From Fatigued to Fantastic!

by Jacob Teitelbaum

  D-ribose (CORvalen) is natural and quite safe, tastes good (sweet like sugar but healthy—comes as a powder) and is low in side effects. Rarely, it can cause a mild drop in blood sugar as it gets energy production moving. If patients feel dizzy or hungry when they take it, simply have them take it with a meal or lower the dose.

  Iron. If the iron percent saturation is under 22 percent or the ferritin is under 40 mg/ml, supplement with iron. I recommend Chromagen Forte, one a day for four months. It should be taken on an empty stomach, since food decreases iron absorption by more than 60 percent. It should not be taken within six hours of thyroid hormone, since iron blocks thyroid absorption. Caution should be taken in supplementing with iron because continuing supplementation beyond what is needed can result in excess body iron stores, and iron is very pro-oxidative. Check levels before supplementing, as even one dose of iron can be harmful in persons with primary hemochromatosis. Continue treatment until the ferritin level is between 50 and 100 and the iron percent saturation is over 22 percent. If hair thinning is a problem, continue Chromagen for a target ferritin of 70 to 100.

  If the B12 level is under 540 pg/ml, I recommend B12 injections, 3,000 micrograms IM three times a week for fifteen injections, then as needed based on the patient’s clinical response. Studies in CFS show absent or near-absent CSF B12 levels despite normal serum B12 levels.33 Metabolic evidence of B12 deficiency is seen even at levels of 540 pg/ml or more.34 Severe neuropsychiatric changes are also seen from B12 deficiency even at levels of 300 pg/ml (a level over 209 is technically normal).35 As an editorial in the New England Journal of Medicine suggests, the old-time doctors may have been right about giving B12 shots.36 Compounding pharmacies can make B12 at 3,000 mcg/cc concentrations. I use hydroxycobalamin, although methylcobalamin may be more effective, though also somewhat more expensive. The Energy Revitalization System multivitamin also contains 500 micrograms of B12 daily for ongoing use.

  Coenzyme Q10, 200 milligrams a day. This is a conditionally essential nutrient that improves energy production in patients with CFS/FMS. It is especially critical in patients on Mevacor-family cholesterol treatments (which can actually cause fibromyalgia pain). I use the Vitaline form made by ITI (which is the one used in many studies), as quality control is especially important with this nutrient.

  Potassium-magnesium aspartate. This can be very helpful in fatigue states.7 The dose is 500 milligrams, twice a day for three months.

  Treating with acetyl-L-carnitine, 500 milligrams twice daily for four months is strongly recommended. Biopsies show CFS patients’ intracellular levels to be routinely low. This not only causes weakness, but also contributes to the average thirty-two-pound weight gain seen in CFS/FMS.

  Vitamin D insufficiency is associated with seasonal affective disorder symptoms, deep muscle pain, and compromised immunity. It can exacerbate these symptoms, which are already present in persons with CFS/FMS. Supplemental vitamin D at 600 to 1,000 IU daily (present in the vitamin powder) is recommended. Vitamin D deficiency is estimated to cause more than 85,000 cancer deaths a year in the United States.

  Diet. There is no one diet that is best for everyone. I recommend that patients eat those things that leave them feeling the best (which is not always the same as what they crave). Having said this, however, the majority of CFS patients find that they do best with a high-protein, low-carbohydrate diet. Patients should avoid sugar, as well as excessive caffeine (which is a loan shark for energy) and excess alcohol. Warn patients that there may be a seven-to ten-day withdrawal period when coming off sugar and caffeine. If they have low blood pressure and/or orthostatic dizziness, they should also consider markedly increasing their salt intake.

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  Widespread nutritional deficiencies are common, and no single tablet will take care of them all. The Energy Revitalization System vitamin powder replaces thirty-five tablets of supplements daily with one drink and one capsule and should be used long term. In addition, add 5 grams ribose (CORvalen) three (later two) times daily in all patients. Some patients may also benefit from 200 milligrams of coenzyme Q10, and 1,000 milligrams of acetyl-L-carnitine daily for about four months.

