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- The Metabolic Work up
-REMEMBER **What helps one person may not benefit the next.
By Royce K. Bailey M.D., M.P.H., F.A.A.C., M.A.A.C.
The American College of Rheumatology in 1992 established two criteria for a diagnosis of fibromyalgia:
- Pain in all four quadrants of the body and in the axial skeleton (bones of the head, throat, chest and spine) that’s been present on a more-or-less continuous basis for at least three months.
- Pain in at least 11 of 18 tender points, which are specific spots on the body that hurt when pressure is applied.
If you have different symptoms (and most people with the diagnosis of fibromyalgia do), then you do not have fibromyalgia. But what do you have??? It is important to make sure you do not have: Rheumatoid arthritis, Multiple sclerosis, Lupus, Lyme’s disease, Myasthenia gravis, Crohn’s disease, auto-immune disorders, HIV, etc.
1. Heavy Metal Toxicity
Doctor’s Data-Urine toxic element
Mercury (985.0), Arsenic (961.2) and Lead (984.1) Screening blood or urine
Testing: Great Smokies LAB: 253-0621 (Urine 24 hour $55.00)
Nash,D., “Blood Lead, Blood Pressure, and Hypertension In Perimenopausal and Postmenopausal Women,” JAMA 2–3;289:1523-32.
Treatment: John Wilson M.D. Great Smokies Medical Center for Chelation, 828 252-9833
James Biddle M.D. Asheville Integrative Medicine for Chelation, 828 252 5545
2. Food Allergies
Wheat/Celiac Sprue intolerances. Check AntiGliadin Antibodies if diarrhea present.
Testing: Rast Blood Test. May include Drugs (995.2), grasses (477.8), animals (477.8), molds (477.8), herbs (693.1) or specific foods.
Soy product intolerances can cause fatigue, headaches, rashes, stomach and chest pain.
Treatment: Elimination trials
3. Multiple Chemical Sensitivity Syndrome
Chemical/Environmental Sensitivities; respiratory fumes/vapors (506.9). Formaldehyde, perfumes, cleaners, etc.
Treatment: Elimination trials
4. Clotting Abnormalities
A positive D-Dimer blood test because of inappropriate fibrous stranding may require heparin, lovonex or coumadin treatment.
Acquired coagulation defect (286.7), Thyroid peroxidase antibodies, Lupus anti-coagulant, Anti-phospholipid antibodies, Factor 5 Ligand deficiency, etc.
Empiric Trial for Headaches that transiently respond to diuretics or prednisone and clotting abnormalities.
5. Endocrine Insufficiency
Pituitary and other endocrine abnormalities are far more common than generally realized. Evaluate fully, including growth hormone levels (Insulin Growth Factor 1-IGF-1). Measure free T3 and free T4 levels with TSH and check basal AM body temperatures. Test for auto-antibodies. Thyroid abnormalities require Cytomel 5 mcg up to 50 mcg BID or Amour Thyroid 30 mg (T3 and T4 animal extract-supplies both T3/T4 in one pill). Clinical hypothyroidism can result from receptor blockade and the inability to convert T4 to the active hormone T3 (converts to reverse T3 instead), thus hypothyroidism can exist despite normal serum hormone levels.
Treatment: push T3 and T4 to high normal range. Consider sustained release T3: 45-120 mcg a day.
Hypofunction pituitary (253.1); Anterior Pituitary Deficiency (253.4) evaluation to include ACTH, LH, FSH, Prolactin, IGF-1, Cortisol and TSH blood levels.
6. Narcolepsy Symptoms (347.0)
Falling asleep during the day can be treated with amphetamines.
Treatment: Provigil 200 mg BID or other similar med (there are several). Ritalin in adults may help too.
7. Sleep Disorders
Most fatigued patients don’t sleep. Sleep Disorders may require a work-up for oxygen and/or CPAP. Apnea sleep disturbance (780.51) or Obstructive Sleep Apnea.
