Guaifenesin
Treatment
by R. Paul St. Amand, M.D.
Over the past 37 years, I have successfully
treated 3,500 fibromyalgia patients
with several uricosuric (gout) drugs
including, most recently, the simple
medication, guaifenesin. Many of my
patients have also had vulvodynia, which
I consider part of the disease.
Symptoms
of Fibromyalgia
Among the many symptoms
of fibromyalgia, the most prominent
are pain and stiffness in the muscles,
tendons, and ligaments. Other common
symptoms include fatigue, irritability,
depression, poor memory, and lack of
concentration. Fibromyalgics typically
also suffer with irritable bowel syndrome,
urethral syndrome, painful intercourse,
headaches (often one-sided), burning
hands and feet, and more. In short,
people with fibromyalgia have a lot
of complaints.
Fibromyalgia appears to be an inherited
biochemical abnormality that primarily
affects women. Symptoms can develop
at any age, including childhood, and
progress in cycles. At first, they may
be mild, with long gaps or remissions
between attacks. Eventually, however,
the symptoms worsen, with no more good
days in between the bad days.
After patients begin taking guaifenesin,
the symptoms reverse as they developed,
in cycles, but several times faster
— like rewinding a videotape of
one's illness. Unfortunately, they often
are worse than before, since the reversal
involves many areas simultaneously.
Gradually and progressively, however,
more good days appear, cluster together,
and the patient is finally restored
to normal. My experience is that about
two months at the proper dosage reverses
at least one year of accumulated disease.
Treatment
and Theory
Guaifenesin, a drug used
to liquefy mucus, is mildly uricosuric.
Uricosuric drugs are used to treat gout
by causing urinary excretion of uric
acid. Many years ago, quite by accident,
I discovered that uricosuric drugs also
work for fibromyalgia. (I must stress,
however, that fibromyalgia and gout
have no connection.) Unlike the potent
uricosuric drugs used in the past, guaifenesin
has few, if any, side effects.
Having stumbled onto an effective treatment,
it seemed appropriate to formulate a
theory based on the results. Upon analyzing
twenty-four hour urine collections in
a few patients, before and after treatment,
I found a significant increase in the
excretion of phosphate and a moderate
increase of oxalate and calcium after
guaifenesin was started. I suspected
that the body cells of fibromyalgics
retain abnormal amounts of substances
that should have been excreted by the
kidneys. This abnormality, which may
be due to an inherited enzymatic deficiency,
leads to symptoms fibromyalgics experience
in so many tissues and systems of the
body.
My hypothesis, which is subject to further
research, is that an excess of intracellular
phosphate, and possibly oxalate, builds
up in cells and depresses formation
of energy (ATP) in the cells' "power
stations," the mitochondria. Other
researchers have discovered multiple
biochemical abnormalities in connection
with fibromyalgia.
Management
Facts
The required dosage of
guaifenesin is determined by patient
response. It varies from 300 mg. twice
a day to as high as 3,600 mg per day.
Guaifenesin has been used for over twenty
years; has no significant, listed side
effects; and is safe for children.
Treatment progress is measured both
by symptom improvement and by filling
in body maps showing the location and
size of tender points, spasms, or hard
patches felt in the muscles and ligaments.
As guaifenesin "clears" fibromyalgia
out of the body, these patches decrease
in size and eventually disappear.
Aspirin & Aloe: A key aspect of
treatment is that salicylates, contained
in aspirin and other compounds, completely
block the effects of all uricosuric
drugs, including guaifenesin. Moreover,
skin readily absorbs salicylates into
the body. Salicylates are manufactured
by all plants, the choicest parts of
which are concentrated to make herbal
medications, many cosmetics, and deodorants.
Thus, patients being treated with guaifenesin
cannot take aspirin or herbal medications,
or use any skin creams or topical products
which contain herbs, including aloe.
Castor oil, Listerine, Ben Gay, and
razors with aloe strips are among the
many culprits that block the action
of guaifenesin. When blocking occurs,
patients have no adverse effects; they
simply obtain no benefit for fibromyalgia.
Hypoglycemia: Another complicating factor
in guaifenesin treatment is hypoglycemia,
or "low blood sugar," better
defined as carbohydrate intolerance.
Some of the many symptoms of hypoglycemia
are tiredness, panic, palpitations,
and lightheadedness after eating sugar
or starch. Hypoglycemia can be controlled
by a strict diet that eliminates sugar,
most carbohydrates, and caffeine.
As an endocrinologist, I see many hypoglycemics
and have found that around 40% of my
fibromyalgia patients are hypoglycemic.
It is mandatory that the two syndromes
be treated concurrently, or the patient
will not feel better. The added energy
drain of hypoglycemia, untreated, can
also make guaifenesin treatment intolerable.
Maintenance Dosage: Since inherited
abnormalities like fibromyalgia cannot
be cured, only controlled, patients
must take guaifenesin for the rest of
their lives, or the symptoms will return.
Therefore, a maintenance dosage is necessary,
usually the same amount it took to clear
them. Some of my earliest patients have
been taking uricosuric drugs for over
30 years, and maintain a high quality
of life.
*DISCLAIMER:
"The materials and information
on this web site are intended to provide
general information for you. Please
consult your physician on specific medical
questions. Do not use the information
given on these pages as a substitute
for a physician consultation. All information
on this server is provided without warranty
of any kind. Further, we do not warrant,
guarantee, or make any representations
regarding the use, or the results in
terms of correctness, accuracy, reliability,
currentness, or otherwise."
Back
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Guaifenesin
- Fibromyalgia / Myofascial Pain Syndrome
Medications
This is EXPERIMENTAL THERAPY.
Dr. Devin Starlanyl, MD
©
Devin Starlanyl, 1995-1998.
Guaifenesin (pronounced
like "Gwhy-fen-es-in"), is
a medication often used to loosen phlegm
and mucus in lungs. It has been in use
for over 20 years. R. Paul St. Amand
M.D., an Internal Specialist, Endocrinologist
and professor at UCLA, a has discovered
that it may reverse the process of fibromyalgia.
He suspects that one inherited problem
in FMS is a tendency toward a defect
in phosphate excretion, which ultimately
causes an accumulation of phosphates
within the mitochondria (our cellular
"chemical factories"). We're
not sure of the exact mechanism.
Guaifenesin
is the active ingredient in many cough
medication expectorants. If possible,
use the pure guaifenesin (now only available
in the USA in prescription form), because
the over-the-counter varieties have
sugar and alcohol. Store guaifenesin
between 59 and 86 degrees F -- not in
the refrigerator or very warm room.
You may become thirsty at first, and
want to carry some pure water around.
Drink a lot of water. Guaifenesin will
thin your thick secretions, and help
your body get rid of some wastes.
The
average starting dose is 300 mg twice
a day, although some people who are
sensitive to medications may have to
start at 300 mg a day. (If you have
reactive hypoglycemia as a perpetuating
factor, you MUST be on a balanced "Zone"
diet for the reversal to take place.
(See "Mastering the Zone"
by Barry Sears PhD for recipes and information.)
Dr. St. Amand has found less patients
needing the diet than I have, but his
patients appear to be more sensitive
to "blocking" factors. Remember,
we are trail-blazing here.) There will
probably be a period of flu-like fatigue
as stored toxins and excess phosphates
start releasing. You should have a noticeable
reaction in 3 to 10 days. If you get
no reaction, something is blocking the
guaifenesin, you have reactive hypoglycemia,
or you need to raise the dosage to 600
mg twice a day if tolerated. Your body
is working hard during this time to
process wastes so that they can be excreted.
After this, if needed, guaifenesin dosage
is generally raised 300 mgs a day at
a time, after 10 days, until the reversal
begins. Map your pain patterns before
starting this therapy, and mark each
area from 1 to 10 in pain intensity
to help you monitor therapy progression.
AVOID
SALICYLATE USE DURING GUAIFENESIN TREATMENT.
SALICYLATES, FOUND IN MEDICATIONS LIKE
ASPIRIN, MANY HERBS AND TRILISATE WILL
BLOCK THE BODY'S EFFORTS TO EXCRETE
EXCESS PHOSPHATES. If you use salicylate,
the wastes are liberated, but will circulate
in the blood without being excreted.
Large quantities of herbs and herbal
teas should be avoided -- many are rich
in salicylate. Small amounts of herbs
for seasoning are acceptable. Even aloe
has salicylate. Every person has a different
degree of sensitivity to salicylate
on guai. Some people are able to tolerate
more than others without guai being
blocked. Many topical creams, such as
some topical rubs, sunscreens and cosmetics
are salicylate-containing. Check with
your pharmacist. Many common medications
such as Alka-Seltzer, Listerine and
Pepto-Bismol have salicylate.