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  General Pain Relief

  Although pain will often resolve within three months of simply treating SHIN as discussed above, it is also critical to eliminate pain directly. Many studies show a marked analgesic and anti-inflammatory effect from optimal doses (the effect is very dose dependent) of two herbals, willow bark (containing at least 240 milligrams of salicin) and Boswellia (900+ milligrams), which have been shown to be as effective as or more effective than NSAIDs and COX-2 inhibitors but without the GI or other toxicity.37–54 These herbals are excellent for arthritic, inflammatory, and other pain. They can be found in optimal doses combined with cherry (which is high in antioxidants and also has COX-2-inhibiting effects) in an excellent pain herbal called the Pain Formula by Integrative Therapeutics. Have the patient begin with two to four tablets three times a day as needed. Although it can be helpful for acute pain, it is especially helpful when taken on a regular basis for six weeks, as the effect continues to increase over time. Once pain is controlled, the dose can be lowered or it can simply be taken as needed.

  In addition to anti-inflammatory herbals, the herbs in the Revitalizing Sleep Formula (discussed above under Sleep) can also be very helpful for muscle pain. Other natural remedies that help pain include 5-HTP (300 milligrams at bedtime), high-dose curcumin, and ginger. The medications Neurontin, Lyrica, Ultram, and Skelaxin are also far more effective for fibromyalgia pain than NSAIDs.

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  Treating the underlying metabolic problems will often eliminate the pain. In addition, the Pain Formula herbal mix and the medications Neurontin, Lyrica, Ultram, and Skelaxin are also far more effective for fibromyalgia pain than NSAIDs.

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  Autonomic Dysfunction

  This is especially important to treat in patients under eighteen years of age. Low blood pressure and dizziness, increased thirst, polyuria, cold extremities, and night sweats are a few of the symptoms that reflect autonomic dysfunction in CFS/FMS. A study at Johns Hopkins Hospital showed that a majority of CFS patients had neurally mediated hypotension (NMH) on tilt-table testing.55 This means that the blood pressure of CFS/FMS patients can severely drop with standing or minimal exertion. If the patient has low blood pressure, dizziness, or a positive tilt-table test, a treatment trial is appropriate. Treatment consists of markedly increasing salt and water intake. In children, fludrocortisone (Florinef), 1/10-milligram tablets, one to two daily, can be helpful, although it is usually not helpful in adults. Florinef helped only 14 percent of adult CFS patients in an NIH study, versus 10 percent of placebo patients. Fluoxetine (Prozac), sertraline (Zoloft), and especially dextroamphetamine (Dexedrine) are clinically much more effective in treating NMH in CFIDS patients, and I rarely use Florinef in anyone over twenty. Dexedrine also has many other benefits in CFS/FMS. I think it is overused in ADHD and underused in CFS/FMS.

  Psychological Well-Being

  Many illnesses are associated with various psychological profiles. In CFS/ FMS, a common profile is a mega-type-A overachiever who, because of childhood low self-esteem, overachieves to get approval. These patients tend to be perfectionists and have difficulties protecting their boundaries—that is, they say yes to requests when they feel like saying no. Instead of responding to their bodies’ signal of fatigue by resting, they redouble their efforts. Taking time to rest, and getting and staying out of abusive personal and work environments, is critical. As they start to feel better, they need to be instructed to take it slowly and not to go back to the toxic environment or level of over-functioning that made them sick in the first place. They especially need to be instructed not to make up for lost time by trying to do too much. A simplified approach to helping these patients overcome an unhealthy psychodynamic can be found in my book Three Steps to Happiness! Healing Through Joy.

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  Although it is important to treat the underlying metabolic problems in CFS/FMS, most chronic illnesses will not fully resolve unless mind-body issues are also treated. In CFS and FMS this means patients must stop seeking approval, and learn to say no when they feel like it. Teach patients to keep their attention on what feels good from a centered place. In summary, follow your bliss!

