Dr Podell

<h2 id="Epstein-Barr-Virus(EBV)" title="Information on CFS treatment using Valcyte, Valtrex or Famvir">Should We Treat Epstein-Barr Virus (EBV) or HHV-6 with Valcyte, Valtrex or Famvir?</h2>

<p>Image: brozova/123RF Stock Photo</p>

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<p>Most Chronic Fatigue Syndrome doctors believe that many (but not all) CFS/ME cases are due to the reactivation of Herpes Class viruses such as Epstein-Barr Virus, Human Herpes Virus-6 (HHV-6), Cytomegalovirus (CMV) and/or Herpes Simplex Virus. These viruses lie dormant in our body. Later they can flare up, causing severe illness. This may be similar to where Chicken Pox reactivates to cause Shingles. Enteroviruses, Mycobacteria, Lyme-like bacteria, Parvovirus and autoimmune disorders have also been proposed as potential causes.</p>

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Many but not all chronic fatigue physicians offer selected patients <a href="http://www.drpodell.org/ValcyteConsent.pdf" title="download Valcyte pdf" target="blank">Valcyte</a> (valganciclovir), <a href="http://www.drpodell.org/ValtrexConsent.pdf" title="download Valtrex pdf" target="blank">Valtrex, or Famvir</a> — anti-virus medicines against Herpes class viruses. Jose Montoya, M.D., professor of infectious disease at Stanford Medical School, favors treating with Valcyte for CFS patients who have very high antibody levels against both Epstein-Barr and HHV-6 viruses. Dr. Montoya, Dr. Andreas Kogelnik and others from Stanford published a small but well designed <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed/23959519" title="information on trial related to Valycyte">double blind study</a> testing Valcyte against a placebo for a six month course of treatment.</p>

<p>Image: Epstein Barr virus 

on Wikipedia</p>

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Their results were encouraging but not conclusive. Ideally, we would expand and repeat Dr. Montoya’s study. Unfortunately, Dr. Montoya could not obtain funding to do another double blind trial. Sadly, lack of research funding for CFS/ME has long been a fact of life. However, I am optimistic because Dr. Montoya at Stanford and Dr. Kogelnik in Mountain View, California both continue to treat selected CFS/ME patients with Valcyte. Based on my personal conversations with them, both believe that Valcyte has helped a substantial sub-group of their patients.

<a href="http://www.drpodell.org/newpatients.shtml" title="Chronic Fatigue Syndrome treatments">Contact Dr. Podell for questions about chronic fatigue syndrome treatments</a>.</p>

<h2 id="Potential-Paths-Toward-Treatment" title="Information on what causes CFS">Potential Paths Toward Treatment</h2>

<p>There are no Food and Drug Administration Approved CFS treatments. But there are promising paths we are eager to follow:</p>

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<th>POTENTIAL APPROACHES TO TREATMENT</th>

<th>EXAMPLES OF POTENTIALLY USEFUL TREATMENTS</th>

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<td>Anti-viral Medicines</td>

<td>Valtrex, Famvir, Valcyte</td>

</tr>

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<td>Strengthening Immune Support</td>

<td>AHCC (Shitake Mushroom), Reishi Mushroom, Specific Probiotics, Immunovir, repair nutritional deficiencies e.g. zinc</td>

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<td>Reducing Immune System Inflammation: Medicines</td>

<td>Low Dose Naltrexone, Minocycline, Doxycycline, Rituximab, perhaps Colchicine, pentoxyfilline</td>

</tr>

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<td>Reducing Immune System Inflammation: Natural Products</td>

<td>Curcumin, Pycgnogenol, Panax Ginsent, Green Tea, Ginger, bifidobacteria infantis 35624, French Oak Wood Extract (Ribovit)</td>

</tr>

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<td>Improve Mitochondrial Energy Metabolism</td>

<td>Nicotinamide Riboside, Pycgnogenol, Creatine, Carnitine, Coenzyme Q, Lipoid Acid, Magnesium, Kaprex</td>

