All posts by Cort Johnson

P2P Report Urgently Calls for Major Increases ME/CFS Research: Tightening Needed

January 19, 2015

“We hope our work has dignified ME/CFS and those affected, while providing expert guidance to the NIH and the broader research community.” – P2P Executive Draft Summary

pathways-to-prevention

ME/CFS is the third disorder to go through the P2P program

The Pathways to Prevention Program (P2P) is an NIH program begun in 2012 that is tasked with identifying research gaps, methodological weaknesses and suggesting research needs for disorders that cause major health problems but are not being addressed well by the medical field.  The limited published data and few randomized controlled trials in these disorders of “broad public health importance” have made it difficult to produce systematic reviews.

That chronic fatigue syndrome is only the third disorder or condition — after polycystic ovary syndrome and opioids and chronic pain — to go through the P2P process, suggests the NIH may be increasing its commitment to this disorder.

The Panel was tasked with (1) identifying research gaps, (2) determining methodological limitations, and (3) providing future research recommendations regarding diagnosis and treatment.

Panelists “Get” Community Needs

In the first part of the P2P Draft Report it was gratifying indeed to see a panel of outsiders – none of whom had any connection to chronic fatigue syndrome (ME/CFS) – “get” the major issues facing the chronic fatigue syndrome community.  In retrospect perhaps it’s not so surprising; people who take the time to get to know the ME/CFS community and the problems it faces have become allies in the past.

big-leap

Major gaps in every area were identified…Will the panel recommendations help to surmount them?

The first part of the report  identified numerous gaps that are keeping the field from progressing. In the second part they provide a long list of recommendations that would, if acted upon, result in significant and long-sought progress in this field. The panelists appear to have thrown virtually everything they can think of at this disorder which has so many needs.

The lack of specific funding recommendations or time or numerical targets, however, left me wondering if panel understands the kind of cultural shift that has to occur at the NIH before ME/CFS gets its due. The panel is up against a culture of dismissal that has even been willing to ignore its own studies showing that high prevalence rates, disability rates, high economic losses, and enormous unmet needs are present.

The NIH, we know, will very likely do everything it can to ignore, distort, wave off, and pretend to comply with the P2P report’s recommendations.  Jennie Spotila and Mary Dimmock have pointed out the federal government can be very good at taking the least possible action to fulfill minor recommendations while ignoring or not acting on major recommendations. Does the panel, for instance, recognize

  • head-in-sand

    The P2P is up against an embedded culture of neglect and dismissal at the NIH

    that this million-person disorder has been in the bottom five percent of NIH funding for decades?

  • that adjusted for inflation the NIH is spending about what it did on ME/CFS twenty years ago -when it was considered a small, niche disorder?
  • that disorders of ME/CFS’s prevalence, effects, and economic losses typically receive twenty times as much funding?
  • that most major cities in the U.S. do not have one expert ME/CFS practitioner?
  • that the NIH’s response to that dearth of ME/CFS experts has been to turn down requests for Centers of Excellence year after year? That over a decade of requests has not produced one COE?
  • that similar disorders such as fibromyalgia, which also affect large numbers of people (often women) and produce severe economic losses, but do not usually kill, are in a similar situation?

The panel recognizes help is needed in every aspect of this field and the P2P report is going to help – there’s no doubt about that – the only question at this point is how much. With that in mind, I propose ways to tighten up some recommendations and add some others. I believe the Panel must be as specific as possible and not allow wiggle room.

First the gap is presented, then the recommendation, and then ways to tighten it up. I look forward to hearing suggestions from others.

January 16th is the last day to submit comments using this email address:  prevention@mail.nih.gov. They ask that each comment reference the line number of the report it’s referring to. 

The P2P Panel’s Recommendations to Fill Gaps in ME/CFS Research and Treatment

“Innovative biomedical research is urgently needed to identify risk and therapeutic targets, and for translation efforts.“ – P2P Draft Report

GAP: A Definition Needed to Provide the Foundation for Research and Clinical Trials

The panel endorsed a large-scale effort to finally find a suitable definition for ME/CFS that included creating a team of stakeholders, creating a research network, and examining commonalities with other disorders.

team-building

A team of stakeholders should agree on a definition

Create Team of Stakeholders – The panel recommends creating a team of stakeholders (patients, clinicians, researchers, and federal officials) that will come to consensus on a definition now, even if it’s an imperfect one.

That’s almost been done; the Canadian Consensus and International Consensus Criteria involved patients, clinicians, and researchers, but not federal officials.  The advocacy letter requesting that the NIH adopt the Canadian Consensus Criteria (CCC) indicated also that a large number of stakeholders agree that the CCC should be adopted, but also did not include federal officials.

A National and International Research Network should be developed to clarify the definition and “advance the field”.  This is an important part because no suitable research definitions are present at the moment. The CCC and ICC are fine clinical definitions, but studies suggest they may result in selection of a high percentage of ME/CFS patients who also have psychiatric disorders and allow a significant percentage (15-20%) of healthy people to be identified as having ME/CFS.  A better research definition can be developed.

leaking-pipe

Tightening the recommendations is recommended.

Tightening

  • NIH shall develop a National Research Network consisting of 3-5 centers in the US each with a dedicated research budget of $5 – 10 million and make efforts to enroll other countries in producing similar centers. A funded grant opportunity (Request For Applications (RFA)) should be issued within one year to produce the outcome measures and studies needed create a validated research definition. (See research section for more.)

Identify Commonalities and Co-morbidities with Other Disorders – Produce a Conference to Highlight Them –   the panel recommended that Gulf War Syndrome, Lyme disease, fibromyalgia, multiple sclerosis, and Parkinson’s disease be studied alongside ME/CFS to discover commonalities and differences. A conference to enable discussion and interaction between researchers studying these disorders should occur.

Tightening

  • An NIH sponsored conference to examine commonalities and differences among ME/CFS, Gulf War Syndrome, Lyme disease, fibromyalgia, multiple sclerosis, and Parkinson’s disease and others should take place within one year.
  • The conference should lay the foundation for a $5 million RFA to further explore commonalities and differences in these disorders.

GAP – New Knowledge is Needed

Bench to Bedside ME/CFS Research is Recommended.

Bench to bedside or translational research is what Centers of Excellence do: they research (bench) and treat patients (bedside) in the same facility, yet the panelists don’t specifically recommend them — although they do recommend something that appears to be similar (See Collaborative Centers recommendation below.)

Tightening

  • Five Centers of Excellence should be established within two years, and five more within five years. (See Network  of Collaborative Centers below.)

GAP: Many Research Needs Are Present

“Determining the most important physiologic measures and pathophysiology, as well as genome-wide association studies (GWAS) and phenotyping, is essential for stratifying patients.”

test-tubes-blood

Many research needs were identified

The P2P panel recommends that a broad and deep effort employing the latest technology be mounted to understand the pathophysiological mechanisms at play in ME/CFS. Specifically they recommended priority be given to efforts to:

  • Develop biomarkers using genomic, epigenomic, proteomic, and metabolomic strategies.
  • Identify subsets using physiologic markers and genome-wide association studies (GWAS).
  • Use fMRI and other imaging studies to understand the neurological problems in ME/CFS.
  • Use cutting–edge technologies such as high throughput sequencing and neuroimaging to investigate the effects the gut microbiome has on ME/CFS.
  • Identify who is at high risk of getting ME/CFS, chart the geographical distribution of the disorder, and illuminate health care disparities (who has access to good medical care and who does not).
  • Develop algorithms to determine who is at high risk of coming down with ME/CFS after an infection.
  • Put the data from large “-omics” (genomics, proteomics, metabolomics, etc.) studies in publicly accessible databases that enable researchers to use data mining techniques to understand the  molecular mechanisms present, to do pathways analyses, and to aid drug companies in drug discovery/drug repurposing.
  • Identify immunological mechanisms and pathways (cytokines, inflammation, NK cell dysfunction) that contribute to the progression of the disease.
  • Use twin studies to identify differences in gene expression.
  • Investigate the effects (if any) of homeopathy, non-pharmacologic, complementary, and alternative medicine treatments. Studies addressing biopsychosocial parameters (including the mind-body connection), function, and QOL should be encouraged.

A National Biobank – A national registry/repository should be created to house the results of these studies and to help researchers better understand the pathogenesis, prognosis, and biomarkers present  in ME/CFS.

upwards

A key recommendation: spending on ME/CFS research be brought in line with that found in other disorders if similar size, prevalence and economic costs

Issue : The panel’s recommendation that a broad range of pathophysiological targets be explored is very helpful. Their unwillingness, however, to recommend specific federal spending targets, or specific grant programs (RFAs) could allow the federal government to fund one or a couple of studies from each section and say they met the recommendations.

The NIH is currently funding, for instance, at least one neuroimaging study, a gene expression after exercise study, a natural killer cell study and a microbiome study. Funding one or two studies in an area every four to five years means more of the glacial pace of progress that has characterized this field for decades. This is not the rate of progress that patients, the panel earlier noted, want and deserve, and it’s not the outcome that the P2P panel, judging from its otherwise very helpful report, wants to see.

Tightening

  • The NIH bring pathophysiological research funding for ME/CFS into line with that provided for disorders of similar size, economic losses, and disability rates (excluding comorbid disorders such as fibromyalgia, interstitial cystitis, etc. which receive low funding) within five years.
  • The NIH should produce a series of $5 million RFAs over the next three years to address critical questions regarding the role the immune, autonomic, and central nervous systems and metabolism play in ME/CFS.

GAP: Inadequate Methods and Measures to Assess Treatments and Identify Subgroups

tools

A Working Group should identify the right tools to assess ME/CFS

Throughout the report the panel referred to inadequate outcome and other measures. The NIH has been saying this for years, but without doing anything about it.  Now they get their chance.

Establish Methodological Working Group – to oversee the development of these measures, plus:

  • Online tracking tools should be utilized.
  • Immobile patients should be included.
  • A community-based research approach should be used to increase patient involvement in determining priorities for research and patient care.
  • Assess psychiatric comorbidities to assist with measurement of quality of life.
  • Long-term longitudinal studies already underway should include ME/CFS.

GAP: Provider Education Lacking

Few physicians understand how to treat or even to recognize chronic fatigue syndrome.

  • Use  accreditation and licensing programs to produce ME/CFS curriculum.
  • Use Health Resources and Services Administration (HRSA) to facilitate training.

Tightening

  • Create accredition program to license ME/CFS practitioners.

 GAP: Finding New Funding

The panel’s statement that a “relatively small number of researchers” are present in the field vastly overstates the number of researchers studying ME/CFS relative to other disorders and suggests the panel may not have quite gotten to the depth of the NIH’s neglect.

In the Finding New Funding Resources section a number of good, but at times somewhat vague, recommendations are given to address funding needs. The recommendation to create collaborative research centers is a highlight.

Create a Network of Collaborative Centers

research-network

A collaborative research network should be created to move the field forward.

The centers should determine diagnostic and prognostic biomarkers, do epidemiology (e.g., health care utilization), determine functional status and disability, create patient-centered QOL outcomes, and determine the cost-effectiveness of treatments and the role of comorbidities in clinical and real-life settings.

This promising recommendation with its research and treatment components sounds very similar to COE’s. Unless the panel is more explicit, though, the NIH could create two small, overburdened centers and say “job done”.

Tightening

  • Recommending that the NIH fund five COEs, each with a $5 million budget (?) over the next two years, and five more over the subsequent five years would go a long way toward enhancing research and improving access to medical care in  major cities.

Others

  • NIH institutions need to partner together to advance the research and develop new scientists for ME/CFS.
  • More investigator-initiated studies (grant applications) are needed. (How many more? And how? By producing RFAs?)
  • Career development pathways for ME/CFS researchers should be developed.
  • Small grants should target younger investigators to get them into the ME/CFS field.

The ME/CFS field desperately needs new researchers and younger researchers and career development pathways. That would be superb… but what it really needs – and what would solve most of these problems – is dedicated funding for research and, so far as I can tell, that means grant opportunities that come loaded with money; i.e. RFAs. While the spirit of the report suggests funded grant opportunities or RFA’s would be necessary to carry out the panel’s recommendations, the panel has not specifically recommended them.