Dr.
St. Amand has found three subsets in
his practice. One group goes through
FMS reversal relatively quickly at 300
mg twice a day. They often feel bad
solidly until their symptoms clear suddenly.
The largest subset reverses at 600 mg
twice a day. Another subset needs 1800
mg a day or more, and just goes along
slowly through the reversal process.
Soon you will get periods of time where
symptoms ease. Often the reversal is
cyclical, with symptom-free periods
interspersed with "cycling".
At least 40% of the people need more
than 1600 mg a day. The calcium excreted
is limited to inappropriate calcium
surplus. None of Dr. St. Amand's patients
have developed osteoporosis. Dr. St.
Amand warns people that guaifenesin
therapy is "not for the faint of
heart". During the cycling you
can have odd skin rashes, hair loss,
burnt taste in your mouth, pimples,
gunky eyes, and an acidy smelling perspiration
unique to guaifenesin reversal (fortunately),
and very strong-smelling, acid urine.
The urine gets very dark -- deep yellow,
or even brown. Vaginal secretions turn
acidy, and can irritate. During guaifenesin
therapy, avoid adding a lot of phosphoric
acid to your body. Colas are loaded
with it. It makes no sense to add a
lot of phosphoric acid to when your
body is already working hard to get
rid of its excess.
Reversal
signs and symptoms are NOT side-effects
of guaifenesin. They are from toxins
and waste being released by the guai,
and are a good sign, though it won't
feel like it. At least you'll understand
why you often felt "toxic".
You were.
Headaches
are very common. Don't try to rush detox.
It took a long time for your body to
get this sick. You can't clean it up
overnight.
Sometimes
guai works on feeder deposits. These
are large deposits which release vast
quantities of debris as these huge myofascial
lumps dissolve. Your body can only handle
so much at one time. Excess debris forms
temporary deposits -- even on the teeth
sometimes, until the body catches up
processing the wastes. Expect plateaus
in the reversal process. Don't get discouraged.
We are all different. Allow your body
to find the best pace. It will eliminate
the waste material as efficiently as
it can. Meanwhile, do whatever you can
to help it. Drink lots of water, get
as much rest as you can, and avoid stress.
Knowing
that guai thins secretions and works
at a cellular level, I think it may
partially work mechanically, cleaning
off gummy cellular membranes. Thinner
secretions also allow more efficient
breathing. I feel that our reversal
depends on the nature of our deposits:
how many, how dense they are, how much
and what kind of tissue is displaced
and how good your body is at detoxifying.
Also important is our electrolytic balance
-- we need balance for body maintenance,
and to handle the disruption caused
by extra calcium phosphate (and who
knows what else) release. A good mineral
supplement will help. This reversal
process is not easy, but neither is
FMS/MPS. There's no way out but through.
Controlled
studies measure group response, not
individual response, each of us is unique.
The only double-blinded study on FMS
guaifenesin therapy was done by Robert
Bennett M.D. at Oregon Health Sciences
University. This study of 20 women showed
guaifenesin equal to placebo. This response
is not uncommon when attempting to design
experiments for old medications with
new usages. The study is flawed by no
fault of Dr. Bennett, who has done great
things for "fibromites", nor
of Dr. St. Amand, who served as advisor
to the study. We are only now discovering
some of the variables and fine-tuning
treatment. This is experimental.
Point
1: The study was started before we knew
the reversal does not take place if
reactive hypoglycemia is present. I
have found that a little over 85% of
the people I have seen with FMS have
reactive hypoglycemia as a perpetuating
factor. We are talking of about 1000
patients. Some of these with mild FMS
"reversed" with the Zone diet
alone. Of those who tried guaifenesin
(over 500), we are getting about 75
to 80 % drastic improvement. The others
didn't stay with the therapy due to
the toxic-release effects or inability
to follow the diet, except for a less
than 5% who did not get better. Some
needed to delete colas from their diet,
since they took in as much phosphoric
acid as was coming out otherwise. Much
of this therapy may depend on the acid/base
balance of the body. Nancy Medeiros
(see the end of the chapter) is keeping
a running tally of Internet fibromites
on guaifenesin therapy.
Point
2: All the patients in the study were
given 600 mgs of guaifenesin twice a
day. Dr. St. Amand, an internist/endocrinologist
and professor of medicine at UCLA, has
now found that only about 50% of patients
respond at this dosage, even these won't
respond if they have reactive hypoglycemia.
FMS is not a condition that responds
to "cookbook" medicine.
Point
3: Dr. St. Amand did not know about
the blockage of guaifenesin by some
salicylate-containing herbs until September
1995. The study ended in June 1995.
Each of us has a varying tolerance of
salicylate. Now that I am "clearer"
of whatever acids and materials come
out on "guai" therapy, I can
tolerate cola now and then. I still
can't use stevia as a sugar substitute.
Taking even a little of this herb brings
on the FMS achies.
Point
4: The response to guai is not a placebo
response. Placebos do not result in
dark, smelly urine that cleans iron
stains off the toilet bowl. Toilet bowls
do not respond to placebo effect. I
have heard stories from fibromites who
years ago had been placed on guaifenesin
therapy for asthma or upper respiratory
problems. They had to discontinue guai
due to a "worsening" of FMS
symptoms, darkened urine etc. years
before they heard of FMS guai therapy.
Patients who have been seen by Traditional
Chinese Healers, Naturopaths and other
alternative specialists have reported
that they had been very toxic and acidic,
but that they became "balanced"
on guaifenesin therapy.
Perhaps
the phosphoric and oxalic acids coming
out in the urine (and dark "toxic
sweat") carry with them quinolinic
acid. I. Jon Russell has found that
we create this toxin instead of serotonin
in an alternate tryptophan (kynurenine)
metabolic pathway. We just don't know.
Yet. Guai is not a cure. But I have
tried many remedies. Some have helped.
Most have not. I have seen many people
given a new lease on life with guai,
and have experienced it myself, as has
Dr. St. Amand. Others have enjoyed periods
of symptom remission.
With
most people, guaifenesin therapy seems
to result in remission of symptoms.
This is not a cure. The symptoms will
reappear if you overdo. We have found
that at least 50% of people with FMS
have reactive hypoglycemia, and need
this. Otherwise you can be "reversed
-- have all the tender spots go away
-- and you will still feel bad until
you deal with the hypoglycemia. You
may never become symptom-free, because
many symptoms may be due to other processes,
but you will be a lot more comfortable
until a cure can be found.
*DISCLAIMER:
"The materials and information
on this web site are intended to provide
general information for you. Please
consult your physician on specific medical
questions. Do not use the information
given on these pages as a substitute
for a physician consultation. All information
on this server is provided without warranty
of any kind. Further, we do not warrant,
guarantee, or make any representations
regarding the use, or the results in
terms of correctness, accuracy, reliability,
currentness, or otherwise."
Back
To Top
Guaifenesin
General Information
What
is Guaifenesin?
Guaifenesin
is an expectorant, that is, a medication
that promotes elimination of mucus from
the lungs. The expectorant effects of
guaifenesin promote elimination of mucous
by thinning the mucous and lubricating
the irritated respiratory tract. Guaifenesin
is an ingredient in many over-the-counter
cough and cold products.
It is a safe
medication that may even be used by
children. Derived from a tree bark extract
called guaiacum, it was first used to
treat rheumatism during the 16th century.
Guaifenesin was first approved by the
FDA in 1952. Twenty years ago, the extract
was synthesized, pressed into tablets
and named guaifenesin. Today, there
are many formulations of guaifenesin
available. Guaifenesin is an expectorant
with weakly uricosuric effects that
has been shown to effectively release
phosphate and oxalate compounds from
the body through the urine. According
to a survey of Dr. R. Paul St. Amand’s
patients, the administration of guaifenesin
caused a 60 percent increase in the
excretion of phosphate, as well as a
rise in both calcium and oxalate excretion
of up to 30 percent when taking guaifenesin.
How
Does Guaifenesin Work?
Dr. R. Paul St. Amand, M.D., Assistant
Clinical Professor of Endocrinology
at Harbor-UCLA believes guaifenesin
therapy can significantly promote good
health. Dr. St. Amand’s theory
of the medicinal effects of guaifenesin
is based on the premise that excess
calcium and inorganic phosphate compounds
accumulate within cells to produce a
state of hyperpermeability. This condition
allows excess fluids, ions and other
unwanted substances to flow into cell
mitochondria, disrupting normal cell
function, including production of ATP,
the body’s energy source. Dr.