Start with a 24 hour O2 sat. study-Free with doctor’s prescription. Sleep Centers at local hospitals and any Durable Medical Equipment (DME) company that supplies O2.
8. Fat Malabsorption Syndrome
BodyBio Fatty Acid Test (In depth Supportive Red Cell Lipid Analysis)-Great Smokies Lab 828 253-0621 If there is any suggestion of autism, this study is essential.
Treatment as outlined by deficiencies.
9. Muscle Aching
Primary Myopathy (359.89) Not all of these may help but a trial of one at a time may.
A Creatine Monohydrate makes more calcium available to your muscles and boosts water levels inside your muscle cells, which helps them synthesize proteins and store glycogen. Caffeine negates this good effect.
Check Creatine level. Supplement up to 5 grams a day (found in health food stores in weight lifting section).
B. MSM (Methylsufonylmethane) Sulfur compounds are needed for bones, teeth, collagen (the protein in connective tissue) and a healthy immune response to inflammation. Sulfur is needed for the manufacture of many proteins including muscles. 6 grams a day in divided doses.
C. Nitroglycerin .3 mg ½ to ¼ tab sublingual for muscle pain relief. If there is no improvement consider this patient to have a sulfur insufficiency. Treat with MSM 2000 mg and up.
D. B12 increases the synaptic relay between nerve cell ends and thus clinically improving muscle/ nerve weakness. Sublingual or nasal OTC, 1000mcg to 5000 mcg every day.
E. Co Enzyme Q10 supports the energy producing pathways in the mitochondria (tiny cell power houses). 100mg to 400mg a day.
F. NADH is a co-enyzme needed in the production of ATP (the cells packets of energy). 1000mg to 5000 mg a day 30 minutes before breakfast.
G. B complex including B6 (stress tab formula), one each day.
H. Trial of treatment as if patient had Lyme’s Disease-Cat’s Claw (nature’s Cipro), 5 drops twice a day.
10. Nitric Oxide Deficiency
If Nitroglycerin (NTG 1/150 sl) has given you some temporary muscle ache relief, try adding L-Arginine. NTG and L-Arginine stimulate production and release of nitric oxide from the endothelial vessel lining. L-Arginine helps sustains nitric oxide levels in the human body and stimulates the release of growth hormone from the pituitary gland (when blood sugar levels are not high). When you move or exercise your body naturally releases nitric oxide which affects the endothelial dilating pathway. Nitric oxide is the muscles “cell signaling” molecule that activities protein synthesis (the process of making new muscle out of protein). Nitric oxide enhances insulin sensitivity, which helps to boost creatine absorption into your muscle cells without the use of sugar.
Treatment: L-Arginine (nitric oxide precursor) 8 grams to 14 grams a day
Amino Acid Deficiency (270.9) Hambrecht, R., “Correction of Endothelial Dysfunction in Chronic Heart Failure: Additional Effects of Exercise Training and Oral L-Arginine Supplementation,” J Am Coll Cardiol 2000;35:706-713.
11. Dehydroepiandrosterone Sulfate (DHEA) Deficiency
Called the “Fountain of Youth Hormone” “The Master Hormone” and the “Mother Hormone,” DHEA assists in the product of vital hormones. It is the precursor chemical ring that makes up your body’s steroids, estrogen, testosterone, cholesterol and vitamin D hormones. Endocrine deficiency; Adrenal gland hypofunction (564.1)
Lab: DHEA-S level.
Treatment: If level is 50 to 200 mg/dl, start DHEA at 25mg a day. If the level is less than 50 mg/dl, start DHEA at 50 mg day. Titrate to normalize the laboratory blood level.
12. Irritable Bowel Disorder (IBS)
Keep a food intake diary to evaluate for food sensitivities as triggers of IBS symptoms.
Treatment: Food avoidance, particularly lactose and complex food combinations.
Melatonin 10 mg a day. This dose may help sleep too.
