyrel comes in 50-milligram tablets, and the usual recommendation is to take one half to six at bedtime (most patients need no more than two). If you take more than two, you can get Desyrel in 150-to 300-milligram tablets as well, decreasing the number of pills you’ll need to take. Your total daily dose should not exceed 450 milligrams.
If you are on other antidepressants, limit the dosage to 150 milligrams a day to avoid the risk of excessive serotonin levels discussed on Chapter 3. The main side effects of Desyrel are next-day sedation (if this happens, either lower the dose or take it earlier in the evening) and, in males, priapism, a condition characterized by a painful erection that does not go away. The latter side effect is rare, and I have never had a patient experience this, despite prescribing Desyrel hundreds of times. Most men find that while it causes an improvement in the strength of their erections, it does so at a comfortable level, as opposed to an erection that will not go away after a normal amount of time. If you develop an erection that does not go away after an hour (despite a cold bath), stop taking the medication and go to a hospital emergency room. If the erections are not lasting extraordinarily long but seem to be even the least bit uncomfortably long, you should stop the Desyrel and switch to other medications.
Clonazepam (Klonopin). Although in the Valium family, and therefore potentially addictive, Klonopin can be very helpful for people with restless leg syndrome or for those whose sleep is disrupted by pain. When used at doses of less than 1 to 2 milligrams at night, we’ve seen no problem with addiction. Most people do not need to go above this dose. Start with half of a 0.5-milligram tablet and work your way up slowly as needed. The main side effect is next-day sedation, which is fairly common. If this occurs, take a lower dose several hours before bedtime, or switch to its shorter-acting cousin Xanax (see Alprazolam, Chapter 3). Most people find that they can slowly increase the dose over time, if needed, as the next-day sedation wears off. Because it is potentially addictive, do not suddenly stop taking Klonopin if you have been on it for more than six weeks. Instead, taper off by decreasing the dosage by 0.25–0.5 milligrams a day every few weeks as symptoms allow.
Gabapentin (Neurontin), tiagabine (Gabitril), or pregabalin (Lyrica). These three medications work by increasing the calming, sleep-inducing neurotransmitter gamma-aminobutyric acid (GABA). Although the three are related, one will often work and be well tolerated even if the others are not. They are likely all effective for pain and restless leg syndrome, and can markedly improve deep sleep. The main side effects are sedation, dizziness, and gastric upset. Lyrica may also cause weight gain. These are also discussed in Chapter 7. Take 300 milligrams of Neurontin, 2 milligrams of Gabitril, or 50 milligrams of Lyrica.
Doxylamine (Unisom for Sleep). This is an antihistamine that is available over the counter. It is worth trying, especially if you tend to have a stuffy nose that interferes with your sleep. However, if you have trouble with severe dry eyes and mouth, this may not be a good medication for you because it can aggravate these symptoms. Some people find that the effect wears off with continued use and that it works best when used intermittently (for example, two days on, then two days off). The standard dose is 25 milligrams at nighttime.
Carisoprodol (Soma). This is predominantly a muscle relaxant, and I recommend using this medication earlier in treatment if you experience severe pain because of your CFS/FMS. Soma is potentially addictive, although I have never seen this in patients who are only using one to two tablets at bedtime (as opposed to people taking it four times a day for pain). The usual dose is half to one 350-milligram tablet at bedtime. The main side effect is sedation.
Doxepin (Sinequan). In high doses this medication is used as an antidepressant, and it is also a powerful antihistamine. As a sleep aid, I recommend taking 5 to 30 milligrams, or taking 10 mg/cc of doxepin liquid at bedtime. Some people, however, get the greatest benefit with the least next-day sedation using a dose of less than 5 milligrams a night. Since it is always best to take the lowest dose possible, you should start with this amount. If you are sensitive to medications, you should start with a lower dose of the doxepin liquid, about one to three drops nightly, but the dose can be increased up to 100 milligrams, if needed. This medication is related to Elavil; however, I recommend doxepin because it causes much less dry mouth, weight gain, next-day sedation, and other side effects often seen with Elavil.
Cyclobenzaprine (Flexeril). This medication is a muscle relaxant, and can be helpful for people who experience severe muscle pain with fibromyalgia. The usual dose is half to one 10-milligram tablet at bedtime, but some people need to take two. Flexeril is also related to Elavil, and does pose some risk for people with abnormal heart rhythms. Rarely, it leads to weight gain, and can also cause dry mouth and eyes.