St. Amand believes these factors cause
the body to experience an energy deprived
state, in which widespread bodily functions
are disrupted. Dr. St. Amand also feels
a possible genetic defect in some patients
may be responsible for the abnormality
in natural phosphate excretion, thus
resulting in the buildup of these chemicals
and subsequent symptoms.
A
Note About Fibromyalgia
Fibromyalgia (FM) is
a chronic disorder characterized by
widespread musculoskeletal pain, tender
points, and fatigue, and according to
the American College of Rheumatology,
fibromyalgia affects 3 to 6 million
Americans. It primarily occurs in women
of childbearing age, but children, the
elderly, and men can also be affected.
People with this syndrome also experience
sleep disturbances, morning stiffness,
irritable bowel, anxiety, depression
and other symptoms.Treatment of fibromyalgia
requires a comprehensive approach. The
physician, physical therapist, and patient
may all play an active role in the management
of fibromyalgia. There are many theories
and treatments being discussed and applied
by different researchers and practitioners,
but according to one leading physician,
guaifenesin is the most effective treatment
to date for reversing the effects of
this debilitating disease.
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MEDICAL
INFORMATION
Guaifenesin
(oral)
(gwye FEN e sin)
Anti-Tuss, Bidex, Breonesin, Duratuss
G, Fenesin, Ganidin NR, GG 200 NR, Guaifenesin
LA, Guaifenex G, Guaifenex LA, Humibid
L.A., Humibid Pediatric, Liquibid, Muco-Fen
1200, Muco-Fen 800, Muco-Fen LA, Naldecon-EX
Senior, Organidin NR, Pneumomist, Q-Bid
LA, Robitussin, Scot-Tussin, Touro EX
What
is the most important information I
should know about guaifenesin?
•
Drink plenty of extra fluids while you
are taking this medication. Extra fluids
may help to relieve chest congestion.
• Do not crush or chew the tablets.
Swallow them whole or break them in
half where they are scored to make them
easier to swallow.
How
is guaifenesin commonly used and known?
•
Guaifenesin is an expectorant.
Guaifenesin loosens phlegm and increases
the lubrication of your lungs allowing
for a productive cough and decreased
chest congestion.
• Guaifenesin is used to reduce
chest congestion caused by the common
cold, infections, or allergies.
• Guaifenesin may also be used
for purposes other than those listed
in this medication guide.
What
should I discuss with my healthcare
provider before taking guaifenesin?
•
Talk to your doctor before
taking guaifenesin if you have other
medical conditions or if you take other
medicines.
• Guaifenesin is in the FDA pregnancy
category C. This means that it is not
known whether guaifenesin will harm
an unborn baby. Do not take this medication
without first talking to your doctor
if you are pregnant.
• It is also not known whether
guaifenesin passes into breast milk.
Do not take this medication without
first talking to your doctor if you
are breast-feeding a baby.
• Guaifenesin has not been approved
by the FDA for use by children younger
than 2 years of age.
Pregnancy
•
Although one analysis
found a correlation between guaifenesin
use in the first trimester and an increased
risk of hernia in the fetus, others
found no increased risk of fetal malformations.
Thus, guaifenesin should be used in
pregnancy only if the physician feels
that the potential benefits outweigh
the potential and unknown risks.
How
should I take guaifenesin?
•
Take guaifenesin exactly
as directed by your doctor. If you do
not understand these directions, ask
your pharmacist, nurse, or doctor to
explain them to you.
• Take each dose with a full glass
of water. Drink plenty of extra fluids
while you are taking this medication.
Extra fluids may help to relieve chest
congestion.
• Take guaifenesin with food if
it upsets your stomach.
• Do not crush or chew the tablets.
Swallow them whole or break them in
half where they are scored to make them
easier to swallow.
• The capsules may be swallowed
whole, or they may be opened and the
contents sprinkled on soft food such
as pudding or applesauce then swallowed
whole without crushing or chewing.
• To ensure that you get a correct
dose, measure the liquid form of guaifenesin
with a special dose-measuring spoon
or cup, not with a regular table spoon.
If you do not have a dose-measuring
device, ask your pharmacist where you
can get one.
• Store guaifenesin at room temperature
away from moisture, heat, and direct
sunlight.
What
happens if I miss a dose?
•
Take the missed dose
as soon as you remember. However, if
it is almost time for your next dose,
skip the missed dose and take only your
next regularly scheduled dose. Do not
take a double dose of this medication.
What
happens if I overdose?
•
An overdose of guaifenesin
is unlikely to occur. If you do suspect
an overdose, call an emergency room
or poison control center near you.
What
should I avoid while taking guaifenesin?
•
Use caution when driving, operating
machinery, or performing other hazardous
activities. Guaifenesin may cause dizziness.
If you experience dizziness, avoid these
activities.
What
are the possible side effects of guaifenesin?
•
No serious side effects
are expected from guaifenesin therapy.
Stop taking guaifenesin and seek emergency
medical attention if you experience
an allergic reaction (difficulty breathing;
closing of your throat; swelling of
your lips, tongue, or face; or hives).
• Other, less serious side effects
may be more likely to occur. Continue
to take guaifenesin and talk to your
doctor if you experience
· dizziness or headache,
· a rash, or
· nausea, vomiting, stomach upset,
diarrhea, abdominal pain, or drowsiness
may occur.
• Side effects other than those
listed here may also occur. Talk to
your doctor about any side effect that
seems unusual or that is especially
bothersome.
What
other drugs will affect guaifenesin
?
•
There are no known interactions
between guaifenesin and other medicines,
although the possibility exists. Talk
to your doctor and pharmacist before
taking any prescription or over-the-counter
medicines.
Dosing—
•
The dose of guaifenesin will be different
for different patients. Follow your
doctor's orders or the directions on
the label. The following information
includes only the average doses of guaifenesin.
If your dose is different, do not change
it unless your doctor tells you to do
so.
For
regular (short-acting) oral dosage forms
(capsules, oral solution, syrup, or
tablets):
For cough:
Adults—200 to 400 milligrams (mg)
every four hours.
Children
younger than 2 years of age—Use
and dose must be determined by your
doctor.
Children 2 to 6 years of age—50
to 100 mg every four hours.
Children 6 to 12 years of age—100
to 200 mg every four hours.
For long-acting oral dosage forms (extended-release
capsules or tablets):
For cough:
Adults—600 to 1200 mg every twelve
hours.
Children younger than 2 years of age—Use
is not recommended.
Children 2 to 6 years of age—300
mg every twelve hours.
Children 6 to 12 years of age—600
mg every twelve hours.
Where
can I get more information?
•
Your pharmacist has additional
information about guaifenesin written
for health professionals that you may
read.
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Improvement
of Cervical Factor with Guaifenesin
by Jerome H. Check,M.D., H.G Adleson,
B.S.,
Chung-Hsis Wu, M.D.
Guaifenesin
is an expectorant capable of increasing
respiratory tract fluid. It is a common
ingredient of many antitussive preparations.
A study was designed to see whether
this agent could also improve cervical
mucus, as manifested by improved sperm
survival and fertility.
Materials
and Methods
Forty couples with a
minumum of 10 months of infertility
were selected where there was no sperm
motility on postcoital testing. Hostile
cervical mucus rather than defective
spermatogenesis was assumed on the basis
of accepting in the study only those
couples where the baseline spermogram
after 48 hours abstinence had at least
a count of 25 x 10 6/cc, a 2-cc volume,
70% motility, grade 3 of 4 quality,
and less than 20% abnormal forms.
The
postcoital test was performed on the
2nd day before the temperature rise.
Two baseline postcoital tests with no
sperm motility 2 hours after intercourse
were required before the couple was
entered in the study. After wiping off
the cervix with cotton, the mucus was
aspirated with a tuberculin syringe.
If the mucus quality (spinn-barkeit,
ferning, lack of cellularity) was good
but with no sperm motility, the couple
was not included in the study. Similarly,
if cervical mucus was absent, the couple
was not accepted for the study.
Ovulation
was established on the basis of a serum
progesterone level x2 over 10/ng/ml
taken 1 week before menses and a biphasic
basal body temperature chart with a
minimum of a 13-day luteal phase. If
drug therapy was required to establish
ovulation, the couple could be selected
as long as the drug required was not
clomiphene citrate and/or human menopausal
gonadotropins.
Each
woman was treated with 200mg guaifenesin
orally three times daily from day 5
to her temperature rise in either the
commonly available antitussive elixir
form or in capsule form.
