CFS lupus erythematosus by mikeholy


									                Chronic Fatigue
               Kenneth J. Friedman, Ph.D.
        Associate Professor of Pharmacology and
               New Jersey Medical School
                   Newark, NJ 07103

Prepared for the Everglades AHEC             April 11, 2008

         Disclosures for Dr. Friedman

   New Jersey Chronic Fatigue Syndrome
    Association: Board Member and Chair of
    Medical Student Scholarship Committee
   P.A.N.D.O.R.A.: Secretary, and Chairman of
    Public Policy Committee
   Vermont CFIDS Association: Member
   Consultant to MedaCorp: provide advice and
    expertise to unknown clients
   Consultant to Hemispherex: limited to public
    policy not drug development
Part I:

    Chronic Fatigue Syndrome
        CFS Case Definition and Criteria

   A CFS patient must have:
       Persistent or relapsing fatigue of 6 months or
        longer duration
       Fatigue severity significant enough to greatly
        reduce activities of daily living
       All other known medical conditions excluded
        by clinical diagnosis
     CFS Case Definition and Criteria
   All of the above and concurrently have four or
    more of the following eight symptoms:
       •Post-exertional malaise lasting more than 24
       •Unrefreshing sleep
       •Impaired memory and concentration
       •Muscle pain
       •Multi-joint pain without redness or swelling
       •Headache of a new type or severity
       •Sore throat
       •Tender cervical or axilliary lymph nodes
           Political History of CFS

   CFS was formally defined in 1988

   CFS is known by other names: CFIDS,
    ME, Myalgic Encephalitis, Myalgic
    Encephalopathy, ME/CFS, CFS/ME

   Comparable illnesses have been
    documented for centuries
     Cause/Contributing Factors of CFS

   The cause of CFS is unknown.
   Epstein Barr Virus was at one time
    thought to be the cause.
   Research has shown this to be false:
       EBV appears to be precipitate/trigger CFS in
        some patients.
       Not all CFS patients have or had EBV
         Possible Contributing Factors
   Infectious agents            Dysautonomias

   Immune System                Neuroendocrine
    Dysfunction                   Dysfunction

   Sleep disorders              Other possible causes

   Current theories:
             Multiple factors may be involved
             Final common pathway
                What is CFS?

   Is CFS…
           a syndrome?

           a disease?

           an illness?

           a disorder?
Because of the controversial nature of CFS,
  a number of myths surround it. Three of
       the most common myths are:
         Fact or Myth?

CFS is a relatively rare disorder.
             CFS Prevalence

   CFS affects approximately 200-500 per
    100,000 adults

   An estimated 18% of those classified as
    having CFS have been diagnosed by a
    health care professional (CDC)
        Fact or Myth?
The highest prevalence of CFS
is among middle-aged, affluent,
white, professional women.
             CFS Prevalence

   CFS is most common among women
    between 40-54 years of age

   CFS is at least as common among
    black and Hispanics as among white

   Persons of middle-income status are
    at the greatest risk
            CFS Prevalence
   Race
     All races need to be carefully

   Gender
     Women have a much higher rate
      of CFS than men:
       A ratio of 3:1
                 CFS in the
      Pediatric/Adolescent Population

   Limited data on this population.

   Pediatric/adolescent CFS prevalent rate appears
    to be lower rate than in adults.

   Newly published pediatric/adolescent CFS case
    definition relaxes some of the more stringent
    adult criteria.
         Fact or Myth?

CFS is a form of depression.
          CFS and Depression

   CFS and Major Depressive Disorder (MDD)
    have many symptoms in common.

   Both can be overlooked easily.

   Careful evaluation is required.
    CFS and Depression

     Depression is an
       illness that
be diagnosed and treated.
        Differentiating CFS from
   Depressed patients are capable of
    physical activity but lack the

   CFS patients have the motivation for
    physical activity but lack the
    Diagnosis of CFS

The diagnosis of CFS
 is primarily one of
Diagnostic Procedure for CFS


  Symptom Driven

  1.History & Physical findings
  2.Psychological and
    Neurological examination
  3.Exclusionary lab tests
         Diagnostic Procedure for CFS

Meets ≥ 4 of the 8 Symptom Criteria:

            1. impaired memory or concentration
            2. sore throat
            3. Tender cervical or axillary lymph nodes
            4. muscle pain
            5. Multi-joint pain
            6. New headaches
            7. Unrefreshing sleep
            8. Post-exertional malaise