Tightening

  • Patients, ME/CFS experts, and federal officials will work together to set a target for the number of investigator-initiated studies needed to bring research funding into line with the disorder’s effects and come up with ways to meet that target, including RFAs.
  • The NIH will produce a series of $5 million dollar RFAs over the next three years to address critical questions regarding the role the immune, autonomic, and central nervous systems and metabolism play in ME/CFS.
  • Smaller grants targeting young investigators should be produced every year for the next five years. At the end of five years the effectiveness of the small grant project should be assessed.

Adding Working Group Members

failure

Adding more working group members to a group that does not work will not help

Issue – This statement, “Opportunities exist within HHS to engage new ME/CFS working group members, to create efficiency, and to co-fund research that will promote diversity in the pipeline, eliminate disparities, and enhance the quality of the science,” reflects the panel’s understandable ignorance of the structural problems facing ME/CFS at the NIH.

The Working Group is at the top of the list of factors that have stifled – not advanced – opportunities for ME/CFS.  If the last fifteen years has shown anything, it has shown that relying on the Institutes to do anything meaningful under the aegis of the Working Group is a pipe dream.

With the buck not stopping at any of the institutes in the Working group, it’s easy to see why all have essentially washed their hands of it. Adding more members (NIMHD or NCI) to the already long list of Working Group members would, unfortunately, change nothing.

Tightening

  • Recommend that a commission of patient advocates, ME/CFS experts, and federal officials assess the effectiveness of the Working Group in supporting ME/CFS research,  identify structural factors that are impeding funding for ME/CFS, and provide recommendations for change.

GAP: More Clinical Trials Needed

  • Create a website for patient and clinician educational materials and clinical trials.
  • Utilize the NIH Clinical Center for clinical trials.
  • Explore opportunities to fast-track new therapies.

Multimodal treatment – The panel should take note of the enormous numerical disparity between behaviorally-oriented treatment trials and all other kinds of trials found in ME/CFS. The fact that CBT and GET have been the focus of some thirty clinical trials while no other treatment modality has, to my knowledge, received more than one, indicates the powerful  hold that behavioral studies, many of them UK and European government funded,  have had in the clinical trial arena.

While the panel stated that neither CBT nor GET should be considered a primary treatment, it might reflect that, given the history of bias in this disorder, that recommending multimodal clinical trials could be interpreted as recommending a biopsychosocial approach to treatment – an approach that has failed, after many efforts, to get at the cause of ME/CFS.  With so many other compelling research needs present, putting more money into that approach would be counterproductive.

Tightening

  • Multimodal – The panel should make explicit its recommendation regarding multimodal trials to ensure such trials involve drugs and other such treatments that affect pathophysiology.
  • FDA –  New pathways for drug development need to be developed that take into account the barriers found in large, poorly studied heterogeneous disorders that get little interest from drug companies such as ME/CFS.. A panel of patient advocates, ME/CFS physicians and experts, federal officials, and drug company officials should identify those barriers and provide recommendations to surmount them.

Patient Participation Emphasized

“Patients must be at the center of the research efforts, and their engagement is critical” – P2P Draft Report

The panelist made explicit one feature that applies to most of it’s the recommendations: patient involvement is necessary.

Conclusions

funding

Following the P2P reports recommendations would require the federal government to spend money – much more money on ME/CFS…Will they?

In their conclusions, the panel added more recommendations, among them that the Oxford definition be retired. In the interim, they recommended multimodal therapies be employed until a cause and primary therapies are developed. They recommend that federal departments, advocacy groups, and industry work together in public-private partnerships to help advance research for ME/CFS. Federal agencies (e.g., AHRQ, the U.S. Department of Veterans Affairs [VA]) and professional societies should work together to create quality metrics and a standard of care.

Were the federal government to follow the spirit and letter of the P2P draft summary recommendations they would need to — for the first time –spend some real money on ME/CFS. That would probably require re-organizing the way the program is currently maintained and funded. ME/CFS has little chance of advancing significantly under its current structure, and a re-evaluation of the program’s funding mechanisms should be a natural outcome of a report that has exposed so many needs after almost thirty years of research.

The P2P recommendations are not perfect. I believe they need to be significantly tightened up, and numerical targets, in particular, be attached to them. It’s puzzling in particular to me, given the lack of research funding, that the panel did not explicitly call for RFAs.

The panel is essentially recommending, however, that the federal government finally get serious enough about the ME/CFS field to provide it the benefits that other major disorders enjoy: sufficient research funding, collaborative networks, Centers of Excellence, RFAs, validated outcome measures, and a place in the medical curriculum. That would include educating doctors,and enrolling young new researchers in ME/CFS career paths. It’s a potential game-changer.

Now it’s up to us to support the federal government in carrying out the recommendations their own panel has produced.

P2P Panel Surprises – Points Out Vast Needs For Chronic Fatigue Syndrome: Pt I

December 29, 2014

The goal of the Pathways to Prevention (P2P) program is to… identify research gaps in a scientific area, identify methodological and scientific weaknesses.., suggest research needs, and move the field forward through an unbiased, evidence-based assessment of a complex public health issue. The National Institutes of Health

In a surprise the P2P panel “got” the major issues facing ME/CFS

The expectations for the Pathways to Prevention report were, to put it mildly, low. The report’s reliance on four outside experts none of whom, by design, had any experience with chronic fatigue syndrome raised fears. Fifty-one percent of respondents in a Health Rising poll felt outside experts probably shouldn’t be reviewing ME/CFS. Sixty-nine percent had low trust that outside experts could be objective, and seventy-nine percent had low trust that the outsiders could get major issues right.

After all the worries over whether the Pathways to Progress (P2P) panel – none of whom had any expertise in this disorder – could possibly “get” chronic fatigue syndrome and, in fact, might set it back for decades, just the opposite happened: the P2P panel actually “got” ME/CFS, and they produced a report which, if implemented, would push it forward significantly.

Coming from independent, outside experts and relying in part on another independent review (AHRQ report), the 19 page draft reports findings – that ME/CFS has been understudied, that patients have borne the consequences of that neglect, and that a vast increase in the commitment to understand and treat this disorder is needed – should have all the more impact. In the end, the data, as Dr. Bateman suggested it would, won out, and Bob Miller’s sense – he was the patient advocate in the early stages of the process – that the panel was listening and working hard ended up being correct.. A review of the first half of the report follows. A review of the critical recommendations section is next.

Medical Community Fails Chronic Fatigue Syndrome Population

The report begins by citing the high rates of disability and economic costs, and then lays the extraordinary burdens people with ME/CFS face directly at feet of a medical community that has essentially failed in its core commitments to assist and provide care. “ME/CFS is an area where the research and medical community has frustrated its constituents by failing to assess and treat the disease and by allowing patients to be stigmatized.”

Medical Community Neglect Leaves ME/CFS Community with Heavy Burdens

Over the last 20 years, minimal progress has been made to improve the state of the science for patients with ME/CFS, and the public and provider community is frustrated. P2P Report

The report evocatively protrayed the burdens the ME/CFS community faces

The panelists “got” to a surprising degree the heavy burdens ME/CFS patients have borne by confronting an often uncaring medical system. It excoriated a medical system that often treats people with ME/CFS with “disdain, suspicion, and disrespect” and considers them “lazy, deconditioned, and disability-seeking”. These outdated and untrue themes, the P2P asserted, have hampered scientific progress and have led patients to be treated inappropriately with psychiatric drugs that have not helped and at times caused harm.

The panel cited the heavy emotional burdens caused by “frequent and negative interactions” with the medical community ME/CFS patients must carry. The stigma that surrounds ME/CFS leads to patients being isolated. Financial distress is common. The report’s statement that the lack of available medical options “usually”, not sometimes, but “usually” requires patients to “make extraordinary efforts, at extreme personal costs, to find a physician who will correctly diagnose and treat ME/CFS symptoms” indicates that the panel understood how underserved this population is, and provides a strong foundation for the ME/CFS community to press for federally sponsored Centers of Excellence.

Inability to Resolve Fundamental Issues Thwarts Progress

“ME/CFS results in major disability for a large proportion of the people affected. Limited knowledge and research funding creates an additional burden for patients and health care providers.”

Fundamental issues thwart the field from getting better results

The report will assert again and again that the failure to resolve fundamental issues has thwarted efforts to understand and treat this disorder. The inability of the research community to develop “consistent, specific, and sensitive” diagnostic tests and criteria (a definition) has, they stated, hampered all downstream research on pathogenesis and treatment, thereby causing harm”.

Citing small sample sizes, problems with the instruments used to evaluate patients, problems defining ME/CFS patients versus others, the report agreed with the AHRQ draft report’s findings that significant methodological problems have thwarted understanding of this disorder. [One sometimes wonders what the field has done right :). In the end, though, it’s not the researchers so much as basic elements they’re missing – validated endpoints, well-funded studies, a clear and concise definition – as well as some things they haven’t been doing (specificity, sensitivity, including other disease groups) that are getting in the way of their efforts bearing real fruit. These critiques may be painful, but they do provide valuable guidelines – and they provide issues the ME/CFS community can use to advocate for increased support.]

ME/CFS “In”

Addressing the “wastebasket” theme held by many researchers and doctors, the panel simply and powerfully stated, “ME/CFS exists” and referred to it as a “distinct pathologic entity” the causes of which remain unknown.

Oxford Definition – Out

Echoing a P2P panelist’s statement during the recent P2P Workshop that the Oxford criteria should be retired, the panel stated that the flawed Oxford criteria were confounding the science by allowing people with other disorders to participate in “CFS” studies.

Inadequate Research Funding Noted

ME/CFS is an area where the research and medical community has frustrated its constituents, by failing to assess and treat the disease and by allowing patients to be stigmatized. P2P report
The report’s highlighting of “the lack of well-controlled, multifaceted studies using large, diverse samples, and the limited research dollars directed at ME/CFS from both the public and private sectors” should prove invaluable in advocates’ quest to finally get an sufficient federal response to ME/CFS.

Disorder Faces Unique Challenges

ME/CFS faces challenges other disorders do not face

Remarking on the “unique challenges to ME/CFS” the panel appeared to understand, as well, that they were dealing with a disorder that faces challenges that few other disorders do. When asked how to foster innovative research to produce treatments they noted that twenty years of research has produced scant progress leaving patients frustrated.

ME/CFS is Not a Psychological Disorder

Patients want … a meaningful recovery (not just incremental improvement) P2P Report
Importantly, they asserted that, while psychological repercussions often follow ME/CFS, it is not a psychological disorder. ME/CFS overlaps with many other disorders including fibromyalgia, major depressive disorder, and a variety of chronic pain or inflammatory conditions. [Finally, inflammatory disorders are included as a co-morbid condition.] Fatigue is an essential component, but does not nearly begin to “capture the essence of this complex condition.” The panel got the constellation of important symptoms right: fatigue, post-exertional malaise, neurocognitive deficit, and pain. The panel did not [and could not in my opinion given the lack of studies in this area] endorse a single definition for ME/CFS, but their statement that a “clear case definition with validated diagnostic tools is required” will enhance efforts to get the NIH to fund studies to produce a statistically determined research definition that will propel this field forward. Their statement that it is “critical” to include homebound (“non-ambulatory”) patients in studies will, hopefully, spark efforts in that area as well.

CBT/GET Downplayed

CBT and GET….are not a primary treatment strategy. P2P Report
The Panel took the very moderate findings from the AHRQ draft regarding CBT/GET and moderated them even more, stating, in what will be music to many ears, that because neither therapy shows improvement in quality of life, they should not be considered “ a primary treatment strategy”. (The CDC Toolkit, in the P2P panel’s eyes, now contains no primary treatment strategies.)

Doctor’s Lack Basic Understanding

Most doctors lack basic knowledge of the disorder

Doctors lack understanding of basic management skills (pacing, realistic goals, basic rights, understanding of emotions, exercise, relaxation) that can be helpful. Too strenuous exercise programs in the past have turned some patients off to milder, more appropriate exercise regimens (they mentioned stretching) that can be helpful.

Laundry List of To Do’s

The laundry list of “to-do’s” for ME/CFS is long indeed and feature basic research elements this field has not yet produced or hasn’t had the money to utilize. Standard and validated tools and measures are missing, studies are too small to identify subgroups, endpoints need to be clarified, and clinically meaningful symptoms are not being assessed. In perhaps a critique of the European emphasis on behavioral studies, they noted that the biological factors causing and promoting ME/CFS are often neglected in research studies.