Tizanidine (Zanaflex). Although unrelated to cyclobenzaprine, zanaflex is another sleep aid that relieves pain (for more information, see Chapter 7). Stop the medication if it causes nightmares, and do not take it while on the antibiotic Cipro, as it raises blood levels of zanaflex too high. Take half to two tablets at bedtime for sleep, not to exceed 8 milligrams.
Zaleplon (Sonata). Sonata is a comparatively new sleep medication. It helps people fall asleep, and the sedating effect generally wears off within four hours, making next-day hangover uncommon. It is best used in the middle of the night if you wake up and need something to help you fall back to sleep, or if you have trouble falling asleep but not staying asleep. Sonata is not like any other medication—that is, it is the first drug in its class, and therefore of a unique type. It affects receptors for the neurotransmitter gamma-aminobutyric acid (GABA). This makes it seem very promising for people with CFS/FMS.
In research studies on patients who were awakened four hours after taking the medication, they showed no evidence of impairment of waking function. The most common side effects are headache, dizziness, or sedation, but these were found to occur as frequently in patients taking this drug at low dose as in people taking a placebo. There is no evidence of withdrawal symptoms, even if the medication is stopped abruptly. The recommended dose is one to two 10-milligram capsules. Most FMS patients require 20 milligrams (two capsules). It is recommended that Sonata not be taken with, or immediately after, a high-fat or heavy meal, as this decreases its effectiveness. If you are taking the antacid medication Tagamet, you may need to take a lower dose of Sonata because it is cleared out of the body more slowly while on Tagamet. This can, however, be a good thing, if you find yourself waking easily while taking Sonata.
If Other Sleep Medications Do Not Give Eight Hours of Sleep
GHB, gamma hydroxybutyrate (Xyrem). Xyrem is the most effective way known to increase deep sleep and raise growth hormone—thereby decreasing pain for fibromyalgia sufferers. However, because of DEA claims that it was being used as a “date rape” drug, it is now tightly regulated and expensive, and must come from a special pharmacy with special paperwork. For this reason, I do not recommend it as highly as some other natural and prescription treatments. However, if all else fails, Xyrem can be helpful. Take 9 cc (4.5 grams) at bedtime and repeat approximately four hours later, if needed. The first night you use Xyrem, take it by itself without other sleep medications. In our practice, if the Xyrem is not adequately effective by itself, we then add one low-dose tablet of any other sleep medication with each Xyrem dose until the patient is getting good sleep for at least four hours with each dose or for eight hours a night. Be sure to rinse well with water and swallow after taking liquid. If the medication is left in your mouth, it can dissolve enamel and damage teeth. The FDA has approved it for narcolepsy, but a number of studies are being done to evaluate its effectiveness in treating fibromyalgia, and hopefully it will soon be approved for this use as well. This approval will m
ake it more likely that insurance companies will pay for it.
Eszopiclone (Lunesta)—2 to 3 milligrams at bedtime. Initial studies suggested that this would be very promising. Unfortunately, it was not very effective clinically, with approximately 80 percent of patients preferring Ambien. Nonetheless, it can be helpful in a small subset of patients. Its main side effect, besides next-day sedation, is a bad taste left in your mouth during the day. If taken with Sporanox, Nizoral, Diflucan (antifungals), or the antibiotic Zithromax, a lower dose may be needed.
Mirtazapine (Remeron). This medication is unrelated to any of the other medications discussed above. One doctor has noted that it seems to be especially helpful in patients who seem to “hibernate” during the day. Generally, Remeron causes more next-day sedation and weight gain than most other sleep medications. The usual dosage is one to three 15-milligram tablets, taken at bedtime.
Amitriptyline (Elavil). Technically an antidepressant, Elavil was one of the first medications studied for fibromyalgia and was found to be effective. It is also the only medication that many doctors have heard of for treating fibromyalgia. Although Elavil can be very helpful, it has been moved to the bottom of my list because of its significant side effects. These include weight gain, dry mouth, sedation, aggravation of restless leg syndrome, neurally mediated hypotension, and abnormal heart rhythms. However, for people who suffer from nerve pain, vulvodynia (pain in the vulvar area), and interstitial cystitis (severe urinary frequency and burning without infection), amitriptyline is effective even in very low doses. You can take one-half to five 10-milligram tablets at bedtime. If you take more than two tablets, it should be tapered off and not stopped suddenly. I rarely recommend more than
From Fatigued to Fantastic! Page 8