Response
to guaifenesin as reflected by postcoital
evaluation was scored as "no improvement"
(no motile sperm), "marked improvement"
(at least 3 to 5 sperm per high-powered
field with good linear progressive motion),
or "slight improvement" (some
motile sperm but a number or quality
of motility inferior to standards set
for the "marked improvement"
category). Mucus quality was judged
before and after guaifenesin as to spinnbarkeit
and cellularity. If the patient showed
some improvement in the postcoital test,
then the therapy was continued for a
minumum of 6 months unless conception
occured first. If there still was no
sperm survival after two treatment cycles,
the therapy was considered a faliure
and was stopped. Though the patient
would then be treated with other methods,
as far as this study was concerned she
would only be listed in the "no
improvement" category. No patient
in the study was allowed to have treatment
with any other therapy that could positively
or negatively influence the cervical
mucus.
The
tubal factor was investigated by either
hysterosalpingogram or laparoscopy.
Seventy percent of the patients had
a laparoscopy.
| |
Total
|
Marked
Improvement
|
Slight
Improvement
|
No
Improvement
|
| Number
of patients in Subgroup |
40
|
23
(57.5%)
|
7
(17.5%)
|
10
(25%)
|
| I
|
10
|
8
|
1
|
1
|
| II
|
30
|
15
|
6
|
9
|
| Number
pregnant |
|
|
|
|
| I
|
8
|
7
|
1
|
0
|
| II
|
8
|
8
|
0
|
0
|
| %
pregnant |
|
|
|
|
| I
|
80
|
87.5
|
100
|
0
|
| II
|
26.6
|
53
|
0
|
0
|
| Total |
40
|
65.2
|
14.3
|
0
|
Results
The
response to guaifenesin is seen in Table
1. Twenty-three of 40 patients showed
marked improvement in postcoital following
treatment, while 7 showed slight improvement
was associated with improvement in the
mucus quality (improved spinnbarkeit
and decreased cellularity).
Fifteen
pregnancies in 23 couples (65.2%) occurred
in the group showing marked improvement
in the postcoital tests after guaifenesin
therapy. One patient with only a mild
improvement in sperm survival achieved
a pregnancy. In ten patients with hostile
mucus as the only detectable cause of
the infertility, eight became pregnant
in an average 2.4 months. In the remaining
eight patients achieving pregnancies,
where other fertility problems coexisted,
there was an average of 5.6 months of
treatments with guaifenesin. One patient,
despite a marked improvement in sperm
survival and no other apparent cause
for infertility, did not achieve a pregnancy
after 6 months of guaifenesin therapy.
Only one of seven patients showing a
slight improvement in sperm survival
achieved pregnancy. The failure of eight
patients to achieve pregnancices despite
marked improvement in sperm survival
can be accounted for by other associated
fertility problems.
Discussion
The
results indicate that guaifenesin may
improve cervical mucus and improve fertility.
A double-blind study was not deemed
necessary, since it was easy to follow
the objective parameter of sperm survival
and correlate this with subsequent fertility.
There is no evidence that psychological
factors can adversely affect cervical
mucus in the presence of ovulation.
The exact mechanism of action of guaifenesin
is not known, though it would seem to
be reasonably similar to its mechanism
of improving respiratory tract secretions.
Other methods of treating the cervical
factor have been reviewed by Blasco.
An additional technique employing high-dose
estrogen in combination with human menopausal
gonadotropins has been described more
recently. The quoted pregnancy statistic
following conventional therapy of the
cervical factor has been under 30%.
With guaifenesin therapy 40% of the
entire cervical factor group conceived.
In the subgroup of patients whose fertility
problem seemed likely to be related
to the cervical factor only, 80% conceived.
These statistics will probably improve
when guaifenesin therapy is combined
with other treatment modalities for
the cervical factor.
Fertility
and Sterility
May 1982
*DISCLAIMER:
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general information for you. Please
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for a physician consultation. All information
on this server is provided without warranty
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Prevention
of recurrent HIV-associated Sinusitis
Name Of Substance Guaifenesin [USPD
1998; p. 348]
Accessed May 15, 2000.
Standard
Chemical Name 1,2-Propanediol, 3-(2-methoxyphenoxy).
Synonyms
Glycerol
guaiacolate
Glyceryl
guaiacyl ether
Guaiacol
glyceryl ether
Guaiphenesin
Methoxypropanediol
Glyceryl
guaiacolate
Guaiacyl
glyceryl ether
Protocol
ID Numbers Terminated NIAID ACTG 186
Pharmacological
Action
MODE
OF ACTION: Increases
sputum and bronchial secretions by reducing
adhesiveness and surface tension. By
reducing the viscosity of secretions,
guaifenesin increases the efficiency
of the cough reflex and ciliary action
in removing accumulated secretions from
the trachea and bronchi. The drug is
readily absorbed from the gastrointestinal
tract and readily metabolized and excreted
in the urine. It has a plasma half-life
of 1 hour. The major urinary metabolite
is beta-(2-methoxyphenoxy) lactic acid.
In study that assessed changes in nasal
symptoms among 23 HIV-infected patients
receiving either 3 weeks of guaifenesin
(2400 mg daily) or placebo, the guaifenesin
group reported less nasal congestion
and thinner postnasal drainage. Guaifenesin
appears to be effective in managing
HIV-infected patients with symptomatic
rhinosinusitis. [PDR 1997; p 1605]
Diseases
Studied/treated Prevention of recurrent
HIV-associated sinusitis. [Protocol
ID: ACTG 186 ] Classification Code Expectorant
[USP DI 2000; p. 1659]
Other
Major Uses
Used
as expectorant in pharyngitis, bronchitis,
and asthma. [PDR 1997; p 1605]
Substance
Interactions
May
interfere with laboratory test for diagnosis
of carcinoid syndrome may falsely elevate
the VMA test for catechols. [PDR; 1997;
p 1605]
Adverse
Effects
No
serious adverse effects have been reported
with the use of guaifenesin. Doses of
guaifenesin larger than those required
for expectorant action may produce emesis,
but GI upset at ordinary dosage levels
is rare. [PDR 1995; p 461]
Contraindications
Contraindicated in patients with hypersensitivity
to guaifenesin. [PDR 1997; p 1605]
Chemical/physical
Data
MOLECULAR
FORMULA: C10-H14-O4
MOLECULAR
WEIGHT: 198.22 [USPD 1998; p. 348]
MELTING
POINT: 78.5-79 C [Merck Index 1996;
p. 777]
ELEMENTAL
COMP: C60.59%, H7.12%, O32.29% [Merck
Index 1996; p. 777]
SOLUBILITY:
Soluble in water, ethanol, chloroform,
glycerol, propylene glycol, DMF moderately
soluble in benzene; practically insoluble
in petroleum ether. [Merck Index; 1996;
p 777]
METHOD
OF DELIVERY: Oral. [AHFS Drug Information
1997; p 2092]
STORAGE
INSTRUCTIONS: Store at temperatures
no greater than 30 C (86 F). Protect
from freezing. [Protocol ID: ACTG 186
]
Management
of sinusitis in adult cystic fibrosis.
Am J Rhinol. 1997 Jan-Feb;11(1):11-4.
MED/95140436. Friedman WH, Katsantonis
GP, Bumpous JM.
Staging
of chronic hyperplastic rhinosinusitis:
treatment strategies. Otolaryngol Head
Neck Surg. 1995 Feb;112(2):210-4. MED/95180023.
Sisson JH, Yonkers AJ, Waldman RH.
Effects
of guaifenesin on nasal mucociliary
clearance and ciliary beat frequency
in healthy volunteers. Chest 1995 Mar;107(3):747-51.
IPA/95. /1081197. Wagner DL, Patel VS.
Steady-state
human pharmacokinetics and bioavailability
of guaifenesin and pseudoephedrine in
a sustained-release tablet relative
to immediate-release liquids. Int J
Pharm; VOL 114 ISS Feb 14 1995, P171-176,
(REF 6). MED/95023331. Brock MH, Dansereau
RJ, Patel VS.
Use
of in vitro and in vivo data in the
design, development, and quality control
of sustained-release decongestant dosage
forms. Pharmacotherapy 1994 Jul-Aug;14(4):430-7.
MED/93198678. Croughan-Minihane MS,
Petitti DB, Rodnick JE, Eliaser G.
Clinical
trial examining effectiveness of three
cough syrups [see comments]. J Am Board
Fam Pract 1993 Mar-Apr;6(2):109-15.
MED/93023477. Wawrose SF, Tami TA, Amoils
CP.
The
role of guaifenesin in the treatment
of sinonasal disease in patients infected
with the human immunodeficiency virus
(HIV). Laryngoscope. 1992 Nov;102(11):1225-8.
Entry Month 199212 Last Revision Date
20001107 Guaifenesin [USPD 1998; p.
348] - Guaifenesin [USPD 1998; p. 348]
----------------------------
Always watch for outdated information.
----------------------------
This
material is designed to support, not
replace, the relationship that exists
between you and your doctor. This information
is designed to support, not replace,
the relationship that exists between
you and your doctor.
