New treatment for chronic fatigue syndrome

For the estimated 500,000-plus people with chronic fatigue syndrome who have exhausted their treatment options, promising new research offers a glimmer of hope. Several recent studies from Johns Hopkins University in Baltimore suggest that many cases can be virtually cured with a regimen that includes a high-salt diet and blood pressure medication.

The recent findings link chronic fatigue syndrome with a disorder called neurally mediated hypotension--a condition in which blood pressure plummets after long periods of standing, exercise, or exposure to a warm environment. The problem stems from a glitch in the mechanism by which the nervous system regulates blood pressure when the body is in a standing position and gravity pulls blood downward, causing it to pool in the arms and legs. Normally, the body responds by prompting the heart to pump harder, which increases pressure and ensures that plenty of blood circulates to the brain. But in people with neurally mediated hypotension, the brain misinterprets the body's signals and reacts by decreasing the already low blood pressure even more. The result: light headedness, dizziness, confusion, and, occasionally, fainting.

Johns Hopkins pediatrician Peter Rowe, MD, began to suspect that the disorder might be associated with chronic fatigue syndrome when he noticed that except for fainting spells, the symptoms of teenagers with chronic fatigue mimicked those of adolescents with neurally mediated hypotension. Acting on a hunch, he and his colleagues tested seven teens complaining of extreme weariness, four of whom met the criteria for chronic fatigue syndrome (see blue box). All of them had neurally mediated hypotension.

Taking it one step further, they examined 23 adults with chronic fatigue syndrome and found that 22 of them also tested positively for hypotension with what is known as a tilt-table test. Standard blood pressure tests taken in physicians' offices won't pick up neurally mediated hypotension because it occurs only after being upright for several minutes. Thus, patients must be strapped to a table which is then tilted to an almost upright position. Within minutes, those with hypotension tend to become hot, clammy, lightheaded, and nauseous and sometimes find it difficult to speak.

Taking it with more than a grain of salt . . .
The chronic fatigue-hypotension link may open a window of opportunity for treating a disease with an otherwise dismal therapy record. In fact, nine of the 22 chronic fatigue syndrome sufferers with neurally mediated hypotension in the Hopkins study reported complete or near-complete recovery from fatigue with treatment, and seven others noted at least some improvement.

The treatment is a two-pronged approach, the first of which involves diet. Patients are encouraged to boost their sodium consumption by eating salted pretzels, pickles, and other high-sodium foods and by using the salt shaker liberally at the table and when cooking. Researchers believe that increasing both sodium and fluid consumption helps regulate blood pressure in patients with neurally mediated hypotension.

. . . and a pill or two
The other aspect of treatment is a drug program, which must be carefully tailored to the individual and often requires trying several different regimens until an effective program is pinpointed. While a number of drugs and drug combinations can be used, most patients are given a medication called fludrocortisone, which promotes sodium retention. Many are also given drugs that alter heart rate or block the effect of the hormone adrenalin, which plays a key role in triggering the abnormal blood pressure reaction in neurally mediated hypotension.

To be sure, while the Hopkins research holds promise, Dr. Rowe cautions that "until more information comes out of a large-scale trial, we can't know with certainty if this treatment will work for the majority of patients with chronic fatigue syndrome." A much more comprehensive study of the response to drug treatment for neurally mediated hypotension is currently underway at Johns Hopkins and the National Institutes of Health. A number of scientists at other institutions are also examining the issue. They hope to have a more definitive answer within the next several years.

CHRONIC FATIGUE CHRONICALLY MISUNDERSTOOD
It has been nearly a decade since scientists officially established criteria for the diagnosis of chronic fatigue syndrome, yet its causes and cures still remain elusive. Researchers have suspected that viruses, yeast organisms, immune system dysfunction, and other physical problems might be to blame, but they have yet to establish any clear-cut culprits.

Regarding the most recently discovered possibility, a blood-pressure disorder called neurally mediated hypotension, Peter Rowe, MD, of Johns Hopkins University says, "It may prove an important final common pathway for the cluster of symptoms associated with chronic fatigue syndrome."

What separates chronic fatigue syndrome from the fatigue that most people experience now and then? Here's the official definition from the Centers for Disease Control and Prevention, the National Institutes of Health, and the International Chronic Fatigue Syndrome Study Group:

clinically evaluated, unexplained, persistent or relapsing fatigue lasting for at least six months that is not the result of ongoing exertion, is not substantially alleviated by rest, and significantly reduces previous activity levels. It must be accompanied by four or more of the following symptoms:

impairment in short-term memory or concentration severe enough to interfere with usual activities
sore throat
tender lymph nodes
muscle and/or joint pain without joint swelling or redness
headaches of a new type, pattern, or severity
unrefreshing sleep
post-exertion weariness lasting more than 24 hours
For more information about chronic fatigue syndrome, contact the Chronic Fatigue and Immune Dysfunction Syndrome (CFIDS) Association of America at P.O. Box 220398, Charlotte, NC, 8222-0398; 1-800-442-3437.

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