         No Plausible Explanation
        Diagnostic Procedure for CFS
            No Plausible Explanation

      Chronic Fatigue            Chronic Fatigue
        ≥ 6 months                 ≤ 6 months

    Significantly       •Provide appropriate treatment
    affects daily       •Reevaluate at appropriate
activities and work     intervals

           No significant impact
Diagnostic Procedure for CFS

Satisfies 4 or more of the 8 secondary
               CFS criteria

         Diagnosis of CFS

    Diagnostic Procedure for CFS

   See Appendix for:
       Unique aspects of medical history and
        physical examination of CFS patients.
       Recommended laboratory tests and additional

        Diagnostic Challenges 1

   Patients with CFS often have a relatively
    normal physical examination

 A diagnosis of CFS cannot be made
  without a proper psychological evaluation
             Diagnostic Challenges 2

   There are plausible explanations of
    fatigue that preclude a CFS Diagnosis

                                   Chronic active
       Narcolepsy
                                    hepatitis B or C

       Sleep Apnea                Hypothyroidism

       Iatrogenic: e.g. medication side effects.
              Diagnostic Challenges 3

Conditions with Chronic Fatigue Symptoms

    Lupus erythematosus       Severe obesity

    Lyme disease              Tuberculosis

    Multiple sclerosis        Nutritional deficiency,
                                e.g., fad diets,
    Rheumatoid arthritis       supplement use
         Diagnostic Challenges 4

           Psychological Issues
   Several psychological illnesses resemble
    CFS and are exclusionary for CFS
   Exclusionary psychological conditions
    listed in appendix.
      Diagnostic Challenges 5
Abnormal Patient Reports and Behavior
  Psychomotor   slowing
  Cognitive impairment

  Odd interpersonal behaviors

  Angry, hostile responses

  Suicide risk assessment
          Diagnostic Challenges 6
          Autonomic Dysfunction
   Common in a subset of CFS patients

   Rule out types of orthostatic intolerance

   Tilt-table testing may be indicated for some
    patients with appropriate symptom profile
          Diagnostic Challenges 7
        The Presence of Fibromyalgia
   Fibromyalgia may co-exist with CFS

   Emphasis on musculoskeletal pain rather than

   Fibromyalgia will be discussed in Part II of this
Conditions with Overlapping


   OAB                    Pelvic Pain

 IBS                            MCS

         GWI/S          MVP

       CFS Management
The goal is to:
   assist patients to return to as
    normal function as possible
   maximize well-being

   set and maintain realistic
   See appendix for management
    goals and strategies

   No long term prognosis can be made

   Lack of treatment may negatively impact

   The primary care provider can help to
    improve quality of life for people with CFS
       Disability and CFS
 All patients with CFS are impaired and
  many suffer occupational disability

 Application process is protracted and

 The Primary Care Provider is a major
  source of documentation for disability

   CFS has a significant impact on society,
    individually and collectively
       The hardship on individuals is incalculable

       The economic impact alone is estimated to be
        over $8.8 billion per year

       Research and education efforts are ongoing

The goal of primary care
 providers is to help the
     patient reach an
    improved level of
Part II: Fibromyalgia

    Fibromyalgia Syndrome (FM or FMS)

   A syndrome characterized by widespread
    muscle pain, fatigue and multiple tender
   Tender points- specific places on the body
    – neck, shoulders, back, hips, and
    extremities- where patients feel pain in
    response to slight pressure.
   FMS is a chronic condition.

        Fibromyalgia Syndrome

   80 % of patients are women
   Most commonly affects patients aged 35-
    55 years of age.
   Affects 3 – 6 million Americans.
   The pain and fatigue of FMS can interfere
    with the ability to carry on daily activities.

           Symptoms of FMS 1

   Pain throughout the body and a feeling of
   Muscles affected are in shoulders,
    buttocks, neck and lower back.
   Pain seems to originate tender points.

          Symptoms of FMS 2

   Pain exacerbated by stress, weather
    changes, loud noises and anxiety.
   Symptoms range from mild to severe.
   Symptoms may be intermittent.