</tr>

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<td>Stimulant Medicines</td>

<td>Ritalin (methylphenidate), Provigil/Nuvigil</td>

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<td>Treat orthostatic low blood pressure and/or POTS</td>

<td>Hydration, exercise reconditioning, licorice root, potassium, Beta blockers, Ritalin, Proamatine, Mestinon (pyridostigmine)</td>

</tr>

</tbody></table>

<p>In the Montoya study Valcyte treated patients did NOT have major side effects. In contrast, when used for its FDA approved indication—CMV virus infections among patients with AIDS or after organ transplants—Valcyte did cause major side effects. Also, when tested in animals Valcyte increases the risk of cancer. Valcyte is also very expensive. Insurance coverage is rarely obtained unless the patient also has high antibodies against cytomegalovirus (CMV). Even then insurance coverage is difficult.

In contrast, Valtrex and Famvir are relatively safe and relatively inexpensive anti-virals. Both are approved by the FDA to treat herpes simplex virus (e.g. cold sores, genital herpes) and also shingles. In our New Jersey office we first consider Valtrex or Famvir. I do use Valcyte, but only in very special cases. None of these anti-viral drugs are FDA approved to treat CFS.

From a different perspective, <a target="_blank" href="http://phoenixrising.me/interviews-3/an-interview-with-dr-john-chia-m-d-enteroviruses-and-chronic-fatigue-syndrome-part-ii-persistence-treatment-and-the-future-by-cort-johnson" title="interview about enteroviruses">John Chia, M.D.</a> recommends focusing on a different set of viruses, called enteroviruses. He advocates for the use of a natural anti-viral product called Equilibrant.

Have more questions about Epstein-Barr treatments? Contact <a href="http://www.drpodell.org/newpatients.shtml" title="Contact information on Epstein-Barr treatment">Dr. Podell</a> today!</p>

<h2 id="CFS-Immune-System" title="Information on CFS and strengthening the immune system">Treating CFS by Strengthening the Immune System</h2>

<p>Image: Lingzhi mushroom on Wikipedia</p>

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<p>Among Chronic Fatigue Syndrome patients certain parts of the immune system tend to be weak. Strengthening these weak parts might be of benefit. An important test for immune system weakness is called Natural Killer (NK) Cell Function. NK Cell functional testing is a difficult test to do. For selected patients we send out this test. However, whether or not NK cell functional activity is low, strengthening the CFS immune system could likely be useful. One powerful immune stimulant, <strong>AHCC</strong>, a form of Shitake mushroom, has been shown to suppress HHV-6 virus levels in cancer patients undergoing chemotherapy. Reishi (also known as Lingzhi) mushroom might have similar good effects. Thus AHCC and Reishi mushroom might be considered as natural additional treatments for Epstein Barr or HHV-6 viruses.</p>

<h2 id="CFS-Reducing-Inflammation" title="Information on Chronic Fatigue Syndrome treatments">Treating CFS by Reducing Inflammation</h2>

<p>Experts agree that although the CFS immune system is weak in several ways, in other ways it is over-stimulated or inflamed. Fortunately, we have several medicine and natural products that can suppress inflammation. For example, Stanford Medical School researchers have helped Fibromyalgia patients in two small double blind studies using low doses of an anti-narcotic medicine called Naltrexone. At low doses (much lower than its normal dose), <a href="http://www.drpodell.org/Naltrexone-LDN.shtml" title="information about low dose naltrexone">low dose naltrexone (LDN)</a> appears to calm over active immune cells in the brain. These immune cells are called microglia. LDN has not been specifically tested to treat CFS. Fortunately, LDN is a very safe treatment.

<strong>Minocycline and doxycyline</strong>, two antibiotics related to tetracycline have anti-inflammatory effects in addition to their actions as antibiotics. They seem to help patients with early rheumatoid arthritis. But, they have not been systematically tested as treatment for CFS.