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  Treating Anxiety and Depression Naturally

  Anxiety and depression can be seen in chronic illness of any sort, including CFS and fibromyalgia. Fortunately, natural treatments for these can be effective. For anxiety, it is important that patients get adequate amounts of B vitamins and magnesium. In addition, clinical experience has shown that very high-dose vitamin B1 (thiamine) at a level of 500 milligrams one to three times daily can be helpful in decreasing anxiety after several weeks of use. Passionflower, theanine (from green tea), and magnolia can also be helpful and can work quickly, calming the patient without being sedating. An excellent product for the treatment of anxiety in general (which contains all of the above) is called Calming Balance (available from Health Freedom Nutrition; 800-980-8780).

  For depression, nutritional support including B vitamins, magnesium, tyrosine, and 5-HTP can be helpful. In addition, Saint John’s wort at 900 to 1,800 milligrams daily and magnolia can also be effective for mild to moderate depression. All of the above are combined in a formula called Happiness 1–2–3! (also available from Health Freedom Nutrition; 800-980-8780). Although some of its components work fairly quickly, the Saint John’s wort can take six weeks to be optimally effective, so patients should know to give the herbal an adequate amount of time. Because this product can be so effective at raising serotonin, I would not use the maximal dose in those on high levels of antidepressants (e. g., Prozac at 40 milligrams a day or higher) to avoid excess serotonin levels. In addition, making sure that you do not miss subclinical hypothyroidism (regardless of the blood tests’ levels) and adding a mercury-free fish oil (such as Eskimo-3) can also be helpful.

  Treatment Review

  Although this chapter and the summary below will give you an excellent start in treating fibromyalgia, CFS, and myofascial pain syndrome metabolically, the treatment protocol at www.vitality101.com has more than 270 useful natural and prescription therapies with resources and far more detailed instructions for use (organized by category). For example, dozens of sleep and pain therapies are reviewed, and the information on each treatment is given in far more clinical detail. I will be happy to e-mail you this free file, plus long-and short-form patient questionnaires that you can modify for use in your office, as they can dramatically simplify the care of these patients. Simply e-mail me at Endfatigue@aol.com or in the Q&A section at www.vitality101.com. This book (From Fatigued to Fantastic!), and the recently released Pain Free 1–2–3: A Proven Program to Get YOU Pain Free! also contain more detailed information, including more than five hundred references related to our treatment recommendations.

  Treat CFS, fibromyalgia, and myofascial pain syndrome by restoring energy levels metabolically. Do this by using the SHIN protocol. SHIN stands for Sleep, Hormonal support, Infections, and Nutritional support. In addition, give pain support when needed. It is almost never acceptable to leave somebody in pain. Below I have listed some of the key parts of the protocol. The most important and commonly used treatments are indicated with two asterisks and in bold. Almost all of the treatments can be stopped after three to twelve months, except for the Energy Revitalization System vitamin powder plus something for sleep, which should both be taken long term. Many patients also prefer to stay on ribose long term.

  NUTRITIONAL TREATMENTS

  **Energy Revitalization System vitamin powder: Half to one scoop a day (as feels best). If diarrhea occurs, mix the powder with milk and/or start with a lower dose and work your way up to the dose that feels best, or divide the daily dose into smaller doses and take two to three times a day. These products are made by Integrative Therapeutics/ITI and are also available retail at www.vitality101.com and most health food stores. One drink and one capsule replace more than thirty-five tablets of supplements daily and give outstanding overall nutritional support for almost everyone.

  Vitamin B12: If blood levels are less than 540, give 3,000 micrograms IM three to seven times weekly for fifteen doses, then as needed.

  Chromagen Forte (iron): One tablet a day if ferritin is under 40.

  Take on an empty stomach and not within six hours of taking thyroid hormones.

  MITOCHONDRIAL ENERGY TREATMENTS

  Use these for four to nine months. Then drop the dose to the lowest dose that maintains the effect (or stop it if no benefit).