*DISCLAIMER:
"The materials and information
on this web site are intended to provide
general information for you. Please
consult your physician on specific medical
questions. Do not use the information
given on these pages as a substitute
for a physician consultation. All information
on this server is provided without warranty
of any kind. Further, we do not warrant,
guarantee, or make any representations
regarding the use, or the results in
terms of correctness, accuracy, reliability,
currentness, or otherwise."
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Interference
With Lab Tests
Guaifenesin can falsely
elevate the results of laboratory tests
for vanillylmandelic acid (VMA), which
is the main urinary metabolite of catecholamines
(adrenaline and noradrenaline). In addition,
it is well known that guaifenesin can
cause false positive results in tests
for the serotonin metabolite, 5-hydroxyindoleacetic
acid . You should stop taking guaifenesin
48 hours before giving urine for either
of these tests.
By
the way, aspirin also interferes with
VMA and 5-HIAA tests. Ephedrine and
caffeine cause increased values in 5-HIAA
tests. Foods that are high in serotonin
(avocados, bananas, eggplant, pineapples,
plums, and tomatoes) can also cause
false positives in 5-HIAA tests. An
awful lot of foods and even artifical
coloring and flavoring can cause false
positives on a VMA test.
*DISCLAIMER:
"The materials and information
on this web site are intended to provide
general information for you. Please
consult your physician on specific medical
questions. Do not use the information
given on these pages as a substitute
for a physician consultation. All information
on this server is provided without warranty
of any kind. Further, we do not warrant,
guarantee, or make any representations
regarding the use, or the results in
terms of correctness, accuracy, reliability,
currentness, or otherwise."
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WHAT
ARE SALYCILATES?
Salycilate
Sensitivity
Salicylate
sensitivity is the body's inability
to handle more than a certain amount
of salicylates at any one time. A salicylate
sensitive person may have difficulty
tolerating certain fruits, vegetables,
or any products which contain aspirin.
What
Are Salicylates?
Salicylates
are chemicals that occur naturally in
many plants. They act as preservatives
to delay rotting and as protectants
against harmful bacteria and fungi.
They are stored in the bark, leaves,
roots, and seeds of plants. Salicylates
can be found naturally in some foods
and its compounds are used in various
products.
Symptoms
of Intolerance
Salicylates sensitivity can manifest
itself in many ways:
Anaphylaxis
(rare)
Asthma
Breathing difficulties
Changes in skin color
Congestion
Fatigue
Headaches
Hyperactivity
Itchy skin, rash, or hives
Itchy, watery, or swollen eyes
Lack of concentration or memory
Mouth ulcers or raw hot red rash around
mouth
Nasal polyps
Persistent cough
Sinusitis
Some cognitive and perceptual disorders
Stomach aches or upsets
Swelling of eyelids, face, and lips
Swelling of hands and feet
Urgency to pass water or bedwetting
Wheezing
Sources
of Salicylates
Here is a list of products that may
contain aspirin or salicylate compounds:
Acne
products
Breath savers
Bubble baths
Cosmetics
Fragrances and perfumes
Gums - mint flavored
Hair shampoos, conditioners, or sprays
Herbal remedies
Lipsticks
Lotions
Lozenges
Medications
Mouth washes
Muscle pain creams
Pain medications
Razors with aloe strips adjacent to
the cutting edge
Shaving creams
Skin cleansers or exfoliants
Sun screens or tanning lotions
Supplements derived from rose hips or
bioflavonoids
Topical creams
Toothpastes
Wart or callus removers
Watch
Out for These Terms
When reading labels be sure to also
watch out for these terms:
Aspirin
Acetylsalicylic acid
Artificial food colorings
Artificial flavorings
Azo dyes
Benzoates (preservatives)
Benzyl salicylate
Beta-hydroxy acid
Choline salicylate
Disalcid
Ethyl salicylate
Isoamyl salicylate
Magnesium salicylate
Menthol
Methyl salicylate
Mint
Octylsalicylate
Peppermint
Phenylethyl salicylate
Salicylate
Salicylic acid
Salicylaldehyde
Salicylamide
Salsalate
Sodium salicylate
Spearmint
Salicylates
in Foods
Raw foods, dried foods,
and juices contain higher levels of
salicylates than cooked food. The salicylate
content in foods is highest in unripened
fruit and decreases as the fruit ripens.
All fruit and vegetables should be ripe
and thickly peeled before eating. Salicylates
are often concentrated just under the
skin of fruit and vegetables, and in
the outer leaves of vegetables.
The
Feingold Program
For those people who
want to avoid salicylates and feel overwelmed
with the challenge, should take a few
minutes to visit the Feingold Association
Web site. Shula Edelkind of the Feingold
Association (feingold.org) reports they
do ongoing product information research.
She states, "All people have to
do is use our Foodlist & Shopping
Guide. We have done the hard work for
them. People can avoid the colorings,
flavorings and salicylates, and still
have a 'normal' American diet complete
with fast food and junk food."
*DISCLAIMER:
"The materials and information
on this web site are intended to provide
general information for you. Please
consult your physician on specific medical
questions. Do not use the information
given on these pages as a substitute
for a physician consultation. All information
on this server is provided without warranty
of any kind. Further, we do not warrant,
guarantee, or make any representations
regarding the use, or the results in
terms of correctness, accuracy, reliability,
currentness, or otherwise."
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Guaifenesin
in the News
FDA orders most long-acting
guaifenesin products off market
Only
Adams' Mucinex product currently approved;
other manufacturers have until end of
November to distribute 'illegal' products.
Last
October, FDA issued warning letters
stating that single-ingredient extended-release
guaifenesin products are new drugs and
require an approved new drug application
for legal marketing under the Federal
Food, Drug, and Cosmetic Act. The only
approval, issued in July 2002, is for
guaifenesin 600 mg extended-release
tablets from Adams Laboratories.
In
the warning letters, sent to 66 manufacturers,
FDA stated that its actions "reflect
the Agency's effort to maintain the
necessary incentives for companies to
develop and submit to FDA scientific
evidence to prove the safety and effectiveness
of marketed drug products."
FDA
also intends to publish a notice in
the Federal Register about its policy
on unapproved drugs. In a talk paper
posted to the FDA Web site, the agency
explained that it reviewed products
in this category after approving the
Adams' product last July, and it concluded
that products with unproven safety and
effectiveness should not remain on the
market when an approved product had
become available. This preserves the
incentives for companies to develop
and submit new drug applications, as
required by law, FDA added.
Guaifenesin's
main use is for productive coughs. It
is the only FDA-approved nonprescription
expectorant. As a pre-1962 product,
its effectiveness has never been well
established, but it causes few adverse
effects and is commonly included in
many cough-and-cold products. As part
of FDA's review of OTC products, immediate-release
guaifenesin was previously ruled to
be safe and effective.
NOTE:
Now in 2004 Guaifenesin in dosages of
600mg and below are ONLY available Over
The Counter (OTC)!
*DISCLAIMER:
"The materials and information
on this web site are intended to provide
general information for you. Please
consult your physician on specific medical
questions. Do not use the information
given on these pages as a substitute
for a physician consultation. All information
on this server is provided without warranty
of any kind. Further, we do not warrant,
guarantee, or make any representations
regarding the use, or the results in
terms of correctness, accuracy, reliability,
currentness, or otherwise."
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Treatment
of Fibromyalgia in Detail
Robert
Bennett MD, FRCP
If you are reading this you probably
have a common syndrome of chronic musculoskeletal
pain called fibromyalgia. This chronic
pain state is now appreciated to be
caused by abnormalities of sensory processing
within the spinal cord and brain. As
such you will usually experience a bewildering
(both to you and your doctor) array
of bodily and psychological problems
that can seldom be “cured”.
However, armed with both patience and
knowledge, many fibromyalgia patients
can be helped to live with less pain
and be more productive. In my own evolving
experience of dealing with this problem
I can identify 7 aspects of management
that are of importance for your doctor
to successful manage your fibromyalgia.
My
Advice to Doctors who care for Fibromyalgia
Patients
1.
Realize that FM patients are going to
be a chronic challenge.
2.
Be non-judgmental and prepared to be
an advocate.
3.
Understand the pathophysiological basis
for symptoms.
4.
Analyze and treat pain complaints in
a systemic approach.
5.
Recognize and treat psychological problems
at an early stage.
6.
Recognize associated syndromes of disordered
sensory processing.
7.
Involve all FM patients in a program
of stretching and gentle aerobic exercise.
