Archive for the ‘chronic diseases’ Category
Posted by Alex
No treatment has been proved to benefit patients with CFS in large randomized controlled trials that have been replicated by other investigators in other populations of patients. Moreover, without a better understanding of the pathogenesis of CFS, it is unlikely that definitive treatment will be identified. Indeed, the pharmacologic treatment of CFS primarily involves the treatment of the symptoms associated with CFS. In my experience, patients with CFS are unusually sensitive to any drug or substance (e.g., alcohol) that affects the central nervous system; one should start with a low dose and then gradually escalate it as necessary.
Low-Dose Tricyclic Agents
The most widely used treatment of CFS is sedating tricyclic antidepressant agents in low doses: amitriptyline (Elavil)* or doxepin (Sinequan),* 5 to 20 mg at bedtime. For unusually low doses, the liquid form of the medication may be necessary. Low-dose tricyclic agents have been proved efficacious in randomized trials of a similar illness (fibromyalgia) and in a number of sleep disorders. No such trials have been conducted in patients with CFS. In my anecdotal experience, most patients immediately notice that their sleep is less frequently interrupted and that they awaken feeling somewhat more refreshed.
Patients with concomitant depression do not report an improvement in the core symptoms of depression when given these low doses of tricyclic agents. Patients should be warned that during the first week of therapy, even extremely low doses of tricyclics may cause them to feel groggy in the morning; that reaction usually dissipates after about 1 week. When this reaction does not dissipate, patients can be switched to a less sedating tricyclic agent, such as desipramine (Norpramin),* 20 to 50 mg at bedtime, or to the triazolopyridine antidepressant trazodone (Desyrel),* 25 to 50 mg at bedtime.
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Posted by Alex
Nonpharmacologic Management
Management of the patient with CFS requires more than pharmacotherapy. First, the clinician must make a personal judgment as to whether patients are accurately relating their symptoms -both those that they admit to and those that they deny. CFS is an illness defined only by symptoms. Thus, an occasional patient seeking secondary gain may fabricate a “perfect story” for CFS. Somewhat more commonly, patients who have been told that they are suffering from major depression and who find that diagnosis to be stigmatizing read about CFS in the media and come to believe that it explains their fatigue. So, the first task of the clinician is to make an admittedly arbitrary judgment as to the veracity of the symptoms reported. In my experience, with CFS and other illnesses, it is generally wisest to believe what the patient tells you.
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Posted by Alex
Chronic fatigue syndrome (CFS) is characterized by at least 6 months of exceptional fatigue, with several associated chronic symptoms. Chronic diseases that would exclude the diagnosis of CFS include untreated hypothyroidism, sleep apnea, chronic active hepatitis, any psychotic disorder, dementia, anorexia nervosa or bulimia nervosa, recent substance abuse, and severe obesity. Bipolar affective disorder excludes a diagnosis of CFS, but nonpsychotic unipolar major depression or anxiety disorders do not. As so defined, patients with CFS represent a small fraction (1 to 3%) of all patients seeking medical care for the complaint of chronic fatigue.
Patients with CFS may be of any age, of either sex, and from all walks of life; the typical patient is a 35-year-old white woman. The onset is often sudden, frequently after an acute “viral” syndrome. In unusual cases, CFS follows in the wake not of a nondescript “flulike” illness but of a well-defined acute infectious illness, including acute infectious mononucleosis and Lyme disease (despite adequate antibacterial therapy and the resolution of Lyme disease-specific symptoms).
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Posted by Alex
Myasthenia gravis occurs at all ages, sometimes in association with a thymic tumor or thyrotoxicosis, as well as in rheumatoid arthritis and lupus erythematosus. It is commonest in young women with HLA-DR3; if thymoma is associated, older men are more commonly affected.
Onset is usually insidious, but the disorder is sometimes unmasked by a coincidental infection that leads to exacerbation of symptoms. Exacerbations may also occur before the menstrual period and during or shortly after pregnancy. Symptoms are due to a variable degree of block of neuromuscular transmission caused by autoantibodies binding to acetylcholine receptors; these are found in most patients with the disease and have a primary role in reducing the number of functioning acetylcholine receptors. Additionally, cellular immune activity against the receptor is found. Clinically, this leads to weakness; initially powerful movements fatigue readily. The external ocular muscles and certain other cranial muscles, including the masticatory, facial, and pharyngeal muscles, are especially likely to be affected, and the respiratory and limb muscles may also be involved.
Clinical Findings
A. Symptoms and Signs: Patients present with ptosis, diplopia, difficulty in chewing or swallowing, respiratory difficulties, limb weakness, or some combination of these problems. Read the rest of this entry »