Promising Avenues for Future Research Cited

In contrast to the AHRQ’s report that simply wiped out most ME/CFS research findings because of methodological problems, the P2P draft report asserted that “strong evidence” indicatesthat the potent avenues for future research include the immune system, metabolism (exercise), the mitochondria, neurotransmitter signaling, and the microbiome [but not the autonomic nervous system?]. Their call for large, multi-center studies with diverse groups of patients (to replace the small studies typically done now) can only help advocates’ efforts to increase funding. Research priorities should focus on finding biomarkers and developing treatment options. Key research needs include:

Determining the pathogenesis of ME/CFS, in particular the role herpesviruses and other viruses play in triggering the disorder is critical. Encouragingly, the authors plucked out the role infectious mononucleosis (IM) plays in adolescents. (This should be included to include the role IM during adolescence plays in adults coming down with ME/CFS later.) They also highlighted

  • Understanding that the genetic predisposition present.
  • Is ME/CFS a spectrum disorder?
  • Are different pathways responsible for different symptoms?

Conclusion

“We noted … the limited research dollars directed at ME/CFS from both the public and private sectors. P2p Report”

In a surprise, the panel of outside experts – none of whom had any experience with ME/CFS – mostly “got it” about ME/CFS. Any report will have shortcomings and this one will as well, but the list of ways the panel got it right is impressive. The report suggests that, given enough time and information, outside experts can be trusted to understand.

ME/CFS faces many challenges. Next up – the Panel’s recommendations…

Halfway through the Pathways to Prevention report, it’s identified many barriers to progress and has provided the ME/CFS community ample opportunities to press the federal government for change. The panel is in agreement on many longstanding issues that advocates have asserted plague ME/CFS, including paltry public and private research funding, lack of knowledgeable doctors, poor patient care, and a stigmatization of ME/CFS the medical community has fostered and allowed to continue.

The report downplays the significance of CBT/GET treatments, states the Oxford Definition is causing more harm than good, and, in agreement with the AHRQ report, provides a list of basic issues that need to be resolved. The future research section missed some points (such as the autonomic nervous system) and may have over-emphasized others, but it always focused on pathophysiology.

The report got the major issues right. We’ll see how they do in the all important Future Directions and Recommendations section next.

Study Suggests Hormones, Autoimmunity and/or Viruses at Work in ME/CFS

December 15, 2014

Age Patterns Provide Pointer

A Norwegian study of ME/CFS patient records that found two age peaks in Chronic Fatigue Syndrome, one starting from ages 10-19, the other from 30-39, could tell us something about the disorder.

Two age peaks in the incidence of chronic fatigue syndrome/myalgic encephalomyelitis: a population-based registry study from Norway 2008–2012   Inger Johanne Bakken1*, Kari Tveito2, Nina Gunnes1, Sara Ghaderi1, Camilla Stoltenberg1,3, Lill Trogstad1, Siri Eldevik Håberg1 and Per Magnus1 Bakken et al. BMC Medicine 2014, 12:167

mountain

ME/CFS can occur almost any time but two distinct age-related peaks showed up in a Norwegian study …What does it mean?

It wasn’t as if people of other ages didn’t come down with Chronic Fatigue Syndrome – many people in other age groups did – but the numbers of ME/CFS cases spiked in these age groups.

The least likely times to come down with ME/CFS were at the two ends of the age spectrum: from 5-9 and after the age of 55.

Just 121 cases were reported from ages 5-9, but after the age of nine the incidence of ME/CFS spiked up sharply with almost 700 cases reported from ages 10-14 and 15-19. From 20-29 it dropped about 30% with about 500 cases reported, and then zoomed up again to about 700 cases from ages 30-39. From ages 40-44, 45-49, 50-54 declined until at ages 55+ the incidence was very low indeed.

That’s in contrast to many disorders which get more prevalent as we age.

As in other surveys, young female and adult women in their most productive years were much more likely (75%) to come down with ME/CFS than men.

What does it all mean?

Females Dominate

The high rate of females with ME/CFS combined with the unusual pattern of incidence points a finger directly at female hormones.   Three periods of major hormonal fluctuations occur in women; during puberty, during pregnancy and during menopause. Spikes in ME/CFS incidence occurred during two of these; puberty and when women often get pregnant, but not during menopause.

Sex Hormones, ME/CFS and IBS

make-female

As expected females dominated

A CDC study indicating women with ME/CFS have greatly increased rates of gynecological disorders also suggested that sex hormones could play a major role in the disorder. Despite the female predominance in ME/CFS and FM sex hormones have not been well studied in either disorder, but they have been better studied in another female dominated disorder  that often co-occurrswith ME/CFS and Fibromyalgia – irritable bowel syndrome.

The same pattern of disease development over time is found in IBS. The incidence of IBS peaks in women from their teens to about their mid-forties and then declines over time. By the time women reach their seventies their incidence of IBS drops to that found in men.

Estrogen

Estrogen is the major female  hormone produced. Its many effects on the body and its widely varying production had made it difficult to  study, but Broderick’s ME/CFS model suggests that estrogen triggered dysregulation of the HPA axis may play a key role the development of Chronic Fatigue Syndrome in females.

That’s Low Estrogen – If estrogen plays a role it’s probably low not high estrogen levels that are the problem. Estrogen effects neurotransmitter production and activity and electrical excitability, and has a neuroprotective effect on central nervous system functioning.

estrogen

Estrogen has many effects on the body. It surely plays a role somewhere – but where?

Pain Connection – Some evidence suggests low estrogen level may play a role in chronic pain.  The greater degree of emotional arousal women with IBS display in response to pain could reflect reduced estrogen levels. The association of high estrogen levels with increased opioid receptors suggests higher estrogen levels may reduce pain.

Gut Connection – Female hormones not only influence gut motility – a key feature of IBS – but also gut secretions, gut contractions, immune functioning and pain sensitivity. The fact that about a third of women with IBS issues have them only during menstruation again suggests reduced sex hormone levels could play a role.  Reduced hormone levels during menstruation have been linked to abdominal pain and bloating.

Overall, the evidence suggests that estrogen probably plays a protective role in IBS, multiple sclerosis, pain disorders and possibly chronic fatigue syndrome.  However, the lower incidence of ME/CFS during menopause – when estrogen levels tend to be low – suggests that more than estrogen is  involved.

A Positive Role for Male Hormones

In contrast to women, age appears to play little role in the development of IBS in men:  they experience no significant changes in IBS incidence throughout their lifespan.

menstrual

IBS symptom flares in the premenstrual period implicate estrogen

Male hormones often get a bad rap 🙂 but the lower rates of incidence and the lack of a discernible pattern of incidence in men suggests they may have a protective function. Broderick’s modeling studies suggest that male hormones such as testosterone are protective in ME/CFS and some evidence suggests the same may be true in IBS.

Testosterone also appears to have pain reducing properties that provide protection against the development of pain disorders.  Low testosterone levels in men, for instance, have been associated with increased sensitivity to rectal pain.  Some men with ME/CFS have find testosterone supplementation helpful.

Hormones, or the lack of them, may very well be a contributing  factor to getting ME/CFS, but the spikes in incidence also point a finger at two other factors: viruses and autoimmune disorders.

The Viral Connection – Epstein Barr Virus

Spike in Adolescence  – The increasingly late exposure to the Epstein-Barr virus found in the Western world could contribute to the spike in ME/CFS prevalence in adolescence.

Exposure to EBV in infancy, when cytotoxic T-cell levels are at their highest, is usually hardly noticed, but a first exposure to EBV in adolescence often results in a severe illness such as infectious mononucleosis/glandular fever  –  which appears to trigger ME/CFS in about ten percent  of patients.

gone-viral

The earlier age peak could, in part, reflect late EBV exposure

Spike in Middle Adulthood – Attributing the spike in ME/CFS prevalence in from 30-39 to EBV activation is a bit more difficult. Pregnancy in combination with the stress of child rearing could help explain it, however.

EBV reactivation in response to stress is well documented, but EBV reactivation also commonly occurs during pregnancy. One study found EBV reactivation in 35% of pregnant women by the second trimester and reactivation rates may be as high as 50% in pregnant women experiencing depression or high rates of stress.

Dramatic changes in estrogen,  progesterone and interestingly enough, cortisol – given Broderick’s model of ME/CFS – also occur during pregnancy.

Pregnancy is  also  associated with an increased risk of autoimmune disorders and the incidence of  MS increases in the first six  months after pregnancy.

Reductions in symptoms that often also occur in existing cases of ME/CFS and multiple sclerosis during pregnancy are believed to reflect spikes in estrogen.  (Anti-inflammatory cytokines that spike during pregnancy could play a role as well.)  Coming up shortly we’ll explore an estrogen targeting drug for MS that could possibly spell good news for people with ME/CFS and FM.

Set to Up to Fail? – Studies indicating that infectious mononucleosis increases the risk of coming down with multiple sclerosis later in life two-threefold raises the question whether a similar pattern might exist in chronic fatigue syndrome. Could a severe case of mononucleosis as a teenager set you up for getting ME/CFS several decades later?

Autoimmune Disorders

A similar age-related  incidence pattern is also found in some autoimmune disorders. Lupus is most commonly diagnosed between the ages of 15-35. Multiple sclerosis (MS) is most commonly diagnosed in people between the ages of 20 and 50 years.  Sjogren’s  Syndrome typically begins in the same “middle adult” years  that ME/CFS spikes are seen in.

Conclusion 

complex-issue

The age peaks may reflect a complex array of factors that coincide during certain periods to raise incidence levels.

The age spikes  found in this study  suggests chronic  fatigue syndrome shares  features with several other disorders.  Similar patterns of incidence in IBS, multiple  sclerosis, lupus and Sjogren’s Syndrome, and high rates of female predominance also occur in some autoimmune disorders (systemic lupus erythematosus (SLE; females:males – 9[ratio]1), autoimmune thyroid disease (8[ratio]1), scleroderma (5[ratio]1), rheumatoid arthritis (4[ratio]1) and multiple sclerosis (3[ratio]1)).

Determining what the spikes mean will  take time and much in the very complex interactions involving hormones and the immune system. The evidence suggests that a constellation of factors, perhaps involving hormones, immune activation, central nervous system excitation, and in some cases viruses play a role in producing ME/CFS.  This study highlights “danger points” when women may be particularly vulnerable.

The reduced incidence of ME/CFS and autoimmune and pain disorders in men, on the other hand, may reflect the protective effects male hormones provide.

Next Up – a possible breakthrough multiple sclerosis drug that affects estrogen activity. Could it have potential for ME/CFS?

Drug Combo in Pridgen Antiviral Fibromyalgia Trial Identified – Some Results Available

A lengthy article originating on the University of Alabama website and an  abstract presented to the American College of Rheumatology Conference indicates that the two drugs Dr. William “Skip” Pridgen and virologist Carol Duffy PhD used in their Fibromyalgia antiviral trial were Famciclovir, better known as Famvir and Celexicob, best known as Celebrex.

The report also indicates that  Duffy found only herpes simplex – 1 viruses (HSV-1) in the gastrointestinal tissues of the FM patients. Neither of these drugs nor this type of herpes virus have been commonly used or associated with chronic fatigue syndrome.

HSV-1

Duffy found only herpes simplex-1 viruses in the gut tissues of FM patients

We also learned Pridgen discovered the two drug combo similar to the way Fluge/Mella uncovered Rituximab in chronic fatigue syndrome – by observation. Suspecting that herpes viruses might be to blame for the gastrointestinal issues in his patients, Pridgen started them off on Famvir.  The drug helped but symptoms remained.

After Pridgen noticed much greater improvement in the symptoms of the patients also put on Celebrex for their arthritis he combined the two drugs – for everyone.

In the University of Alabama article, Duffy reported the improvement on the two drug combo was immense.

““The patients who took both drugs, however, came back and said everything was better. Their fibromyalgia was gone. Their chronic fatigue was gone. Their headaches were gone. All of these things had cleared up. When the first few patients approached him, he thought it was a fluke, but as more and more and more patients said the same thing, he knew it couldn’t be a coincidence.”

The Triad

That drug combo never been used in herpes virus infected patients before, but it made sense to Duffy. She knew that some herpes viruses  increase the production of COX-2, a pro- inflammatory enzyme. While Famvir stopped the herpes viruses from replicating, Celebrex weakened the viruses, making them “unstable”.  Since Celebrex also has some antiviral properties, the drug combo hit the virus in three ways.