    Specific Symptoms of FMS 1
   Sleep disturbances (which may add to the
    feeling of fatigue).
   Morning stiffness.
   Numbness or tingling of extremities.
   Restless leg syndrome.
   Temperature sensitivity.
   Cognitive and memory problems (Fibro
   Painful menstrual periods.
     Specific Symptoms of FMS 2
   Headaches and jaw pain.
   Sensitivity to odors, bright light, noise,
    food, changes in weather, and medicines.
   Gastrointestinal problems: IBS, diarrhea,
    constipation, heartburn and difficulty
   Women way have pelvic pain, painful
    sexual intercourse
   Frequent urination, strong urge to urinate,
    pain in the bladder.
   Cause is unknown.

          Possible Causes of FMS
   Possible causes include:
      Imbalance of CSF substances
      Neurotransmitter imbalance in the brain
      Low level of serotonin
      Abnormal sleep – lack of non-REM
      Stress
      Infections
      Injuries
      Inherited genetic tendency – runs in
               Co-morbid conditions

   FMS commonly seen in patients with:
       Rheumatoid arthritis
       Lupus

             Diagnosis of FMS 1

   Dx of FMS is given only after other
    muscle, joint and gland diseases with
    similar symptoms have been ruled out.
   Detailed medical history and physical
   Blood tests and radiological tests
    performed to exclude other illnesses with
    similar presentations.

              Diagnosis of FMS 2

   There is no diagnostic test for FMS
   There is no object test for FMS
   Patients often accused of faking or
    imagining symptoms.
   Dx best made on the established criteria
    of the American Academy of
    Rheumatology (ACR).

              ACR Criteria for FMS

   A history of widespread pain lasting more than 3
    months and the presence of tender points.
   Pain affects all 4 quadrants of the body- right
    and left sides, above and below the waist.
   Pain must be present at 11 or more of the 18
    FMS tenderpoints.
   A designated site is a tender point if a force of 4
    kg results in pain.

             Treatment of FMS -1
   Goal: Manage the symptoms of FMS
   Strategy: Assemble a treatment team
      Physician(s)

      Physical therapist

      Other healthcare professionals

         Massage therapist

         Psychotherapist

      Patient participation

               Treatment of FMS 2
   Pharmaceuticals –
       Analgesics – prescribed for muscle pain
       Antidepressant medications
   Benzodiazepines – tranquilizer with
    hypnotic, sedative properties
   Complimentary and Alternative medicine
    treatments (see Appendix for examples)

           Self-Care for FMS 1
   A healthy living program
     Reduce stress – avoid stressful
     Sleep well – good sleep hygiene; avoid
      caffeine and alcohol, use a comfortable
     Exercise regularly – stretch upon
      waking; low impact exercise. Try to
      maintain body weight.

        Self-Care for FMS 2

 Eat a healthy diet – avoid alcohol,
  caffeine, candy, known foods that cause
  allergic reactions
 Manage symptoms – treat symptoms as
  they arise
 Maintain social contacts – social
  stimulation prevents often
  accompanying depression.
   FMS is a syndrome that causes pain and
    fatigue in muscles, joints, ligaments and
   There is no cure for FMS.
   Treatment of FMS includes:
      Medication

      Improvement of general health through
      Complimentary and Alternative Medicine

      Stress Management
 Comparison of CFS and FMS 1
                   CFS               FMS

Type of      Syndrome          Syndrome
Disorder     Illness           Illness
Prevalence   1 million         3-6 million

Women:Men    3:1               4:1

Diagnosis    Case Definition   Tender Points
             Dx of exclusion   Dx of exclusion
 Comparison of CFS and FMS 2
                  CFS               FMS

Major       Chronic fatigue;   Chronic pain;
symptoms    non-restorative    tender points
Goal of     Manage             Manage
Treatment   symptoms           symptoms
Prognosis   Life-long          Life-long
            disability         disability
The End!

Supplemental Information for Lecture

The Medical History & Physical Exam of
            a CFS Patient
   MH and PE are almost always more
    lengthy than the allotted time period for a
    „routine‟ MH and PE
   Office visits of a CFS patient require more
    time than office visits of most other
      Suggested Lab Tests for the CFS
                 Patient 1
   Urinalysis
   Complete blood count with leukocyte
   Erythrocyte sedimentation rate or C
    reactive protein
   Alanine aminotransferase or aspartate
    transminase serum level
   Albumin
      Suggested Lab Tests for the CFS
                 Patient 2
   Globulin
   Alkaline phosphatase
   Glucose
   Calcium
   Phosphorus
   Thyroid function test (TSH and Free T4)
   Rheumatoid factor (if arthritic complaints
    are present)
    Diagnostic Procedure for CFS

   Additional Testing
       EBV titer
       Tilt table
       Sleep studies
       Other tests as indicated by patient history and
        physical exam.