<strong>Rifaximab</strong> is a powerful immune suppresant drug that is usually used to treat lymphoma or severe rheumatoid arthritis. Norwegian researchers, in a small double blind study, showed that Rifaximab could induce remissions among patients with CFS—although these remissions lasted for only six months. A repeat of this important study is currently underway. Unfortunately, Rifaximab is potentially fairly toxic. Our chronic fatigue clinic has decided to not offer this drug until further studies are reported.

Many natural products can reduce inflammation, although none have been tested formally for CFS. Curcumin (derived from the Indian flavoring, Tumeric), Pycnogenol, Green Tea, Panax Ginseng and Lycopene and others could be considered. A specific strain of probiotics, Bifidobacterium infantis 35624 has demonstrated anti-inflammatory effects. (Align and Natren both sell this strain.)

<a href="http://www.drpodell.org/newpatients.shtml" title="Contact information on Chronic Fatigue Syndrome treatments">Contact us</a> for the best Chronic Fatigue Syndrome treatment.</p>

<h2 id="CFS-Mitochondria-Energy-Metabolism" title="Information on improving energy metabolism">Treating CFS by Improving Mitochondria and Energy Metabolism</h2>

<p>Mitochondria, within our cells, produces the energy that we need. Recent research suggests that among people with chronic fatigue, mitochondrial energy is often reduced. A fairly large number of nutritional supplements have the potential to improve mitochondrial function. But few have been systematically studied for CFS. However, several can be considered for selected patients. Using animal models, Nicotinamde Riboside (derived from vitamin B3) has been shown to increase energy production, especially when combined with Pycnogneol. Creatine, Carnitine, Coenzyme Q and Lipoic Acid are being studied in different systems.</p>

<h2 id="Other-CFS-Treatments" title="Information on Chronic Fatigue Syndrome treatment options">Other Potential CFS Treatments</h2>

<p>Ten percent or more of people with Chronic Fatigue Syndrome also have low blood pressure especially when they stand still for long periods. We call this orthostatic or neurogenic hypotension. Others have rapid heart rate when they stand. We call this POTS for postural orthostatic tachycardia syndrome. Both neurogenic hypotension and POTS can worsen fatigue. Fortunately, there are several effective treatments. Natural treatments include licorice root taken together with potassium. Medicines include Florinef, beta blocker drug, Proamatine (midodrine), Mestinon, and a new medicine called Northera (droxidopa)</p>

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A small but important number of Chronic Fatigue Syndrome patients improve when treated with Ritalin (methylphenidate) or related stimulant medicines. These drugs are tricky and can be abused. However, there is currently an FDA approved <a target="_blank" href="http://www.kpaxpharmaceuticals.com/the-synergy-trial/" title="Information on KPAX Pharmaceuticals. ">double blind study</a> (KPAX002 - The Synergy Trial) treating CFS with methylphenidate together with a nutritional supplement called Kaprex, which seeks to improve mitochondrial energy metabolism.</p>

<h2 id="links" title="Information on helpful sites for fatigue treatment">Helpful Websites</h2>

<p>These websites scan the Chronic Fatigue Syndrome and Fibromyalgia literature. They identify recent articles on treatment and sometimes interview leading CFS clinicians.

<a target="_blank" href="http://phoenixrising.me/" title="Information on Phoenix Rising">Phoenix Rising</a>

<a target="_blank" href="http://www.prohealth.com/index.cfm" title="information on Prohealth">Prohealth</a>

<a target="_blank" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3651660/" title="Information on PubMed - NCBI">Minocycline: far beyond an antibiotic</a>is a review article discusses the use of the antibiotic Minocycline to reduce immune system inflammation.

<a target="_blank" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3962576/" title="information on LDN">The use of low-dose naltrexone (LDN)</a>is a review article discusses the potential uses of Low Dose Naltrexone (LDN)

<a target="_blank" href="http://www.mdpi.com/1420-3049/16/2/1021" title="information on natural products for immune cells">Inhibitors of Microglial Neurotoxicity</a> is about natural products that might reduce inflammation involving the glial cells within the brain. Click on the Download PDF link to review the full article.</p>