Famvir

Famvir

Famvir – rarely mentioned in ME/CFS – was the antiviral of choice for Pridgen

Valtrex, Valcyte and Vistide are often used to treat herpesvirus infections in chronic fatigue syndrome but Famvir is rarely mentioned. (Dr. Dantini appears to use Famvir frequently to treat his ME/CFS/FM patients.)

One of the reasons may be that Famvir is mostly used to treat herpes virus infections such as herpes simplex virus, herpes simplex virus 2 (genital herpes) and herpes labialis that have not been typically associated with ME/CFS.

The Newcomer – Herpes Simplex

Duffy scoured the gastrointestinal tissues of 45 patients for a virus. In the end it wasn’t EBV, cytomegalovirus or HHV-6 that showed up, but herpes simplex virus-1 (HSV-1) – the very virus she’s been studying in her lab.  (That’s a little scary, but a technique called immunoblotting was used to ensure contamination had not occurred.)

Herpes simplex virus is best known for its ability to cause cold sores and genital herpes, but according to a Wikipedia article can also cause  herpetic whitlowherpes gladiatorumocular herpes, cerebral herpes infection encephalitisMollaret’s meningitisneonatal herpes, and possibly Bell’s palsy.

HSV-1

The group believes HSV-1 could be affecting many different tissues in FM and other disorders

HSV-1 can infect various organs in the body including the peripheral and central nervous systems, upper respiratory tract, and gastrointestinal tract. It may play a major role in Alzheimer’s. It’s able to deplete mitochondrial DNA. One article suggests herpes simplex virus may be better adapted to take advantage of poorly functioning natural killer cells than any other herpes virus.

The group believes HSV-1 may be responsible for fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome and perhaps other disorders. A video on the Innovative Med Concepts website indicates the virus can attack the facial, gastrointestinal and pelvic regions and that it ultimately takes up residence in the vagus nerve.

It took Pridgen and Duffy about a year to raise the $4 million dollars for the 100 person plus phase II trial to assess the drug combo’s efficacy and safety.  Along the way they enrolled a member of the drug team that brought Savella to market in FM, and a past president of Pfizer in their effort at Innovative Med Concepts.  Noted FM researcher Daniel Clauw joined their advisory board.

Conference Abstract Provides Results

An abstract presented at the ACR conference yesterday suggested the drug combo produced strong improvement in some measures and not as strong improvement in others. The changes in pain using the revised Fibromyalgia Impact Form appeared impressive (p< 001) as did changes in function and symptoms (p<.004) and overall impact (p<.003). Fatigue was significantly improved but less so (p<.02).

stop-pain

Changes in pain were impressive. Fatigue was improved but not as much

However, only 33% of patients (vs 19% of those not on it) met the criteria for a secondary measure called the  Global Impression of Change Scale which asked about changes in a person’s activity, limitation, symptoms, emotions and quality of life. It‘s not clear how to parse the more impressive results in some of the tests with less impressive results in the last one.

The drug combination was judged very safe with more adverse events found in the placebo group than in the patients taking the drug.

Improving Efficacy Efforts Underway

If the trial wasn’t a complete win it nevertheless produced significant improvements in a notoriously difficult to treat illness.  Since fibromyalgia, like chronic fatigue syndrome, is believed to be a quite heterogeneous illness asking any drug or drug combo to be effective in everyone is unrealistic.

Phase III Trial Will Tell the Tale

tablets

Finding the optimum dose will be a key aim of the big trial

Designed to  assess basic aspects of efficacy and safety, Phase II trials are not the last word in efficacy. As the Pridgen/Duffey team proceeds to the Phase III trial  they’re exploring several ways to bump up efficacy. Duffy is working on diagnostic tests to identify which FM patients are most likely to benefit from the combo, and is doing toxicology tests to determine if higher doses are feasible. The optimum doses of the drug combo will also be determined in the Phase III trial. Expect efficacy rates to rise.

Big Trial Ahead

Next up is the big third phase trial – a jaw dropping $50-100 million trial the FDA needs in order to approve the drug combo for the treatment of fibromyalgia.

No one is satisfied with the state of fibromyalgia treatment – and few have looked to the immune system or to pathogens. If the results of this trial are not breathtaking – they are still very good –  and will hopefully improve as the therapy becomes better targeted.  They should begin to prompt a revaluation of what’s going on FM.

The publication of the study is probably just around the corner….

Going Grassroots: Dr. Unger on the CDC’s Chronic Fatigue Syndrome Multisite Studies

November 8, 2014

The CDC’s Chronic Fatigue Syndrome Multisite Studies

The CDC multisite studies will hopefully change the way physicians think about Chronic Fatigue Syndrome, identify subsets, open up treatment options, provide outcome measures for clinical trials, validate the significance of post-exertional malaise and basically help legitimize ME/CFS.  That’s a lot to ask, but then again these are large studies,  the likes of which we’ve never seen before.

high-stakes

With the CDC focusing most of their resources on the study, the stakes are high.

The stakes are pretty high for Dr. Unger’s CFS team. They  haven’t exactly  been lighting  up the research world with their ME/CFS publications. The last one – on a patient registry – was published over a year ago and publications were pretty spotty  before that. The last really interesting CDC study was a gynecologic study published in 2011.  One ME/CFS expert bluntly  told me “Don’t expect breakthroughs from  the CDC – that’s not what they do”.

Dr. Unger has stated the CDC’s CFS team is devoting most of their energy  to the multicenter studies. If major insights don’t come out of them quite a few people are going to be surprised and disappointed.  They should start appearing in the not too distant future.

To get ready for that, first-we check out an ME/CFS Alert  interview with someone who was smack dab in the middle of all the moving pieces –  former Simmaron research assistant Gunnar Gottschalk – and then present an  interview with  Dr. Unger of the CDC about the studies and other matters.

Gunnar Gottschalk on on the Simmaron Research Foundation and  the CDC’s Multisite ME/CFS  Study

 

 

Background – The Open Medicine Institute Opens the Door

Dr. Kogelnik with his double PhD in medicine and computer science is doing his best to usher the ME/CFS field into a new age. Kogelnik believes lots of data is going to be needed to understand Chronic Fatigue Syndrome. In order to get it he struck a deal with a network of top ME/CFS physicians.  He would give them electronic data bases and show them how to use them and they would provide him with numerically identified data (no names) he could use to assist his  research.

medical-records

Hundreds of hours were spent putting decades of medical records into the database

Everybody won.  With their almost 40,000 charts the Simmaron Research Foundation and Sierra Internal Medicine (Dr. Peterson’s practice) had been almost drowning in immune data. It took hundreds of hours to get the data processed, but whereas accessing that data before required a chart by chart review now it simply requires telling the computer to search for, say, NK cell functioning test results.  The updated approach laid the foundation for Dr. Peterson and the Simmaron Research Foundation to participate in research studies with top  researchers. It also opened the door for the multisite studies.

When some money got freed up at the end of the year Dr. Unger asked for proposals.  Kogelnik jumped at the chance and submitted a grant for a multisite study examining patients at ME/CFS expert’s practices across the country. Unger snatched up Kogelnik’s proposal and added more sites and the multisite study, now the main focus of the CDC’s ME/CFS research group, was born.

The Sites

  • Dr Lucinda Bateman (Fatigue Consultation Clinic, UT)
  • Dr. Nancy Klimas (Center for Neuro Immune Medicine, FL)
  • Dr Andreas Kogelnik (Open Medicine Clinic, CA)
  • Dr Charles Lapp (Hunter-Hopkins Center, NC)
  • Dr. Benjamin Natelson (Pain and Fatigue Study Center, NY)
  • Dr Daniel Peterson (Sierra Internal Medicine Associates, NV)
  • Dr Richard Podell (Richard Podell Clinic, NJ)
klimas-nsu

Dr. Klimas’ Institute For Neuroimmune Medicine in Miami is one of the nine centers involved

Gunnar stated the motto behind the study was getting the CDC on the ground grass-roots style and take close look at ME/CFS patients.  The multisite study is going to give the CDC, he said, a sense of what this illness really is. What are the primary symptoms? Do you have a history of viral infection or autoimmune disorder? What illnesses run in the family? How sick are these patients? How long have they been sick? What do they test positive for? (What do they test negative for?)

For the first time the medical world and the CDC is going to view Chronic Fatigue Syndrome patients, not through the filter of the CDC’s Toolkit or the dumbed down sites on the Mayo Clinic or WebMD, but through the eyes of expert practitioners trying to help them.

Standardized Approach Aids Subset Search 

The doctors came together with the CDC to produce a standardized intake form which included newer, simpler ways of measuring fatigue and other symptoms.

(The group clearly was not satisfied with the current symptom assessment tools used in ME/CFS. The AHRQ panel was not particularly satisfied with them either and reported that no validated tools exist for ME/CFS. That’s a big problem. Somehow you have to find a way to measure fatigue, even if it’s only to determine that a biomarker is actually a biomarker.)

Standardized testing will  greatly enhance the  search for subsets

Standardized testing will greatly enhance the search for subsets

They also agreed to a standardized testing protocol. Before the study these practitioners used different tests to assess the health of their patients. They still do their own tests, but now all patients in the study get a core set of tests. Dr. Peterson’s patients,for instance, will get a comprehensive immune workup that includes everything from NK cell numbers and function and IgG subclasses to clonal T-cell rearrangements, but they’ll also get a standard set of tests.

This group, then, did two things right off the bat the AHRQ panel was calling for; they developed (hopefully) better symptom assessment tests and agreed to a standardized testing protocol.

If subsets don’t pop out after all this everyone is going to be surprised.  Besides characterizing the patients in every way possible (symptoms, disease history, medication use, treatment outcomes, test results) the study may help develop outcome measures for clinical trials. Developing “outcome measures” – standardized tests drug companies could rely on to determine if their products were making a difference in ME/CFS – would be a big deal.

The CDC will also continue to follow up the patients over time to determine how the disease proceeds.

Expansion – the Second Phase of the Multisite Study

The first phase of the multisite study has been finished and we’re awaiting publication of the results.  The CDC study was already very large – 75 patients at each of the 8 sites – and in the second phase, if I have it right, it gets much larger (150 persons at each site.) If those numbers are correct this is easily the biggest ME/CFS study ever undertaken.

Pediatric patients, healthy controls and people with similar illnesses are being added to the second phase of the study and biological data will be collected specifically for the study for the first time.

That biological data includes salivary cortisol awakening levels, gene expression and lactate levels before and after a 1-day exercise test and ‘exercise capacity’.  The blood will be banked to aid future research efforts.

Interlude: The Simmaron Research Foundation’s BioBank Multiple Sclerosis Study

Gunnar spoke about the Simmaron Research Foundation’s BioBank. The BioBank doesn’t get mentioned a lot, but with 6,000 specimens it’s one of the largest in existence and with samples dating back   decades it’s certainly the oldest. The jewel in its crown are its unusually large number of the spinal fluid samples – something Dr. Mady Hornig has called ‘a treasure’.

The Simmaron Research Foundation contracted with the Chronic Fatigue Initiative to analyze 60 of those samples and compare them to  people with multiple sclerosis and healthy controls.  That study got more interesting when a recent study found very low levels of a neuronal repair agent called BDNF in both multiple sclerosis and ME/CFS patients.

A Talk with Dr. Unger

 “Publishing this information is a priority”

unger-cdc

Dr. Unger put her stamp on the CDC’s ME/CFS program with the multisite project

You’ve done a lot of outreach including visiting the clinics involved in the multi-site study. Can you say one thing that surprised you or stuck in your mind from your visits to the different clinics?

It was really a pleasure visiting the clinics and meeting those who care for CFS patients and work so hard on making sure the study is a success.  While the style of each clinic varied, I was impressed by the care taken to make the waiting and examination rooms accommodate the special needs of CFS patients.  In each clinic, the staff provided positive energy and empathy for their patients and it was clear how important these intangible items are to the patients.   The experience emphasizes the need for us to work towards the time when all CFS patients will have access to the level of care provided in these clinics.

Preliminary information on the CDC multi-site studies for CFS was provided at an FDA meeting a year and a half ago, but no studies have been published and no presentations on the studies were given at the IACFS/ME conference. Can you tell us roughly when the studies will start to be published. What subjects will the published studies be on?

At the time when abstracts for IACFS/ME were due, the interim analysis presented at the FDA meeting was publicly  available and therefore not appropriate to submit as new information. We were in the process of finalizing and verifying (sometimes called “cleaning”) the final dataset for the baseline year of enrollment into the multi-site study.