  4. **D-ribose (CORvalen, from Bioenergy; 866-267-8253; www.corvalen.com): One scoop of powder three times a day for three weeks, then two times a day.

  5. Coenzyme Q10: 200 milligrams a day. Vitaline makes the best form.

  6.*Acetyl-L-carnitine: 500 milligrams twice a day for three months.

  SLEEP AIDS

  Adjust dose as needed to get eight to nine hours of solid sleep without waking or hangover.

  7.**Revitalizing Sleep Formula (by Integrative Therapeutics/ITI): 200 milligrams valerian, 90 milligrams passionflower, 50 milligrams L-theanine, 30 milligrams hops, 12 milligrams piscidia, and 28 milligrams wild lettuce. Take two to four capsules each night thirty to ninety minutes before bedtime. It can also be used during the day for anxiety. If valerian energizes you (occurs in 5 to 10 percent of people), use the other components.

  8. 5-HTP (5-Hydroxy-L-Tryptophan): 200 to 400 milligrams at night.

  9. Calcium: 500 to 600 milligrams; magnesium: 100 to 200 milligrams at bedtime.

  10. Melatonin; 0.5 milligram at bedtime.

  11.**Ambien (zolpidem): 10 milligrams, half to one and a half at bedtime.

  12. Desyrel (trazodone): 50 milligrams, half to six at bedtime.

  13. Klonopin (clonazepam): 0.5 milligrams. Begin slowly and work your way up as sedation allows. Take half a tablet at bedtime, increasing to six tablets at bedtime as needed. Can be effective for sleep, pain, and restless leg syndrome. Klonopin may be addictive.

  14. Doxylamine (Unisom for Sleep) or Benadryl: 25 milligrams at night (antihistamines). May also help pain.

  15. Neurontin (gabapentin): 300 milligrams, one to two capsules at bedtime. Also helps pain and restless leg syndrome.

  HORMONAL TREATMENTS

  THYROID SUPPLEMENTATION

  The main side effect of thyroid treatment is triggering benign caffeinelike anxiety or palpitations. Although rare, as also seen with exercise (e. g., climbing steps), if one is on the edge of having a heart attack or severe “racing heart” (atrial fibrillation), thyroid hormone can trigger it. In the long run, though, I suspect that thyroid may decrease the risk of heart disease. To put it in perspective, I’ve never seen angina in treating thousands of patients with thyroid. Increasing the thyroid dose to levels above the upper limit of the normal range may accelerate osteoporosis (which is already common in CFS/FMS). Because of this, check the thyroid (free T4—not TSH) levels after four to eight weeks on the optimum dose of thyroid hormone. Do not take thyroid within six hours of iron or calcium supplements or you won’t absorb the thyroid.

  16.**Armour Thyroid: 30 milligrams (½ grain = 30 milligrams) (natural thyroid glandular). If Cortef is checked, begin the Cortef and/or adrenal support one to seven days before starting the thyroid. Take half a tablet each morning on an empty stomach for one week and then one tablet each morning. Increase by half to one tablet every one to six weeks (until the patient is on three tablets or the dose that feels best). Check a repeat free T4 blood level when on three tablets a day (or the optimum dose) for four weeks. If okay, you can continue to raise the dose by half to one tablet each morning every six to nine weeks to a maximum of five grains (300 milligrams) a day and then recheck the free T4 four weeks later. Adjust it to the dose that feels the best (lower the dose if shaky or if your resting pulse is regularly over 88/minute).


  ADRENAL HORMONES (GLANDULARS AND SUPPORT )

  Helps the body deal with stress and maintains blood pressure.

  17.*Cortef: 5-milligram tablets, half to two and a half tablet(s) at breakfast, half to one and a half tablet(s) at lunch, and 0 to half a tablet at 4 p. m. Use the lowest dose that feels the best. Most patients find that one to one and a half tablets in the morning and half to one tablet at noon is optimal. Take it with food if it causes an acid stomach. Do not take more than four tablets a day.