13. Viral Overload
Transfer Factor has some success in treating symptoms of Cytomegalovirus-CMV (078.5), Human Herpes Virus 6-HHV6 A&B and Epstein Barr Virus (acute-075.0; chronic 139.8). Transfer factor has been shown to neutralizes Candida Albicans overgrowth and suppress Chlamydia. Transfer Factor is extracted from cow’s first milk (may be derived from chicken sources as well). Colostrum’s sole purpose is to transfer immunity from mother to the baby’s immature immune system. Transfer Factor stabilizes autoimmune dysfunction by helping to eliminate “immune cross talk” and re-establishes immune balance. Treatment: Don’t treat with just Colostrum. Transfer Factor has different formulas. Transfer Factor: 200 mg to 1000 mg a day. Keep cold and take on an empty stomach.
14. Syncope/Fainting
Neurally Mediated Hypotension-NMH (458.0) can be diagnosed by Tilt Table Testing. Treatment can dramatically lessen fatigue, palpitations, wooziness and increase stamina by allowing the brain stem to talk to the spinal column, by restoring the Adrenaline “Fright or Flight” mechanism. Also symptoms of Postural Orthostatic Tachycardia Syndrome (POTS) and Parkinsonism sometimes respond to the same treatments.
Treatment for symptomatic autonomic failure:
A. Suboccipital Decompression (neck/skull surgery) resolves/lessens symptoms in 85% of patients.
B. If hypovolemia is the cause of a positive tilt table test then increase sodium (Salt) intake and fluid intake, TED hose and eat smaller-more frequent meals. One may add Florinef (fludrocortisone) .1 mg BID plus potassium or ProAmitine (midodrine) starting at 2.5mg three times a day and increasing stepwise. Other choices may include: ephedrine, sudafed and dexadrine, Sandostatin (octreotide) 150-750 mcg subq in divided doses 2-4 times a day, erythropoietin (procrit), and indomethacin 50mg three times a day.
C. If there is reproduction of symptoms with tachycardia and inappropriate hypotension during isuprel or dobutamine stimulation during the tilt table test adding a beta blocker may help. Serotonin agonist have helped rarely.
15. Magnesium Deficiency
Magnesium deficiency (275.2) is very often present in people with fatigue and quite severe. Hyper-reflexa, muscle twitches, myocardial irritability, poor stamina and recurrent muscle spasms are clues that the patient may have a intracellular magnesium deficiency. 99% of the body’s magnesium is inside the cells so blood testing is inadequate. 1 gm IV or IM at least once a week until neuromuscular irritability has cleared then oral maintenance of one Tbsp black strap Molasses/day or liquid magnesium/calcium source for at least 1000 mg a day. Once stable, add a calcium/magnesium/vitamin D tab 2-4 a day. Avoid magnesium if you have diarrhea or renal failure. Avoid molasses if you are a diabetic. Combination magnesium and malic acid (Krebs energy cycle) also helps in some cases more than just magnesium alone (trade name-Super Malic 3-6 tabs/day).
16. Candida Overgrowth
Yeast overgrowth causes fatigue symptoms. Yeast thrives in an acidic environment. Jump start your body’s change to higher alkalinity with juicing fresh veggies (cabbage works well for several of my patients). Avoid sugars, fried foods, sodas, caffeine products, McDonald’s type diet, alcohol and combinations that can cause fermentation in the gut (milk and sugar). All of these foods are extremely acidic and promote yeast overgrowth.
Treatment: Diet change to more natural/fresh/raw.
17. Vitamin D Deficiency
Vitamin D deficiency (82306) is very common and when corrected can markedly improve fatigue symptoms. Blood test for 25 Hydroxy (25OHD3) deficiency. OTC Vitamin D 5,000 units a day. Prescription: 50,000 units weekly.
18. My Recommendations For All Of My Tired Patients
My “fibromyalgia” patients all do better with liquid trace minerals, including extra magnesium (269.3), B12 500-2000units sl/day OTC (281.0), 1 oz/kg of water/day, vitamin D 5,000 unit a day and omega-3 (Flax seed/Fish Oil) supplement 4 grams/day.
OTC=Over The Counter
(###) are CPT codes for your physician.
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