We are now conducting analyses on these data and will write the papers and submit them to peer reviewed journals as soon as we can.  The first paper will describe the characteristics of patients and their illness as measured by the questionnaires they completed.  All patients enrolled in the baseline study will be included.

Subsequent papers will describe additional features, such as medication use and medical history.  The total time to write, clear, submit and have the articles peer reviewed is difficult to estimate. Publishing this information is a priority, and we will move this process along as quickly as possible.

Treatment and Testing

“The long-term goal is to identify biologically meaningful subgroups so that the design of treatment trials could be refined, both in terms of those enrolled and outcomes measured”

Are you examining treatment effects in the second part of the study?

physician

Treatment efficacy will be highlighted in the second phase of the multisite studies

As patients return to the clinics, we are collecting follow-up information about the characteristics of their illness.  We plan on doing this over several years to get an idea of whether/how their illness changes with time.  This information, often referred to as “disease course,” will reflect both treatment effects and the natural history of the illness.  We are collecting information on medications and therapy, so a correlation between disease course and treatment could be made.

However, information from this observational study (i.e., a study that collects data without introducing a specific intervention) will provide only indirect evidence of treatment effects.

[This excellent news indicates that the second part of the study will, for the first time ever, report not just on the wide variety of treatments used by ME/CFS experts, but on their efficacy.  The report will lack the weight of an interventional study but documenting the efficacy of the wide range of treatment approaches – from antivirals to beta blockers to blood volume enhancers – should  open eyes in the medical community.]

Could this part of the study be used to broaden physician understanding of the appropriate diagnostic tests for Chronic Fatigue Syndrome? Do you expect that the CDC might, based on the data collected, update their recommendations for diagnostic testing in the Toolkit? 

Summarizing the tests used by our clinicians is only one step in understanding the best diagnostic practices for CFS.  We hope that this will form the basis for dialogue between clinicians about the rationale for each test and how they use the test results to improve treatment.  This study information, along with other evidence-based research, may enable updates to future CFS educational materials.

“One of our goals is to use data from this multi-site study to help refine sub-groups of CFS”

I see that lab test data is being gathered for the multi-site study. Does that mean we can expect a study at some point indicating what percentage of people with Chronic  Fatigue Syndrome at these clinics test positive for, say, IgG subclass deficiencies or orthostatic intolerance or even reduced aerobic capacity (understanding that not all practitioners test for them)?

medical-testing

A records review will determine what types of tests and their results ME/CFS experts use to assess their patients health

We have included a record review of testing in order to provide information on the different kinds of tests that CFS expert clinicians find helpful in managing CFS patients.  Because testing is not uniform (not all clinicians order the same tests for their patients) and not random (testing is guided by the individual patient’s symptoms), test results from record review will not be a good estimate of the percentage of CFS patients with test abnormalities.  Tests that are being done as part of the study, such as a measure of orthostatic intolerance that is part of the physical examination or wakening cortisol response, should be available for most patients and will be reported.

In an earlier interview you stated that “The study is expected to provide data to support new initiatives throughout the CFS research community.” What kind of new initiatives do you expect the study might support?

One of our goals is to use data from this multi-site study to help refine sub-groups of CFS and provide information on reliability of measures of illness.  Findings from this study will require validation by others.  Similarly, the validity of patient subgroups suggested by other studies could be tested in our data.

The long-term goal is to identify biologically meaningful subgroups so that the design of treatment trials could be refined, both in terms of those enrolled and outcomes measured.  In addition, the biorepository we are building will be linked to carefully curated patient data.  This could be used by researchers to refine or validate promising biomarkers or disease hypotheses.

The Exercise Study

 “PEM is just one of the factors that could be used to stratify patients”

There is fatigue and there is post-exertional malaise. For myself the inability to do even mild exercise without experiencing significant symptoms is the outstanding aspect of ME/CFS. Everything else is kind of nebulous; the fatigue, the body pains, the cognitive problems – but ask me to exercise and everything gets much worse very quickly. It’s hard for me and others to imagine, therefore, that PEM is not the most biologically significant symptom in this illness, but some people who meet the CFS criteria are significantly fatigued but don’t appear to experience PEM. I have two questions

(1) Don’t we run the risk that we are mixing apples and oranges – and thus doing injustice to both – by not separating these two groups in research studies? 

(2) Will the multi-site study help us understand these two groups better?  

Patient heterogeneity is a problem for research studies.  PEM is just one of the factors that could be used to stratify patients.  Type of onset (acute versus gradual), severity of individual symptoms, and cognitive measures are some other examples.  Information from the multi-site study will hopefully start the process of identifying biologically meaningful subgroups.  When we have good ways to look at all the components of the illness, studies can then be designed to look at subgroups.

apples-oranges-cfs

Are we mixing apples and oranges by not requiring PEM to be present? Dr. Unger suggested other ways to differentiate people with ME/CFS

[Commentary: Dr. Unger has not been convinced in the past that post-exertional malaise is a defining characteristic of ME/CFS or  “ME” and she clearly is not now. The idea that PEM is one factor among many has been the CDC’s stance for some time.

The fact that Dr. Unger is using an exercise test of all things to reveal the biological breakdowns present in this disorder indicates that she recognizes how important a role exertion plays in this illness, but she believes that stratifying patients according to disease onset, cognition or symptoms severity might produce  as biologically meaningful subsets.

That’s questionable. Because many different processes undoubtedly contribute to symptom severity in ME/CFS, focusing on that seems unlikely point a finger at a specific disease process. Nor have differences in cognition (working memory problems vs say information processing speed) ever been suggested as being possible differentiating factors in ME/CFS. Disease onset is a more likely candidate but most studies that have examined disease onset have not found it to be a significant factor.

The Light ME/CFS multiple sclerosis study suggested that the PEM induced fatigue and  pain is different physiologically from the “lassitude” type of  fatigue in MS. If PEM is a more or less unique contributor to fatigue in ME/CFS  it would provide an important tool to differentiate ME/CFS from other disorders. It’s clear that “fatigue” is too crude of a concept to denote  what’s happening  in  ME/CFS.

Dr. Unger ‘s assertion that when we have ‘good ways to look at all components’ of ME/CFS then we should look for subgroups  was echoed, to some extent, by the AHRQ  in their report to the P2P panel.  That we still, after thirty years, don’t have the tools to properly assess the symptom presentation in ME/CFS is nauseating, but simply reflects the lack of federal support for this field.  The NIH’s willingness to point out the flaws in ME/CFS research has never, unfortunately, coincided with a willingness to spend any money to fix them.]

One report suggested the CDC was gathering data on lactic acid accumulation during exercise. Is this so?

We are measuring lactate during the exercise test that is being conducted at several of the clinical sites as part of the combined cognition-exercise protocol.  Lactate is measured at the start of exercise and periodically throughout the test (including peak exercise intensity) and during exercise recovery.

This information will be used along with other measures taken during the test (gas exchange data) to assist with determination of the exercise capacity of participants.

exerccise-test-cfs

Will the CDC’s one-day exercise test suggest aerobic capacity is higher than it really is in ME/CFS?

[One of concerns regarding  using the one-day aerobic exercise test  to measure ‘exercise capacity’  is that studies indicate that a two-day exercise test in ME/CFS is required to pick  significant  decrements in aerobic exercise capacity.  The one-day test then, is a poor and misleading measure of exercise capacity in ME/CFS.  The CDC’s use of the one-day test has lead to fears that the negative results will overshadow the two-day exercise studies that indicate ‘exercise capacity’ is, indeed blunted in ME/CFS.

It’s not clear what Dr. Unger meant when she said the 1-day test will assist with determining the  ‘exercise capacity’ (probably VO2 max, etc. and lactate) of ME/CFS patients. The lactate measurements taken during the test may demonstrate decrements in exercise capacity but past studies suggest aerobic capacity – the ability to generate energy – will largely appear normal in her group.

If  the study results  mirror  what Dane Cook  in his Solve ME/CFS study are finding, however, the one-day test will reveal significant drops in cognitive functioning after exercise.]

In that interview you also stated “We believe that the data collected in our study will help identify the best options for either measuring post-exertional malaise or for identifying measures that correlate with this characteristic.” Could you expand on that a bit?  What data might come out of the study that could help measure the extent of PEM present?

We are asking participants in the exercise and cognition study to complete simple self-reported scales of physical fatigue, mental fatigue (or mental fog), muscle aches, joint aches, headache, muscle weakness and light headedness. In addition, we are asking participants to complete online cognitive tests after they return home.  We hope that changes in these measures across multiple time points before, during, and after testing will provide insights to the extent of PEM.

[It’s a bit mystifying that Dr. Unger did not include lactate or gene expression in her answer since she is measuring them in response to and after exercise as well, but perhaps the question was not phrased well. Differing gene expression results or lactate levels in ME/CFS patients and controls could surely help  measure the extent of PEM present in ME/CFS. ]

Do you see any possibility that we might identify some diagnostic factors that could predict the presence of PEM without having ME/CFS patients get on a bicycle? 

It is not clear whether there are diagnostic factors that correlate with PEM, but we will be evaluating all measures collected as part of the study.  Ideally, we would like to have an alternative to formal exercise testing.

Will the gene expression part of the study target the same genes that the Lights identified during their exercise studies? Will you be banking the blood collected during and after the exercise test so that it can be assessed again when future research suggests it might be appropriate to do that?

We will have one blood sample collected before and one after exercise testing.  RNA from whole blood can be tested for multiple genes including those identified in the Lights’ studies.  The samples will be available to test different hypotheses.)

Other CDC ME/CFS Research

“A review of the literature on CFS suggests that CFS shares some features with accelerated aging …”

What was the rationale for the telomere length study? How does that fit in with past/future CDC research?

telomere

Reduced telomere lengths puts ME/CFS in the same conversation as aging, cancer, heart disease and infection

Your question about telomere length probably refers to information that Dr. Rajeevan presented at the 2014 IACFS/ME meeting.  We conducted an analysis of telomere in archived samples from our population-based study of CFS.  This was prompted because of the association of telomere length with aging, cancer, heart disease, infection and stress.  A review of the literature on CFS suggests that CFS shares some features with accelerated aging and post-infective fatigue.

Around the time that the laboratory had finished testing telomere length, we also completed the testing to identify genes that had different methylation patterns in CFS cases compared to non-fatigued controls.  Samples in the methylation analysis were also part of the population study.  The exploratory methylation testing identified several genes that differed in methylation, but only one gene that also showed a difference in expression.   That gene was TERT (telomerase reverse transcriptase), an enzyme that is involved in maintaining telomeres.  These observations need to be confirmed in other populations.

Many factors that occur with CFS could contribute to both methylation and telomere length, so the findings are not clear.  They do suggest that some of the same biologic factors that are seen in a variety of chronic conditions are also seen in CFS.

Resources

  • Beth Unger on the CDC’s multi-center study on YouTube
  • CFSAC committee meeting – Spring 2013 –  The Multi-site Study Pt II – YouTube

Symposium Calls For Use of Immunotherapy To Treat Chronic Pain

October 2, 2014

“Despite the availability of different drugs, most patients with chronic nociceptive pain do not receive satisfactory pain relief…”

We all know the medical profession is poor at providing pain relief in general, but its record with regards to neuropathic or nerve pain is something else indeed. Despite the fairly large array of drugs physicians use (few of which were developed to reduce nerve pain), no more than 30-40% of  nerve pain patients receive as much as 50% relief from the medications doctors  provide.

pain

The medical profession is poor at treating pain. The experience of these doctors and researchers suggests it may be missing some options.

Despite research that has uncovered important factors in the production of pain, much clearly remains to be learned.  The production of pathological pain has been shown to be a very complex process. Researchers know, for instance, that damage to the ion channels on nerves, increased levels of excitatory neurotransmitters and reduced activity in the pain inhibition pathways in the brain all play a role.

These authors suggest, though, that a critical component of the pain production pathway – the immune system – has been, if not ignored, then not fully investigated.  Studies show that a variety of immune components, from mast cells to macrophages and cytokines to the microglia play a role in pain production.

Recent studies suggest that autoantibodies to the potassium channels – the dorsal root ganglia – key pain processing sites located just outside the spinal cord -are opening up new windows on how pathological pain may be produced.

Other than corticosteroids and anti-inflammatories, however, few immune affecting drugs are used to fight pain.  Human immunoglobulin G (IgG) is an immune drug these authors believe may be useful in pain disorders where evidence of increased cytokine production can be found. IgG can be delivered intravenously (IVIg) or subcutaneously (SCIg) and may work by suppressing the immune system.