Treatment
of pain in fibromyalgia
Pain
is the primary over-riding problem for
most of you. Many of the problems you
experience are largely a secondary consequence
of having chronic pain. When pain is
even partly relieved, fibromyalgia patients
experience a significant improvement
in psychological distress, cognitive
abilities, sleep and functional capacity.
A total elimination of pain is currently
not possible in the majority of fibromyalgia
patients. However worthwhile improvements
can nearly always be achieved by a careful
systematic analysis of the pain complaints.
As a generalization fibromyalgia related
pain can be divided into general pain
(i.e. the chronic background pain experience
and focal pain (i.e. the intensification
of pain in a specific region –
usually aggravated by movement). The
latter is probably a potent driving
force in the generation of central sensitization.
Attempts to break the pain cycle, to
enable patients to be more functional
are especially important. In general,
most FM patients do not derive a great
deal of benefit from NSAID preparations
or acetoaminophen, although NSAIDs are
very useful in the treatment of associated
joint pain problems such as osteoarthritis.
Prednisone and other steroids have been
shown to be ineffective in the long
term treatment of fibromyalgia.
General
Pain. The use of NSAIDs (e.g. ibuprofen,
aspirin etc.) is usually disappointing;
it is unusual for FM patients to experience
more than a 20% relief of their pain,
but many consider this to be worthwhile.
Narcotics (propoxyphene, codeine, and
oxycodone) often provide a worthwhile
relief of pain. In most patients, concerns
about addiction, dependency and tolerance
are ill founded. Ultram (Tramadol) and
Ultracet (tramadol + Tylenol), are the
most useful pain medications in many
patients. They both have the advantages
of having a low abuse potential and
is not a prostaglandin inhibitor; tramadol
reduces the epileptogenic threshold
and it should not be used in patients
with seizure disorders.
Currently
opiates are the most effective medications
for managing most chronic pain states
(Friedman OP 1990, Portenoy 1996) .
Their use is often condemned out of
ignorance regarding their propensity
to cause addiction, physical dependence
and tolerance (Melzack 1990, Portenoy
et al 1997, Wall 1997) . While physical
dependence (defined as a withdrawal
syndrome on abrupt discontinuation is
inevitable) is inevitable, this should
not be equated with addiction (Portenoy
1996). Addiction is a dysfunctional
state occurring as a result of the unrestrained
use of a drug for its mind-altering
properties; manipulation of the medical
system and the acquisition of narcotics
from non-medical sources are common
accompaniments. Addiction should not
be confused with "pseudo-addiction".
This is a drug-seeking behavior generated
by attempts to obtain appropriate pain
relief in the face of under-treatment
of pain. Opiates should never be the
first choice for pain relief in fibromyalgia,
but they should not be withheld if less
powerful analgesics have failed. In
my experience many fibromyalgia patients
want to try opioid medications, but
then give up on them due to unacceptable
side effects, such as mental fog, increased
tiredness, dizziness, constipation and
itching.
Local Pain. Although you are experiencing
widespread body pain -- a manifestation
of central sensitization -- you will
also have multiple areas of tenderness
in muscles - so called "myofascial
trigger points". The severity of
pain and the location of these "hot
spots" typically varies from month
to month, and the judicious use of myofascial
trigger point injections and spray and
stretch (see section on focal pain)
is worthwhile in selected patients.
It is often worthwhile for your physician
to identify the most symptomatic points
for myofascial therapy.
The
steps involved in the injection of trigger
points are:
1.
Accurate identification of the trigger
point.
2.
Identification and elimination of aggravating
factors.
3.
The precise injection of the myofascial
trigger points with 1% procaine (a local
anesthetic).
4.
Passive stretching of the involved muscle
after the local anesthetic has taken
effect; this is
often aided by spraying the overlying
skin with an ethyl chloride spray.
In
most FM patients, this myofascial therapy
needs to be repeated over a period of
several weeks and occasionally over
several months. Unresponsiveness is
usually due to failure to eliminate
an aggravating factor, imprecise injection
of the trigger point, or failure to
inject satellite trigger points. Trigger
points are usually injected with 3 to
5 ml of 1-% procaine. Please note that
these are not “steroid shots”.
Performing
“myofascial spray and stretch”
often enhances the efficacy of trigger
point injections immediately after the
injections. Spray and stretch consists
of an application of a vapocoolant spray,
such as ethyl chloride over the muscle
with simultaneous passive stretching.
A fine stream of the spray is aimed
toward the skin directly overlying the
muscle with the active trigger point.
A few sweeps of the spray are passed
over the trigger point and the zone
of reference. This is followed by a
progressively increasing passive stretch
of the muscle.
Evaluation
by an occupational and physical therapist
often provides worthwhile advice on
improved ergonomics, biomechanical imbalance
and the formulation of a regular stretching
program. Hands-on physical therapy treatment
with heat modalities is reserved for
major flares of pain, as there is no
evidence that long-term therapy alters
the course of the disorder. The same
comments can be made for acupuncture,
TENS units and various massage techniques.
Treatment
of Sleep Disorders.
Non-restorative sleep is a problem for
most of you and contributes to your
feelings of fatigue and seems to intensify
their experience of pain. Effective
management involves (1) ensuring an
adherence to the basic rules of sleep
hygiene, (2) regular low grade exercise,
(3) adequate treatment of associated
psychological problems (depression,
anxiety etc.) and (4) the prescription
of low dose tricyclic antidepressants
(amitryptiline, trazadone, doxepin,
imipramine etc. Some fibromyalgia patients
cannot tolerate TCAs due to unacceptable
levels of daytime drowsiness or weight
gain. In these patients benzodiazopine-like
medications such as Ambiem (zolpidem)
are usually very useful. Some fibromyalgia
patients suffer from a primary sleep
disorder, which requires specialized
management. About 25% of male and 15%
of female fibromyalgia patients have
sleep apnea. Unless specific questions
about this possibility are asked sleep
apnea will often be missed. Patients
with sleep apnea usually require treatment
with positive airway pressure (CPAP)
or surgery. By far the commonest sleep
disorder in fibromyalgia patients is
restless leg syndrome. This can be effectively
treated with L-Dopa/carbidopa (Sinemet
10/100 mg at suppertime) or clonazepam
(Klonipin 0.5 or 1.0 mg at bedtime).
Exercise
for Fibromyalgia Patients
Fibromyalgia
patients cannot afford not to exercise
as deconditioned muscles are more prone
to microtrauma and inactivity begets
dysfunctional behavioral problems .
However, musculoskeletal pain and severe
fatigue are powerful conditioners for
inactivity. All fibromyalgia patients
need to have a home program with muscle
stretching and gentle strengthening,
and aerobic conditioning. There are
several points that need to be stressed
about exercise in FM patients: (i) Exercise
is health training, not sport’s
training. (ii) Exercise should be non-impact
loading. (iii) Aerobic exercise should
be done for 30 minutes each day. This
may be broken down into three 10 minute
periods or other combinations, such
as two 15 minute periods, to give a
cumulative total of 30 minutes. This
should be the aim -- it may take 6-12
months to achieve this level. (vi) Strength
training should emphasize on concentric
work and avoid eccentric muscle contractions.
(vii) Regular exercise needs to become
part of the usual lifestyle; it is not
merely a 3-6 month program to restore
them to health. Suitable aerobic exercise
includes: regular walking, the use of
a stationery exercycle or Nordic track
(initially not using the arm component).
Patients who are very deconditioned
or incapacitated should be started with
water therapy using a buoyancy belt
(Aqua-jogger).
Recognition
and treatment of psychological distress
As
you suffer from chronic pain there is
a distinct possibility that you may
develop secondary psychological disturbances,
such as depression, anger, fear, withdrawal
and anxiety. When “an event”
is associated with the onset of the
fibromyalgia you may adopt the role
of a "victim". Sometimes these
secondary reactions become the "major
problem" for some patients. The
prompt diagnosis and treatment of these
secondary features is essential to effective
overall management of fibromyalgia patients.
Some fibromyalgia patients develop a
reduced functional ability and have
difficulty being competitively employed.
In such cases your doctor will hopefully
act as an advocate in sanctioning a
reduced or modified load at work and
at home. Unless you have a severe psychiatric
illness (e,g, major depressive illness
or a psychosis), referral to psychiatrists
is usually non-productive. Psychological
counseling, particularly the use of
techniques such as cognitive restructuring
and biofeedback, may benefit some patients
who are having difficulties coping with
the realities of living with their pain
and associated problems.
Fibromyalgia associated syndromes
It
is not unusual for fibromyalgia patients
to have an array of bodily complaints
other than musculoskeletal pain. It
is now thought that these symptoms are
a result of the abnormal sensory processing
– as described in the previous
section. Recognition and treatment of
these associated problems are important
in the overall management of your fibromyalgia.
