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Treatment: Pharmacologic Therapy
Pharmacologic therapy is directed toward the relief of specific symptoms experienced by the individual patient. Patients with CFS appear particularly sensitive to many medications, especially those that affect the central nervous system. Thus, the usual treatment strategy is to begin with very low doses and to gradually increase dosage as necessary and as tolerated. It is important to remember that use of any drug for symptom relief should be attempted only if an underlying cause for the symptom in question has not been found. The best example is use of a sleep-enhancing medication for non-restorative sleep. Although the patient may state that they sleep better, the sleep disorder remains obscured and thus treatment of the sleep disorder not given. It is also important to remember that all medications can cause untoward side effects, which may lead to new symptoms. Prescription
Medications Low-dose tricyclic antidepressants: Tricyclic agents may be prescribed for CFS patients to improve sleep and to relieve mild, generalized pain. Examples include doxepin (Adapin, Sinequan), amitriptyline (Elavil, Etrafon, Limbitrol, Triavil), desipramine (Norpramin), and nortriptyline (Pamelor). Effective dosages are often much lower than those used to treat depression. Some adverse reactions include dry mouth, drowsiness, weight gain, and elevated heart rate. Other antidepressants: Newer antidepressants have been used to treat depression in CFS patients, although non-depressed CFS patients receiving treatment with serotonin reuptake inhibitors have been found by some health care providers to benefit from this treatment as well or better than depressed patients. Examples of antidepressants used to treat patients with CFS include serotonin reuptake inhibitors, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil); venlafaxine (Effexor); trazodone (Desyrel); and bupropion (Wellbutrin). A number of adverse reactions, varying with the specific drug, may be experienced, but include agitation, sleep disturbances, and increased fatigue. Anxiolytic agents: Anxiolytic agents may be used to treat symptoms of anxiety in CFS patients. Examples include alprazolam (Xanax) and lorazepam (Ativan). Clonazepam (Klonopin) is another member of this family of drugs that is used to control exaggerated nervous systems problems such as vertigo, burning or exaggerated tenderness in the skin, and . nervous. limb movements, may also be useful. However, they should not be used in the general treatment of CFS. Common adverse reactions include sedation, amnesia, and symptoms accompanying acute withdrawal (insomnia, abdominal and muscle cramps, vomiting, sweating, tremors, and convulsions). Stimulants: Fatigue by itself is not a good indication for symptomatic therapy. However, if the fatigue represents lethargy or daytime sleepiness, treatment may be indicated. Trials of a wakefulness agent, modofanil (Provigil), have been completed, but the results have not yet been published. In a small group of patients with excessive sleepiness, the drug decreased symptoms compared with placebo. This drug is currently indicated only with the diagnoses of narcolepsy and excess daytime sleepiness when identified by the proper sleep studies. Antimicrobials: An infectious cause for CFS has not been identified, and antibiotics, antivirals, and antifungal agents should not be prescribed for treatment of CFS, unless the patient has been diagnosed with a concurrent infection. A controlled trial of the antiviral drug acyclovir found no benefit for the treatment of patients with CFS. Indiscriminant use of antimicrobials can have a myriad of adverse effects, including increasing the risk for resistant organisms. Anti-allergy therapy: Some CFS patients have histories of allergy, and these symptoms may flare periodically. Non-sedating antihistamines may be helpful for CFS patients with allergies. Examples include desloratadine (Clarinex), fexofenadine (Allegra), and ceterizine (Zyrtec). However, anti-allergy therapy has no efficacy in the treatment of CFS itself. Some of the more common adverse reactions associated with use of these medications include drowsiness, fatigue, and headache. Sedating antihistamines such as benadryl can also be of benefit to patients at bedtime. The tricyclic antidepressants mentioned above also have potent antihistamine effects. Antihypotensive/antitachycardia therapy: CFS does not respond to treatment with antihypotensive or antitachycardic drugs and general use of such medications may be harmful. However, such medications may be useful in specific circumstances. For example, fludrocortisone (Florinef) has been prescribed for CFS patients who have had a positive tilt table test. However controlled studies have not found Florinef alone effective in the general treatment of CFS patients. Beta blockers such as atenolol (Tenormin) have also been prescribed for patients with orthostatic hypotension. Midodrine (Proamatine), an agent that directly increases blood pressure, may be useful in selected patients identified by an abnormal tilt test. Increased salt and water intake is also recommended for these patients but should be done only under supervision of a health care provider. Adverse reactions include elevated blood pressure and fluid retention. | ||
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