The fifteen members of this workshop came from Italy, Sweden, Switzerland, Japan, Canada, the U.K., and the U.S. to report on where and when IgG may be useful in treating chronic pain. Some studies were reported on and a good deal of the information derived from case studies.

Symposia Report Immunoglobulin G for the Treatment of ChronicPain: Report of an Expert Workshop, Stefano Tamburin, MD, PhD,* Kristian Borg, PhD,†Xavier J. Caro, MD,‡ Stefano Jann, MD,§Alexander J. Clark, MD,¶ Francesca Magrinelli, MD,* Gen Sobue, PhD,** Lars Werhagen, PhD,†Giampietro Zanette, MD,†† Haruki Koike, PhD,**Peter J. Späth, PhD,‡‡ Angela Vincent, FRCPath,§§ and Andreas Goebel, MD, PhD¶¶ Pain Medicine 2014; 15: 1072–1082

 Sjogrens Syndrome

Sjogrens Syndrome (SS) is an autoimmune disorder mostly affecting women.  Often misdiagnosed as other disorders, including ME/CFS and Fibromyalgia, SS can cause a wide variety of neuropathic (nerve) problems.

IVIG

IVIG is the focus of this review -but other immune drugs may apply.

Some evidence suggests that the neuropathic pain in SS, which can be quite severe, comes from neuron loss in the dorsal root ganglia perhaps caused by ‘cytotoxic autoimmunity” – a intriguing result given similar findings in some Chronic Regional Pain Syndrome patients.

Of five patients treated with IgG for SS with severe neuropathic pain, all showed ‘remarkable’ reductions in pain (73% reduction VAS scale) within two weeks which lasted from two to six months.  Long term follow-up indicated two had relapsed, but resumption of treatment was successful.

Fibromyalgia

Several findings including increased cytokine levels in the skin and blood suggest the immune system plays a role in Fibromyalgia.  An inverse correlation between Il-2 receptor levels and reduced nerve density in the skin (small nerve fiber neuropathy) suggested immune mediated nerve destruction had occurred.

myelinated nerves

Caro finds immune therapies to be the most effective for his Fibromyalgia patients

Studies reporting large nerve fiber demyelination in the periphery and reduced nerve fiber density in the skin suggest FM may in part be a neuropathic disorder.  Pain symptoms in FM are similar to those reported by people with neuropathic pain.

Caro found that from fifty to seventy percent of 45 FM patients responded positively (<50% reduction in pain) to IVIG ((0.4 g/kg/day for 5 days followed by 1.2 g/kg every 3 weeks, given as 0.4 g/kg/day). The pain reduction usually started five days after the end of the first course of IVIG and then peaked at 3-6 months.  Relapse may occur after that.

Caro, who has been treating and studying Fibromyalgia for decades, stated that he’s had more success using immune modulating treatments than using traditional approaches using  FDA approved drugs.

Post Poliomyelitis Syndrome (PPS)

Pain associated with poliomyelitis relapse decades after apparent recovery presents an interesting case for immune mediated therapies. The pain, which usually occurs in combination with muscle weakness and atrophy, and can be severe, is localized to the muscles and joints.  Neuropathic pain usually occurs in combination with nerve compression or disc herniation.

Structural components do not tell the entire story, however. Increased cytokine levels in the cerebral spinal fluid, serum and peripheral blood suggest systemic inflammation is present and may be contributing to pain.

Four studies examining IVIG effectiveness in PPS found significant reductions in CSF cytokines, reduced TNF-a levels in the blood, significant clinical improvement, increased muscle power, quality of life and/or reduced pain. Decreased pain levels were still evident a year after treatment in one study.

One of the authors reported 35% of PPS patients experienced a greater than 50% reduction in pain

Complex Regional Pain Syndrome (CRPS)

CRPS is one of the most painful disorders known. We saw in a recent blog that autoimmune processes appear to play a significant role in some CRPS patients.

An open-label trial of low-dose IVIG (0.5g/kg) found that 3/11 CRPS patients received >70% pain relief – an astounding feat in CRPS – after repeated treatments. Six of eleven received no benefit.  The pain, unfortunately, returned to baseline levels within three months.

wow!

Long term use of IVIG completely eliminated CRPS in some patients

In a small follow up trial three patients who had received >30% relief continued on a weekly maintenance dose (0.5g/kg or 1g/kg). Not only did two of the three patients experience ‘profound and sustained pain reduction” during the 3-12 months they were on the drug, but both remained in remission 12 months after the termination of the treatment.

Given the successes the following “Liverpool” protocol was suggested in CRPS:

  1. Patients should first be treated with an intravenous loading dose of 0.5 g/kg; if >40% pain relief is achieved, patients should—commencing 2 weeks after the loading dose—be offered
  2. a trial of 6–12 months of low-dose maintenance treatment; either 0.5 g/kg/month divided into weekly portions (or even smaller portions if a “push technique” is used instead of a pump) for subcutaneous therapy, or 0.5 g/kg every 3 weeks intravenously
  3. after 3–6 months an attempt should be made to halve these doses,
  4. after 6–12 months an attempt should be made to stop treatment.

A multicenter trial examining the efficacy of long term IVIG use in CRPS is currently underway in the UK.

Diabetic Polyneuropathy

Diabetes mellitus is the commonest cause of peripheral neuropathy.  The most intense kind of peripheral neuropathy in diabetes is diabetic lumbosacral radiculoplexus neuropathy (DLRPN), an extremely painful and difficult to treat form of peripheral neuropathy.

Eighty percent of five patients with diabetic polyneuropathy responded well to IVIG with pain intensity dropping from 77/100 on the Visual Analogue Scale (VAS) to 33.  Pain reduction peaked at one to two months and one patient relapsed at seven months.

diabetic-neuropathy

Some diabetic neuropathy patients that didn’t respond to steroids – did respond to IVIG

The fact that general inflammatory markers (erythrocyte sedimentation rate, rheumatoid factor, antinuclear antibodies) are negative in DLRPN, yet anti-inflammatory treatments may be helpful suggests DLRPN consists of a local microvasculitis.  Indeed, the reduction in pain with IVIG makes sense if ischemic damage to the nerve roots and peripheral nerves has been caused by a microvasculitis.

Some patients that responded to IVIG do not respond to the immune suppressant effects of steroids.

Distal Symmetric Painful Polyneuropathy is another form of polyneuropathy found in diabetes. Twelve patients for whom standard treatments were ineffective received either IVIg (0.4 g/kg/day for 5 days) or continued with their standard treatments.

In the five diabetic patients treated with IVIg, mean pain intensity significantly dropped and 80% of patients were responders (i.e., pain reduced by >50%).  The study was very small, but this was a far higher percentage of relief than achieved by traditional pain medications.

Autoantibody Caused Pain 

Autoantibody attack of neurons and glial cells has been definitively linked to central nervous system problems. In acquired neuromyotonia antibodies to the VGKC complex causes peripheral nerve hyperexcitability and pain symptoms similar to those found in FM (aching, cramping, shooting, lancing, or burning pains). (One study has found peripheral nerve excitability in Fibromyalgia.)

These same antibodies have been linked to pain in Morvan’s syndrome and people with idiopathic pain.  Immune therapies including IVIG and steroids have effectively reduced pain levels in some of these patients.

These findings suggest that pain in autoimmune disorders such as multiple sclerosis and neuromyelitis optica may be amenable to IVIG. The authors called the arena of autoantibody induced pain via neuronal  attack  “ripe  for investigation”.

Conclusions

“Polyvalent IgG represents a promising treatment in a number of chronic pain (neuropathic, nociceptive, and complex) conditions”

The Workshop participants propose that, in contrast to prevailing thought, that nerve or neuropathic pain may at times be immune mediated and respond well to immune therapies, in particular, antibody therapy. They note IgG is generally well tolerated with mild side effects, if any, but that costs are high (up to $8500 per protocol  in the U.S.), and insurance reimbursement for pain can  be problematic.

step-by-step

The authors hope to spark rigorous study to assess the effectiveness of IVIG and other immune therapies in treating chronic pain.

Most of the evidence for IgG use in pain comes from case studies and rigorously controlled trials are needed.  Much work remains to be done to validate these findings and at least study is underway. A successful outcome to the British IVIG study of CRPS – one of the most intractable and painful of all pain disorders – would surely open eyes.

IVIG administration appears to be successful in a subset of patients with these pain disorders.   Long term IVIG treatment has been rarely tried but has lead to complete remission in a few cases.  Future immune analyses should be able to identify those patients in pain who would benefit from immunotherapies such as IgG.

Given the poor track record of treating chronic pain, immunotherapy will hopefully be given the funding and study it needs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment Resistant Depression or Chronic Fatigue Syndrome? Child Psychiatrist Finds Success With Antivirals

September 23, 2014

A Different Kind of Psychiatrist

“I have now treated dozens of adults and adolescents who came to me with the diagnosis of “treatment-resistant depression” and instead they had Chronic Fatigue Syndrome. With proper treatment, this viral illness can be successfully controlled.”

ted-henderson

Dr. Henderson is one of the rare psychiatrists to acknowledge the role the immune system and viruses can play in producing symptoms many associate with psychiatric disorders like fatigue

Chronic Fatigue Syndrome in all its forms is difficult to treat, but one doctor in Centennial, Colorado is apparently having some success with antivirals. Dr. Theodore Henderson is not a virologist or even an infectious disease specialist. He’s a child psychiatrist – perhaps the last profession one might expect to be open to viral theories of ME/CFS or childhood depression.  (I remember Environmental Medicine specialist Dr. William Rea telling me that he could count on the fingers of one hand the number of psychiatrists who didn’t believe environmental illness was mental.)

On his website Dr. Henderson descries the DSM approach that attempts to pigeonhole patients and put them in one category or the other. Instead he tries to approach the neurobiological problems of each patient uniquely.

I approach psychiatry from a brain-based biological perspective.. Most people cannot be pigeon-holed into a single category and most psychiatric conditions are actually a range of disturbed neurobiological processes. As a result, I approach each patient, child or adult, as an individual with a unique brain.

While Dr. Henderson uses traditional approaches to treat mental  disorders, he also recognizes the role the immune system and  viruses can play in producing some psychiatric symptoms.

“More importantly, growing evidence suggests that not all psychiatric symptoms, such as anxiety, fatigue, listlessness, low mood, or poor concentration, result from intrinsic flaws in the patient’s brain. Extrinsic causes, such as infections and toxins, can cause these psychiatric symptoms. The resulting cluster of symptoms might mimic anxiety, depression and other psychiatric disorders, leading to misdiagnosis and ineffective treatment.

Certain rare autoimmune disorders can lead to the formation of antibodies against specific neurotransmitter receptors. Much more widespread autoimmune disorders, such as systemic lupus erythematosus, can lead to cognitive changes, anxiety, seizures, and mood disorders”

Dr. Henderson reported he has been effectively treating both adolescent and adult Chronic Fatigue Syndrome patients with antivirals for several years. He recently published a paper describing his results with adolescents.

The Paper

Henderson TA.  Adv Mind Body Med. 2014 Winter;28(1):4-14. Valacyclovir treatment of chronic fatigue in adolescents.
pathogens

Dr. Henderson cites Dr. Lerner’s work with antivirals and ME/CFS on his website

In the paper, Dr. Henderson first cites the low diagnostic rates for Chronic Fatigue Syndrome (20%).  Then he argues that studies suggest reactivated herpesvirus infections, particularly HHV-6, are common in ME/CFS.  Arguing – as did Dr. Brewer at the Simmaron Research Foundation’s Immunology Workshop in San Francisco – that IgM antibodies are not diagnostic in this disease, Dr. Henderson asserted that primary cell cultures in combination with antibody or PCR tests indicate HHV-6 infection rates are very high in ME/CFS.

The Antiviral Subset?

In Dr. Henderson’s experience (approximately 65 patients treated) ME/CFS patients whose illness began with flu-like onset and who have:

  • have elevated IgG levels against a herpesvirus
  • low natural killer cell activity
  • high ribonuclease activity
  • high levels of angiotensin converting  enzyme (>35)
  • high TNF-a levels
  • elevated total IgM or IgG levels

responded well to antivirals.  He undertook a retrospective chart review of 15 adolescents he had treated with valacyclovir (Valtrex) between 2007 and 2013.