Non-restorative
sleep
Cognitive dysfunction
Chronic fatigue
Cold intolerance
Restless leg syndrome
Multiple sensitivities
Irritable bowel syndrome
Dizziness
Irritable bladder syndrome
Neurally mediated hypotension
1. Chronic fatigue: The common treatable
cause of chronic fatigue in fibromyalgia
patients are: (1) inappropriate dosing
of medications (TCAs, drugs with antihistamine
actions, benzodiazapines etc.), (2)
depression, (3) aerobic deconditioning,
(3) a primary sleep disorder (e.g. sleep
apnea), (4) non-restorative sleep (see
above) and (5) neurally mediated hypotension
(see below). A new drug called Provigil
is of some help when used intermittently
for management of fatigue.
2.
Restless leg syndrome: This strictly
refers to daytime (usually maximal in
the evening) symptoms of (1) unusual
sensations in the lower limbs (but can
occur in arms or even scalp) that are
often described as paresthesia (numbness,
tingling, itching, muscle crawling)
and (2) a restlessness, in that stretching
or walking eases the sensory symptoms.
This daytime symptomatology is nearly
always accompanied by a sleep disorder
- now referred to as periodic limb movement
disorder (formerly nocturnal myoclonus).
Treatment is simple and very effective
– DOPA / Levodopa (Sinemet) in
an early evening dose of 10/100 (a minority
require a higher dose or use of the
long acting preparations).
3.
Irritable bowel syndrome: This common
syndrome of GI distress that occurs
in about 20% of the general population
is found in about 60% of fibromyalgia
patients. The symptoms are those of
abdominal pain, distension with an altered
bowel habit (constipation, diarrhea
or an alternating disturbance). Typically
the abdominal discomfort is improved
by bowel evacuation. Due to abnormal
sensory processing these symptoms may
be quite distressing to fibromyalgia
patients. Treatment involves (1) elimination
of foods that aggravate symptoms, (2)
minimizing psychological distress, (3)
adhering to basic rules for maintaining
a regular bowel habit, (4) prescribing
medications for specific symptoms; constipation
(stool softener, fiber supplementation
and gentle laxatives such as bisacodyl),
diarrhea (loperamide or diphenoxylate)
and antispasmodics (dicyclomine or anticholinergic
/ sedative preparations such as Donnatal).
4.
Irritable bladder syndrome: This is
found in 40-60% of fibromyalgia patients.
The initial incorrect diagnoses are
usually recurrent urinary tract infections,
interstitial cystitis or a gynecological
condition. Once these possibilities
have been ruled out a diagnosis of irritable
bladder syndrome (also called female
urethal syndrome) should be considered.
The typical symptoms are those of suprapubic
discomfort with an urgency to void,
often accompanied by frequency and dysuria.
In a sub-population of fibromyalgia
patients this is related to a myofascial
trigger point in the pubic insertion
of the rectus abdominus muscles –
and may be helped by a procaine myofascial
trigger point injection). Treatment:
involves (1) increasing intake of water,
(2) avoiding bladder irritants such
as fruit juices (especially cranberry),
(3) pelvic floor exercises (e.g. Kagel
exercises) and the prescription of antispasmodic
medications (e.g. oxybutinin, flavoxate,
hyoscamine).
5.
Cognitive dysfunction: This is a common
problem for many fibromyalgia patients.
It adversely affects the ability to
be competitively employed and may cause
concern as to an early dementing type
of neurodegenerative disease. In practice
the latter concern has never been a
problem and patients can be reassured.
The cause of poor memory and problems
with concentration is, in most patients,
related to the distracting effects of
chronic pain and mental fatigue. Thus
the effective treatment of cognitive
dysfunction in fibromyalgia is dependent
on the successful management of the
other symptoms.
6.
Cold intolerance: About 30% of fibromyalgia
patients complain of cold intolerance.
In most cases this amounts to needing
warmer clothing or turning up the heat
in their homes. Some patients develop
a true primary Raynaud’s phenomenon
(which may mislead an unknowing physician
to consider diagnoses such as SLE or
scleroderma. Many fibromyalgia patients
have cold hands and feet, and some have
cutis marmorata (a lace like pattern
of violaceous discoloration of their
extremities on cold exposure). Treatment
involves: (1) keeping warm, (2) low-grade
aerobic exercise (which improves peripheral
circulation), (3) treatment of neurally
mediated hypotension (see below), and
(4) the prescription of vasodilators
such as the calcium channel blockers
(but these may aggravate the problem
in-patients with hypotension).
7.
Multiple sensitivities: One result of
disordered sensory processing is that
many sensations are amplified in fibromyalgia
patients. In general fibromyalgia patients
are less tolerant of adverse weather,
loud noises, bright lights and other
sensory overloads. Treatment involves
being aware that this is a fibromyalgia-related
problem and employing avoidance tactics.
8.
Dizziness: Is a common complaint of
fibromyalgia patients. Before this symptom
is attributable to fibromyalgia a thorough
for other causes should be pursued (e.g.
postural vertigo, vestibular disorders,
8th nerve tumors, demyelinating disorders,
brain stem ischemia and cervical myelopathy).
In many cases no obvious cause is found,
despite sophisticated testing. Treatable
causes related to fibromyalgia include:
(1) proprioceptive dysfunction secondary
to muscle deconditioning, (2) proprioceptive
dysfunction secondary to myofascial
trigger points in the sterno-cleido-mastoids
and other neck muscles, (3) Neurally
mediated hypotension (see below) and
(4) medication side effects. Treatment
is dependent on making an accurate diagnosis.
In patients in whom no obvious cause
is found a trial of physical therapy,
concentrating on proprioceptive awareness
may prove worthwhile.
9.
Neurally mediated hypotension: Patients
with this problem usually have a low
blood pressure that does not go up normally
on standing or on exercise. Although
such patients often have a low ambient
BP with postural changes, these findings
are not a prerequisite for diagnosis.
A tilt table test with the infusion
of isproterenol is the most reliable
way to confirm this diagnosis. Treatment
involves: (1) education as to the triggering
factors and their avoidance, (2) increasing
plasma volume (increased salt intake,
prescription of florinef), (3) avoidance
of drugs that aggravate hypotension
(e.g. TCA’s, anti-hypertensives),
(4) prevent reflex (prescribe ß-adrenergic
antagonists or disopyramide) and (5)
minimize the efferent limb of the reflex
(prescribe a2-adrenergic agonists or
anti-cholinergic agents).
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Cognitive
Therapy - What is it and how does it
help?
by
Carol Burckhardt Ph.D
All
comprehensive fibromyalgia (FM) treatment
programs include non-drug components
such as cognitive-behavioral treatment.
This broad treatment area emphasizes
the relationship between thoughts, beliefs,
emotions and behavior. In fact, it assumes
that thoughts are powerful determiners
of how we feel and behave and that altering
maladaptive thought patterns will result
in desirable behavior changes. Cognitive
strategies include education in recognizing
thought patterns that are maladaptive
along with learning and practice of
specific techniques for decreasing distress,
pain, fatigue, and anxiety. Cognitive
therapy contains 4 components: (1) coping
skills training, (2) self-control training,
(3) problem-solving skills training,
and (4) cognitive restructuring methods.
Although I have found that most people
with FM already engage in a number of
positive coping strategies, are ready
to learn relaxation strategies and able
to develop better ways to solve problems,
when approaching the area of cognitive
restructuring some people respond skeptically.
“Oh,
here we go again! Just thinking positively
doesn’t take my symptoms away.”
“If
I change the way I think about my pain
and my pain decreases, people (my
family, my work colleagues, my doctor)
are going to believe that fibromyalgia
is ‘all
in my head.’”
“What am I supposed to do, try
to fool myself into believing that things
are different?”
Let’s
explore cognitive restructuring with
the goal of understanding better what
it is and what it isn’t and what
its potential is for helping people
with FM manage their symptoms better.
Have
you ever worried about anything? Have
you ever felt your body relax when someone
said a kind word to you? If so, you
have experienced the intimate connection
between thoughts and feelings. Think
about it, when you worry your body responds
with sensations of anxiety (knots in
your stomach, increased heart rate,
sweaty palms, insomnia). Yet, the negative
things you are worrying about aren’t
actually happening at the time that
you are worrying. They are happening
only in your thoughts. On the positive
side, if someone says, “I’m
really sorry that you are in so much
pain,” or, “I want to help
in any way I can,” you may feel
your muscles relax, your stomach stop
churning, and your breathing become
less shallow. Again, these body reactions
happen even though the helper only said
something to you. She didn’t massage
your muscles, give you a Zantac or even
tell you to breathe deeply. If you want
to try out this connection in a simple
way, think about eating a lemon or savoring
a piece of Godiva chocolate and see
what happens. Bet you start to salivate.