Psychological Conditions That Preclude
             a Dx of CFS
   Bipolar disorder
   Schizophrenia
   Dementia
   Psychotic or melancholic depression
   Anorexia nervosa
   Bulimia nervosa
   Active alcohol or substance abuse (current or
    within preceding two years)
           CFS Management 1

   Provide the patient with general
    information about the nature of the illness

     Educationalbrochures, materials, etc.
     Resource contact information
         CFS Management 2

   Develop an individualized plan

     Supportive

     Symptomatic
             CFS Management 3
            Supportive Treatment
   Diet
     Optimal, well-balanced diet

     Weight management issues

     Referral to registered dietitian
             CFS Management 4
            Supportive Treatment
   Activity
     Highly individualized

     Paced; avoid overexertion; find the
      correct balance to prevent “boom or
      bust” cycles
     Referral to physical or occupational
             CFS Management 5
            Supportive Treatment
   Coping skills
     Counseling

     Cognitive behavioral therapy (CBT)

        Although not a cure for CFS, it can
         help improve function and coping
             CFS Management 6
           Symptomatic Treatment
   Although there is no cure for CFS, patients
    can be helped.

   Address the symptoms and tailor a
    management plan accordingly.
             CFS Management 7
           Symptomatic Treatment
   Sleep Disturbances
      Establish normal sleep hygiene

       Limit pharmacological agents

       Explain why limit is necessary

       Refer patients to a sleep specialist
             CFS Management 8
           Symptomatic Treatment
   Cognitive Dysfunction
     Cognitive training is highly specialized
      form of therapy and requires referral to
      a trained clinician
            CFS Management 9
          Symptomatic Treatment
   Depression
     Commonly accompanies CFS and must
      be treated

     Psychological   screening instruments
           CFS Management 10
          Symptomatic Treatment
   Pain
      Simple analgesics

         acetaminophen, aspirin or NSAIDs

     Non-pharmacological    modalities
        paced activity, gentle massage,
         physical therapy, TENS units, cool or
         hot packs
     CFS Management 11 Symptomatic
   Pain
      Pain management counseling

     Referral to a pain management
        Narcotics are not recommended
         except in consultation with pain
         management specialists
     CFS Management 12 Symptomatic
   Dysautonomias
     Increased fluid and salt intake

     Compression   garments

     Referral to a neurologist or cardiovascular
      specialist for pharmacological therapy
      with such drugs as fludrocortisone,
      midodrine, beta-blockers or alpha
     CFS Management 13 Symptomatic
   Other conditions
     IBS

     Fibromyalgia

     TMJD

     Overactive   bladder
              CFS Management 14
             Symptomatic Treatment

   Other conditions
     Pelvic pain

     Pain   syndrome

     Multiple   chemical sensitivities

     Mitral   valve prolapse
Complementary & Alternative Medicine
    (CAM)Treatments for FMS 1

   Physical and occupational therapy.
   Learn pain management techniques
   Learn coping techniques (Cognitive
    Behavioral Therapy – CBT)
   Massage

Complementary & Alternative Medicine
    (CAM)Treatments for FMS 2
   Movement therapies – Pilates, Feldenkrais
   Chiropractic treatments
   Acupuncture
   Herbs and dietary supplements
     There is little scientific proof that herbs
      or dietary supplements are of benefit.

            CAM Treatments for FMS
               Massage Therapy
   Choice of therapies – Swedish, Deep
    (Connective) Tissue, Shiatsu
   Possible benefits include:
      Increased blood circulation
      Loosening of sore muscles
      Increased flow of nutrients to muscles
      Removal of “toxins” from muscles
      Alignment of muscles and joints
      Relieves stress and anxiety

          CAM Treatments for FMS
   Accupressure – application of pressure via
    practitioner‟s fingers at specific points on
    the body to increase the flow of energy
    through disrupted pathways.
   Accupressure – insertion of small needles
    at acertain points of the body to restore
    energy flow through disrupted pathways.

      CAM Treatments for FMS
Trigger Point Therapy/Chiropractic Care

   Trigger Point Therapy – application of
    pressure for a few minutes at/on specific
    trigger points (points at which muscle pain
   Chiropractic Care – realignment of
    vertebrae of the spine. Vertebrae are
    stretched to relieve pressure on nerves.


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