Valtrex is used to treat herpes zoster and herpes simplex and, in Chronic Fatigue Syndrome, Epstein-Barr Virus reactivation. Two studies by Lerner suggest Valtrex can be effective in ME/CFS.

young-man

Many of the adolescents who responded to antivirals had been referred to Dr. Henderson for treatment resistant depression

Dr. Henderson evaluated these patients like any good child psychiatrist would: He looked for mood disorders, a history of childhood abuse, assessed their sleep quality, and reviewed their school performance. He looked for any other significant symptoms and did laboratory work.  He noted that most of them had been referred to him for having ‘treatment-resistant depression’. All experienced fatigue, low motivation, academic problems, and unrefreshing sleep. Most had tried antidepressants or other mood altering drugs without effect. They did not, however, meet the CDI self-report test for depression.

Upon further evaluation six were given a diagnosis of Chronic Fatigue Syndrome, four were given an ME/CFS diagnosis plus anxiety, and three were given a diagnosis of ME/CFS diagnosis plus mood disorders.

Eleven were receiving failing grades in at least one class, and almost half had dropped out of school.  A third were sleeping more than 12 hours a day.

Ten could remember an infectious event they didn’t recover from.  Interestingly, a third of the group reported that they had always experienced significant fatigue.

fatigued-young-woman

The fatigue levels of his young patients were incredibly high

Their self-reported fatigue levels were almost off the charts.  While ‘significant fatigue’ is indicated by a score of 39 on the Fatigue Symptom Index (FSI), their mean score was 95. Similarly, they topped out on the Fatigue Severity Scale with almost two-thirds of the participants scoring near maximum fatigue levels (56 out of a possible 63).

The doctor provided them with the option of going on Valacyclovir, noting that the published evidence that it would work was small and confined to adults, not adolescents.  They began on an oral dose 500 mg BID and worked their way up to 1000 mg BID over a couple of weeks.

Results

“The medical understanding of CFS has been impeded to a degree by the resistance to the concept  of chronic viral infections of the central nervous system.”

Almost all of the adolescents responded quickly to the antivirals. Within three months 12 out of 15 reported greater than an 80% improvement in symptoms. After 8 months 14 out of 15 adolescents reported increased energy, improved sleep, increased motivation, and “return to normal functioning”. Ten of the 14 reported a “complete resolution of fatigue” and their depressive symptoms disappeared. Five of the seven who had dropped out of school returned to school and ultimately enrolled in college.

upwards graph

Fatigue scores generally dropped dramatically in response to antiviral therapies

The changes in the fatigue self-report scores were astonishing. Mean Fatigue Symptom Index (FSI) scores for nine of the fifteen dropped from the whole group FSI score of 56 to and FSI score of 12.  Fatigue Severity Scale scores dropped from 95 to 19. All ME/CFS symptoms measured by the MFSI dropped significantly.

The impressive results bring to mind Dr. Montoya’s initial Stanford valganciclovir trial in adults (9/12 recover) and the reminder that the results of his more rigorous double blinded, placebo-controlled trial, while positive, were much less successful.  Still, Dr. Henderson has clearly experienced real success with his adolescent ME/CFS patients, none of whom had responded to other approaches.

Noting that his adolescent patients were more likely to have acute infectious onset than adults and less likely to experience depression, Dr. Henderson suggested adolescents might have more success with antivirals.

While he didn’t mention it, one wonders if late exposure to Epstein-Barr Virus is playing a major role in adolescent onset ME/CFS.  Adolescence is becoming a more and more likely time of first exposure to Epstein-Barr virus (EBV).  Early exposure to EBV (during childhood) often doesn’t cause symptoms, but as cytotoxic T-cells decline after early childhood, later exposure causes a much more virulent illness. Some researchers believe delayed exposure to EBV is behind the increased levels of autoimmune disorders seen.

As do some others in the field, Dr. Henderson, took issue with the medical community’s unwillingness to more fully investigate the impact central nervous system viruses have on a range of disorders including ME/CFS, multiple sclerosis, schizophrenia, Alzheimer’s, and Autism.

Follow-up

The average duration on the drug was over two years.  Four patients discontinued treatment after about 18 months and remained well at the time of this report. Five patients who discontinued treatment in a similar time frame, however, immediately relapsed and had to go back on the drug.

Treatment Resistant Depression = Chronic Fatigue Syndrome?

“The authors secondary hypothesis is that treatment-resistant depression may often, in fact, be CFS that has been misdiagnosed.”

Dr. Henderson proposed that a significant number of adolescents diagnosed with treatment-resistant depression actually have a form of chronic fatigue syndrome that may respond to antivirals.

question-mark

Remarkably, most of the adolescent referred to Henderson for treatment resistant depression….did not meet the criteria for it

The medical profession’s eagerness to diagnose adolescents experiencing severe fatigue with depression was evident. Despite the fact that most of his adolescent patients did not met the DSM criteria for depression nor did they have CDI scores consistent with depression, many of them were still diagnosed with depression.  Other findings, such as low cortisol and cerebral hypoperfusion, were at odds with a depression diagnosis, yet over half the adolescents had been treated for depression and had not responded.

One is reminded of the saying that if your only tool is a hammer, everything begins to look like a nail.  But Dr. Henderson’s specialty is psychiatry.  He recognizes true depression when he sees it.

In fact, adults with inflammation-associated depression who make up perhaps a third of all cases of depression – do not respond to antidepressants either. Interestingly, a subset of depressed patients without inflammation-associated depression get worse when given anti-inflammatories. (For them some inflammation is good!)

The doctor provided a case report involving an adolescent experiencing fatigue, brain fog, and depression diagnosed with ‘treatment resistant depression’ who had failed to respond to either SSRIs or SNRIds.  Tests showed she had reduced NK cell counts and high IgG titers to EBV and HHV-6. Three months after going on 1000 mg a day of Valacyclovir she had experienced a complete resolution of all her symptoms. Three months later, after forgetting her meds on a trip to Disneyland, her symptoms quickly returned and she spent most of the vacation in bed at her hotel. One week after resuming the medication her symptoms completely disappeared again.

Dr. Henderson proposed a placebo-controlled trial be done involving seropositive (antibody positive) and seronegative ME/CFS patients. The trial should not, he emphasized, employ acyclovir, an antiviral he asserted has low bioavailability and is rapidly eliminated by the body.

Conclusion

In a retrospective case analysis Dr. Henderson reported very high response rates to Valacyclovir (Valcyte) in a small group of adolescents with ME/CFS. Fatigue and other symptoms virtually disappeared for many in the study, a significant portion of whom had been diagnosed with treatment-resistant depression.

He proposed that that many adolescents diagnosed with treatment-resistant depression may have Chronic Fatigue Syndrome.  Dr. Henderson also suggested that the high incidence of infectious onset and low incidence of depression in adolescents with ME/CFS made them good targets for antiviral therapy.

Check out Dr. Henderson’s website and blog here.

 

 

 

 

 

 

 

 

Simmaron Scientist Awarded NIH Grant Probing Cause of Immune Holes in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis

August 31, 2014

NIH Grant to Study Genetics of Immune Response in ME/CFS

Simmaron Research Foundation’s Scientific Director, Isabel Barao PhD, has been awarded the IDeA Clinical and Translational Research Pilot Grant (CTR-IN) from the National Institutes of Health (NIH) to examine ways ME/CFS patients’ genetic heritage may contribute to immune dysfunction and their inability to fight off viruses. Dr. Peterson will select the patients, collect their blood and provide their clinical information. The laboratory work will be performed at University of Nevada School of Medicine (UNSOM), Department of Microbiology and Immunology, where Dr. Barao is academically affiliated.

DNA

This study will probe genetic holes in natural killer cells

The $75,000 grant is small, but it is an important sign of Simmaron’s ability to advance new investigators involved in immunological research on ME/CFS at the NIH. The CTR-IN grant is supported by the National Institute of General Medical Sciences. The 1-year grant supports 20% of Dr. Barao’s pay and supplies for laboratory work.

Dr. Barao has also submitted an R21 grant proposal to the NIH in collaboration with the National Cancer Institute (NCI), Dr. Peterson and UNSOM.

ME/CFS is believed to be a multi-factorial disorder caused by a combination of one’s genetic makeup, an environmental trigger such as a pathogen, and other factors. It’s believed that 20-40% of the reason people came down with ME/CFS lies in their genes.

Take away that genetic component and maybe that infection that never went away passes on through like every other cold did. Maybe that bout of fatigue that stayed and got worse resolves with rest this time. It may take one factor to tip the system into the situation we call ME/CFS. That factor could lie in our genes.

First Line of Immune Defense Down

This grant will help determine if altered FcRs (e.g. CD16) on natural killer (NK) cells have made it more difficult for ME/CFS patients t0 fight off viruses.  NK cells are the cells our immune system uses to hold the invader at bay while cytotoxic T-cells and B-cells gear up to wipe out the invader.

We know that poorly functioning NK cells could be allowing pathogens to get entrenched more deeply into ME/CFS patients’ systems, perhaps even into immunologically privileged parts of our nervous system that the big guns of our immune system have trouble getting to.

Second Line of Immune Defense Down As Well?

pathogens

Could ME/CFS genetics be giving pathogens the upper hand in ME/CFS?

It turns out, though, that natural killer cells not only play a vital role in the first lines of our immune defense – they also play an important role in fighting off chronic infections. This study suggests NK cell problems in ME/CFS may also be allowing chronic viral infections to persist.

During an infection, B-cells start pumping out IgG antibodies that attach to and stop pathogens from infecting our cells. Once IgG antibodies have attached to a pathogen, NK cells are able to recognize, attack and kill cells infected with pathogens through FcRs, using a process called ‘antibody-dependent cell-mediated cytotoxicity’ (ADCC).

Studies have shown that individuals with genetic alterations (polymorphisms) of the genes associated with that ADCC response have an increased risk of cancer and autoimmune disorders. Genetic impairment of the ADCC response could also make it more difficult to clear herpes viral infections, which are of such interest in ME/CFS.

A Talk With Isabel Barao Ph.D

Dr. Barao is Adjunct Assistant Professor at UNR’s Department of Microbiology and Immunology and Scientific Director of Simmaron Research.

How did you get involved in ME/CFS research?

In 2009, the Whittemore Peterson Institute (WPI) invited me to be their scientific consultant and to find out why NK cells are dysfunctional in CFS. I conducted immunological studies at the WPI until September of 2010.

What has your research into ME/CFS told you about this disease thus far?

Isabel Barao Ph.D

Isabel Barao Ph.D

I believe that variations in particular genes that affect the functioning of the immune system increase the risk of CFS.

You recently presented a paper at the 1st Annual Mountain West CTR-IN meeting suggesting that ME/CFS patients may have higher than normal levels of “hybrid” immune cells. Can you tell us what those immune cells are and what effects they might have?

The ‘hybrid’ lymphocytes are NKT-like cells that are increased in the blood of some of Dr. Peterson’s CFS patients and that may have unique properties in CFS patients.

We are characterizing these immune cells further.

You’re also engaged in a Simmaron Research Foundation study examining genetic changes in a range of immune cells in ME/CFS. Most ME/CFS research has focused on natural killer cells but you’re also really interested in other immune cells. Why?

Because NK cells communicate with B cells, T cells, macrophages, etc. and if the communication between them is defective, immune deregulations involving all these cells can occur and lead to disease. 

What comes next and what are the treatment implications if the study is positive?

Our expectations are that FcRs polymorphisms define CFS and its severity and predict those patients who may benefit from ADCC-based therapies.

Read more about Isabel’s work at Simmaron Research Foundation Study Targeting Roots of Immune System Breakdown in Chronic Fatigue Syndrome (ME/CFS)

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Simmaron Foundation’s Immunology Workshop: the Forefront of Diagnosing and Treating ME/CFS

Simmaron’s Immunology Workshop on ME/CFS, Part I

survey

Immunologists came to the Simmaron Foundation’s Immunology Workshop to decide if immune tests should be standard practice in ME/CFS diagnosis and treatment

Immunologists came to the Simmaron Foundation’s Immunology Workshop to decide if immune tests should be standard practice in ME/CFS diagnosis and treatment.

Simmaron Research Foundation is focused on redefining ME/CFS scientifically. They produced the Immunology Workshop at the 2014 IACFS/ME Conference in order to get a consensus from immunologists and practitioners on whether immune testing should help guide diagnosis and treatment in Chronic Fatigue Syndrome (ME/CFS). Immunologists were invited to give presentations and then queried regarding whether immune tests should be incorporated into diagnostic protocols for this disorder.  Dr. Unger, the head of the CDC’s CFS program, was invited to attend.