What I’m trying to convince you
of is that a very powerful connection
exists between how you think, how you
perceive messages from yourself and
others, and how you feel both emotionally
and physically.
These
ongoing thoughts are the little voice
in your head that babbles to you all
the time. Sometimes people I see in
counseling aren’t aware that they
are constantly engaged in a running
automatic dialog. If that seems to be
the case, I ask them to spend the next
week listening to themselves. Invariably,
they come back with all sorts of tales
that their conscious mind has been telling
them. This cognitive part is always
actively evaluating, rationalizing,
scheming, analyzing and distorting reality
at times. Have you ever said something
and then wondered, “Why did I
say that?” followed by, “That
was a dumb thing to say.” Or maybe
your neighbor brought over a plate of
freshly baked cookies. You smiled, thanked
her and felt both a little happy and
a little sad. Then you realized that
your thoughts were centering around,
“She probably thinks I can’t
cook. I look like such a mess and my
house is a disaster. I’m just
inadequate.”
All
people engage in cognitive distortions
from time to time. Some very common
negative thoughts that people with FM
have include:
“Why me?” Life isn’t
fair.”
“My pain will never get better.”
“I shouldn’t ask for help.”
“No one understands me.”
What
cognitive restructuring focuses on is
helping you to identify the long-standing
patterns of automatic thinking associated
with unhappiness, anxiety, depression,
and physical symptoms. Once these patterns
are identified, you can decide if you
wish to change them. In other words,
cognitive restructuring is an active,
individual process that you control.
A good therapist serves as a guide to
the process, often asking questions
such as,
“Can
you think of an alternative way to view
this situation?”
“Is believing that you are worthless
helpful to you?”
“Is your pain always this bad?”
“Who told you that you should
______?”
Sometimes she/he might suggest a different
label like,
“Instead
of seeing yourself as a martyr, maybe
you could think of yourself as a
nurturer.”
“Maybe instead of telling yourself
that you should do something, you could
ask
yourself if you want to do it.”
These questions and suggestions are
meant to help you reframe or restructure
your thoughts into more realistic and
helpful thoughts. As these new thoughts
and belief become more a part of you,
they won’t feel foreign or feigned.
For example, reframing the belief that
life isn’t fair into, “perhaps
that is true, but believing and telling
myself that doesn’t help me feel
any better; instead I will tell myself
that living my life to the fullest is
more important than being frustrated
about whether it is fair,” is
likely to change your emotional state
from one of depression and anger to
one of peace and joy. As the ancient
writer of Proverbs said, “ A depressed
spirit saps one’s strength but
a happy mind is good medicine.(17:22)
”
First
published in The Fibromyalgia Times,
3(3), 14-15, 1998
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Fibromyalgia
in Frida Kahlo's life and art
The
great Mexican painter Frida Kahlo (1907-1954)
is without doubt one of the most intense
and emotive artists of the twentieth
century. Frida's life changed dramatically
at the age of 18, when she was involved
in a terrible accident. A streetcar
violently impacted the bus in which
she was riding. She suffered multiple
bone fractures, including the third
and fourth lumbar vertebrae, and had
a deep abdominal wound inflicted by
a metal rod. She was confined for several
months in a plaster corset. From that
time on, Frida suffered severe, widespread
pain and profound fatigue. Generalized
pain and exhaustion lingered with her
for the remainder of her life.
Through
the years, a variety of diagnoses were
offered to explain her chronic illness,
such as tuberculosis and syphilis, that
were later ruled out. She received diverse
types of treatments, including medications
and long periods of confinement in a
metal or plaster corset. In efforts
to relieve her pain, she underwent several
orthopedic operations on her spine,
both in Mexico and in the United States,
without improvement in her symptoms.
Despite
her debilitating illness, Frida was
engaged in an active social life. She
had a tempestuous marriage to the famous
Mexican muralist Diego Rivera. She traveled
extensively and had relationships with
the world leaders and artistic personalities
of her time. Frida began painting after
her accident. During periods of immobilization
in a plaster corset, she used a special
easel, and a mirror was attached to
the canopy of her bed so that she could
focus on herself. Although her painting
skills were largely self-taught, she
was also acquainted with the traditional
schools of painting. Both in her oeuvre
and in her customs, she looked back
with devotion to her Mexican roots.
The Surrealists claimed her as one of
their own. The stillness of her self-portraits
reflects the influence of her father,
who was a photographer.
Frida
used to describe her own paintings as
"the most frank expression of myself".
Her self-portraits are impassioned.
Anguish and pain are the common themes
of her work. These emotions are dramatically
expressed in her oil painting, "The
Broken Column (see picture on left).
As Hayden Herrera observed, Frida's
determined impassivity creates an almost
unbearable tension. Pain is made vivid
by nails driven into her naked body.
A gap resembling an earthquake fissure
splits her torso. The opened body suggests
surgery. Inside her torso, we see a
cracked ionic column. The corset's white
straps accentuate her beautiful body.
Her hips are wrapped in a cloth suggestive
of Christian martyrdom. She stares straight
ahead with dignity. Tears dot her cheeks,
but her features refuse to cry. An immense
and barren plain in the background conveys
physical and emotional suffering.
To
explain Frida's chronic illness, we
offer an alternative diagnosis. Our
opinion is that she suffered posttraumatic
fibromyalgia. This prevalent syndrome
is characterized by persistent widespread
pain, chronic fatigue, sleep disorders,
and vegetative symptoms, and by the
presence of tender points in well-defined
anatomic areas. The concept of fibromyalgia
as a clinical entity as we know it today
was probably unknown to most physicians
of the early twentieth century. Our
diagnosis explains her chronic, severe,
widespread pain accompanied by profound
fatigue. It also explains the lack of
response to diverse forms of treatment.
The onset of fibromyalgia after physical
trauma is well-recognized.
A
drawing in Frida's diary reinforces
our diagnostic impression. She depicts
herself in pain, and 11 arrows point
to anatomic sites that are near the
conventional fibromyalgia tender points.
Of course, because fibromyalgia is an
illness without anatomic sequelae, our
contention cannot be proven or disproven.
What appears certain is that Frida's
self-portraits convey widespread pain
and anguish with the emotional overtones
that fibromyalgia patients frequently
use to describe their illness.
We
are indebted to Dr. Leonardo Zamudio,
who allowed us to have access to Frida
Kahlo's medical records, to Ms Dolores
Olmedo, who gave permission to reproduce
"The Broken Column," and to
Dr. Robert Kalish, who kindly reviewed
the manuscript.
Manuel
Martinez-Lavin, MD, Instituto Nacional
de Cardiologia Ignacio Chavez, Mexico
City, Mexico
Mary-Carmen
Amigo, MD, Instituto Nacional de Cardiologia
Ignacio Chavez, Mexico City, Mexico
Javier
Coindreau, MD, Instituto Nacional de
Cardiologia Ignacio Chavez, Mexico City,
Mexico
Juan
Canoso, MD, American British Cowdray
Hospital, Mexico City, Mexico
REFERENCES
1.
Herrera H. Frida: a biography of Frida
Kahlo. New York: Harper Row; 1983.
2.
Tibol R. Frida Kahlo: una vida abierta.
Mexico City: Universidad Nacional Autonoma
de Mexico; 1998.
3.
Zamora M. Frida Kahlo: the brush of
anguish. San Francisco: Chronicle Books;
1990.
4.
Monsivais C. Vazquez-Bayod R. Frida
Kahlo: una vida, una obra. Mexico City:
Conaculta; 1992.
5.
Del Conde T. Frida Kahlo: la pintora
y el mito. Mexico City: Universidad
Nacional Autonoma de Mexico; 1992.
6.
Wolfe F, Smythe HA, Yunus MB, Bennett
RM, Bombardier C, Goldenberg DL, et
al. The American College of Rheumatology
1990 criteria for the classification
of fibromyalgia: report of the multicenter
criteria committee. Arthritis Rheum
1990; 33:160-72.
7.
Martinez-Lavin M, Hermosillo AG, Rosas
M, Soto M-E. Circadian studies of autonomic
nervous balance in patients with fibromyalgia:
a heart rate variability analysis. Arthritis
Rheum 1998; 41:1966-71.
8.
Buskila D, Neumann L, Vaisberg G, Alkalay
D, Wolfe F. Increased rate of fibromyalgia
following cervical spine injury: a controlled
study of 161 cases of traumatic injury.
Arthritis Rheum 1997; 40:446-52.
9.
Freeman P. Frida Kahlo: Diario: autorretrato
intimo. Mexico City: La Vaca Independiente;
1995.
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