Overviews of  some of the presentations make up Pt I of the Immunology Workshop Overview.

(I used my notes from the Workshop to build the foundation for this blog and then expanded on many of the subjects presented; i.e. the blog reflects my interpretation of the presentations and what they mean; it may not in places reflect the presenters viewpoints.)

Troy Querec, Ph.D, CDC – Natural Killer Cell Testing 

The CDC ignored natural killer (NK) cell functioning in ME/CFS for many years, but they appear to be convinced now that it’s a key problem.

Natural killer cells are called ‘natural killers’ because they don’t need to be activated to kill cells that don’t have the right MHC markers on them. They are also the only immune cells that can recognize infected cells without antibodies and MHC markers being present.

medical tests

The NK cell function test that reveals how effective NK cells are at killing invaders is laborious, expensive and, according to an NSU presentation at the IACFS/ME conference, not suited to most labs.  (This isn’t the first immune test relevant to ME/CFS that has not been readily available. Most of the tests associated with the RNase L enzyme are still available only at one lab in country.)

Recognizing the need for your average doctor to have access to a less expensive test of NK cell functionality, the CDC is working on one. (They’re not the first. The Klimas/Fletcher group in Miami was reportedly working on one several years ago.)

They’re focusing on measuring how effective the receptors found on the surface of NK cells are at turning the cells on. Receptor deficiency could play a role in the poor NK cell functioning found in ME/CFS. To that end they’re developing CD 107 antibodies that attach to the receptors.

Because shipping has also been shown to reduce NK cell viability, they’re also proposing ways to optimize NK cell viability during the shipping process. This involves keeping cells in their natural habitat – the whole blood – and isolating PMBC’s first. They propose a pilot study to determine ways to optimize viability of NK cells during shipping.

Finding an easier and more effective way to measure NK cell functionality would go a long way to establishing NK cell dysfunction as a biomarker for ME/CFS.

Dr. Constance Knox – B-cells and Chronic  Fatigue Syndrome

“Lots of vacuums in this field” 

After noting how little we know about the role B-cells play in ME/CFS, Dr. Knox echoed Mady Hornig’s statements that there are “lots of vacuums in this field” and then went onto a short overview.

A cornerstone of our immune defense, B-cells directly ‘attack’ pathogens and trigger other parts of the immune system to respond.

B_cell_activation

B-cells could be a major contributor to ME/CFS but the role they play is largely a mystery

First, they are activated by antigens (proteins associated with pathogens) brought to them by macrophages and dendritic cells – two innate immune cells. B-cells then produce hordes of pathogen specific antibodies that search for the pathogen outside the cell and attach to it in order to prevent it from attacking our cells. They also take that antigen and present it to killer T-cell’s which then mount a pathogen specific defense which gets at pathogens located inside the cell.

Two recent findings have overturned medical dogma concerning B-cells.

Naturally Occurring Antibodies: At one time it was thought B-cells only produced antibodies that were directed at specific invaders, but it’s now clear that naturally occurring antibodies – which are not directed at specific pathogens – are present as well. These antibodies are derived from unusual sugar residues synthesized in the gut – an interesting finding given the emphasis both Dr. Hornig and Dr. Lipkin place on the gut in ME/CFS.

Regulatory B-Cells – Cells regulating the powerful T-cell response (T-regulatory cells) received most of the attention until regulatory B-cells were discovered. Regulatory B-cells make up only 0.5% of total B-cells but are powerful regulators of immune activation and inflammation. They induce two important anti-inflammatory cytokines (IL-10, TGF-beta), which dampen the inflammation produced by the innate immune system.

b-cell signaling

Problems with B-cell signaling would pose problems for other parts of the immune system.

IL-10 restores Th1/Th2 balance (a problem in ME/CFS) and inhibits inflammatory cascades while TGF-B wipes out some types of T-cells, dampens the activity of cytotoxic T-cells, and takes other actions to reduce inflammation. These cells often get upregulated in states of chronic inflammation and elevated levels of both have been found in ME/CFS.  (They suggest the immune systems of ME/CFS patients are attempting to reign in inflammation.)

Research  is need to determine if either cell plays a role in ME/CFS, but several ongoing studies may give us clues regarding the role B-cells play. Rituxian (Rituximab) – an monoclonal antibody directed against mature or activated B-cells – reduces B-cell numbers. (A successful result in Rituximab trial could indicate B-cells in ME/CFS are triggering an autoimmune response or could implicate EBV infection.)

A 2011 study documenting increased rates of lymphoma in ME/CFS patients suggests more problems with B-cell regulation may  be present in a subset of  patients.

David Baewer, M.D., Ph.D – Serology and HHV-6 Infections

Most humans carry latent herpesviruses in their cells that do little harm. Once activated, though, in people with poorly functioning immune systems such as transplant patients, these seemingly innocuous viruses can cause enormous damage. With their immune systems intentionally knee-capped in order to avoid an immune attack on their transplanted organ, they are ripe for herpesvirus activation. Several antivirals under development that could assist some people with ME/CFS come from research devoted to preventing herpesvirus activation in transplant patients.

herpesvirus

Some researchers believe herpesvirus activation is common in ME/CFS -but that the typical virus tests are not up to the job.

Dr. Baewer proposed that the same  general processes causing herpesvirus reactivation in transplant victims is occurring in ME/CFS. Standard testing for herpesviruses, however, is unable to distinguish the kind of active herpesvirus infections he believes are present in ME/CFS.

He noted that primary active infections – which occur when the body is first introduced to a pathogen – are often diagnosed via a high IgM response.

The kind of herpesvirus infection suspected in ME/CFS, however, (and the kind that mostly occurs in adults) involves reactivation from a latent infection. Because these kinds of infections rarely generate a robust IgM response, Dr. Baewer asserted IgM readings in adults have little clinical value.

Viral DNA with PCR isn’t effective either because it only tells us if the virus is present and it is present in 95-100% of population.

Viral mRNA using reverse transcriptase PCR, on the other hand, shows whether the virus replicating or not.  This type of testing tells which genes in herpesvirus genome are present in the blood – and identifying which genes show up is the key to determining whether the virus is actively replicating or not.

Herpesviruses need to be able to attack and establish themselves in B-cells, ward off the immune system’s efforts to find them and then replicate when the time is right. They are complex viruses with big genomes that have genes associated with maintaining latency, with altering the immune response and with building new viruses. Viral mRNA using reverse transcriptase PCR can identify which stage the virus is  in.

gene

Tests can reveal which stage of its lifecycle EBV is in. Unfortunately, those tests are rarely done in ME/CFS patients

If there is evidence of genes associated with latency, but nothing is present, the virus is simply maintaining latent state. If genes produced later in its life cycle are found, the virus is active but not replicating. If genes devoted to building the outer membrane of the herpesvirus are present – you have an active, replicating virus on your hands.

(The fact that Epstein-Barr virus can hijack the nuclear machinery in B-cells and go through its early, medium and late cycles without ever replicating suggests it can cause much mischief simply sitting in B-cells.  We know that in order to maintain latency, EBV affects how B-cells, a critical part of the immune machinery, function.  We know EBV increases the lifespan of B-cells and that it prompts them to replicate. Some researchers believe EBV’s effects on B-cells underlie all autoimmune processes in the body. )

The smoldering herpesvirus infection hypothesis in ME/CFS produced by Dr. Lerner and researchers at Ohio State University proposes EBV is perturbing immune cells and causing immune cell dysfunction without causing cell death, while producing only very low levels of viral transcription.

Because herpesvirus serology tests will not pick up this type of infection, however, it will never be picked up by standard serology tests.

(to be continued…)___________________

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The Immunology Workshop – Redefining how ME/CFS is diagnosed and treated

Simmaron’s Immunology Workshop Participants

  • Daniel Peterson, M.D. Sierra Internal Medicine, Incline Village, NV
  • Nancy Klimas, M.D. Ph.D Nova South Eastern University, Miami, FL
  • Paula Waziry, Ph.D Nova South Eastern University, Miami, FL
  • Sonya Marshall, Ph.D Griffith University Gold Coast Australia
  • Sharni Hardcastle, Ph.D Griffith University Gold Coast Australia
  • Konstance Knox, Ph.D., Founder, CEO, Coppe Healthcare Solutions
  • David Baewer, M.D. Ph.DMedical Director, Coppe Healthcare Solutions
  • Isabel Barao, Ph.D., Research Assistant Professor, University of Nevada, Reno, Simmaron Research Scientific Director
  • Gunnar Gottschalk, B.S., Simmaron Research, Incline Village, NV
  • Troy Querec, Ph.D., Associate Service Fellow, Centers for Disease Control and Prevention, Atlanta, GA
  • Dennis Mangan, Ph.D., Former Chair, Trans-NIH ME/CFS Research Working Group, Office of Research on Women’s Health, U.S. National Institutes of Health
  • Mary Ann Fletcher, Ph.D., University of Miami Miller School of Medicine Professor of Medicine, Microbiology/Immunology and Psychology
  • Elizabeth Unger, M.D. Ph.D., Chief, Chronic Viral Disease Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases. Centers for Disease Control and Prevention, Atlanta, GA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


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Simmaron Research Foundation Study Targeting Roots of Immune System Breakdown in Chronic Fatigue Syndrome (ME/CFS)

June 13, 2014

Simmaron Research’s  new immune study builds on exciting research that is changing how we think about ME/CFS.

Twenty years ago  the internationally known virus hunter, Dr. Ian Lipkin of Columbia University, didn’t find Borna Virus in people with ME/CFS, but he never forgot the immune dysfunction he found.  Twenty years later he found more immune dysfunction in another study.

Isabel Barao, PhD, Simmaron Research Scientific Director

Isabel Barao, PhD, the Simmaron Research Foundations Scientific Director believes a genetic predisposition to immune problems could underlie ME/CFS

He doesn’t know why it’s there but he does believe that all ME/CFS cases – no matter what pathogen or other factor has triggered them –  devolve to a ‘common pathway’. The fact that pathogens of all types – from Epstein-Barr Virus, to SARS, to Giardia – can trigger ME/CFS suggests a core immune deficiency lies at the heart of the illness.

Every genetic study suggests an inherited susceptibility to Chronic Fatigue Syndrome is present. Dr. Mady Hornig of the Center for Infection and Immunity at Columbia University believes that a genetic predisposition in combination with an environmental trigger (such as an infection) occurring at just the right (wrong) time is probably key to coming down with ME/CFS.

For thirty or forty years you might be able to easily slough off this bug or that pathogen, but at some point for some reason the stars aligned; you were depleted in just the right way, the pathogen hit and with your immune system genetically predisposed to crack under the pressure – it did – and your entire system faltered.

gene strand

Simmaron is looking for the genetic roots of an immune system breakdown

Simmaron Research’s next pilot study is looking for that immune crack in the dike – the genetic underpinnings of the system collapse that occurred. Led by Simmaron’s Scientific Director, Isabel Barao, PhD, in collaboration with researchers at the National Cancer Institute and University of Nevada Reno, it will determine if your NK and B-cells and macrophages are genetically predisposed to respond poorly to a virus, toxin, or cancer cell.

Dr. Barao is studying whether people with ME/CFS have polymorphisms – unusual gene formations – that make their key immune cells less likely to respond well to viruses and other threats. That immune ‘hole’ many people have talked about with regards to ME/CFS could start here. We all know about the rampant NK cell problems in ME/CFS, but this study could help explain the B-cell problems recently uncovered in a German research study – and perhaps even shed light on why Rituximab may be working in some patients.

It’s the initial part of a projected three-part study that could end with drugs for ME/CFS. Once genetic alterations have been found, they’ll be correlated with immune findings. If that holds up, it’ll  be time to look for drugs to fix the problem, two of which are currently in clinical trials.

We-Have-Ideas

Support the Simmaron Research Foundation as it redefines how ME/CFS is understood and treated

Think about it. The high heritability rates in ME/CFS indicate genetic problems exist somewhere. Where better to look than the immune system?

This study is a no-brainer to me. It’s relatively cheap – it has a quick six-month turnaround – and the data it produces will lay the foundation for an NIH grant on topics they’ve  shown they’re willing to fund.

Help us redefine ME/CFS.  Support breakthrough science on immune deficiencies at Simmaron.

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