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Kent Holtorf, MD, on Treating Chronic Fatigue Syndrome & Fibromyalgia - An Update
ImmuneSupport. com 03-27-2007
Dr. Kent Holtorf, MD, is Medical Director of the Holtorf Medical Group Center for Hormone Imbalance, Hypothyroidism and Fatigue in Torrance, California.* He specializes in treatment of CFS and FM patients. Question: Dr. Holtorf, in a past article on the effective treatment of Chronic Fatigue Syndrome and Fibromyalgia* * you stated that "individuals with these syndromes have measurable hypothalamic, pituitary, immune and coagulation dysfunction. These abnormalities then result in a cascade of further abnormalities, in which stress plays a role." Could you discuss in detail how you approach testing for and treating these problems in CFS and FM patients? Dr. Holtorf: There is a mixture of underlying causes of Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM), and each underlying abnormality can trigger further problems. This results in a cascade of multiple physiologic abnormalities and a perpetuating vicious cycle. Successful treatment requires that this vicious cycle be addressed on multiple levels. This cascade of abnormalities [beginning with the "Genetic Predisposition" and then "Triggering Event of Physiologic Stress"] is graphically depicted below - and a few of the abnormalities are also discussed.
[ click to enlarge ] Immune Dysfunction If a complete immune panel is done on CFS and FM patients, almost all have immune dysfunction, which often includes poor natural killer cell function and/or high RNAse-L activity. Natural killer cell function. These cells are very important in killing viruses and bacteria. It is very difficult to eradicate chronic infections when these cells are not functioning well. Antibiotics and antivirals do not work well and are often infective if the immune system is not stimulated as well. You are never able to kill all the infectious agents unless the body is able to clean up the residual left by the antibiotic or antiviral. There are a number of methods to do this. What we use depends on the infection present, but includes both natural and pharmaceutical antivirals, antibiotics, immune boosters and immune modulators. Growth hormone, thyroid and cortisol (adrenal hormone) are also very good immune enhancers. Yes, I said cortisol - low doses of cortisol for people who have adrenal insufficiency act as an immune enhancer. Large doses are immune suppressors. Your body normally increases cortisol in times of infection. Oxidative therapies, discussed below, can be very powerful. We customize the specific treatment for the patient. RNase-L activity: In response to infection, the body can produce an enzyme called RNase-L that breaks down the viral RNA to rid the body of the infection. When the infection is gone this enzyme is then turned off. In CFS, however, the presence of chronic infections can result in the stimulation of an abnormal "super" RNase-L enzyme that also breaks down the cell's own RNA that is used to code for proteins and required for normal functioning. The result is poorly functioning cells and an increase in cellular apoptosis (programmed cell death). Treatment consists of eradication of the chronic infection and immune modulators. The RNase-L activity test can be done by Redlabs USA (http://www.RedlabsU SA.com ). (No affiliation) . Coagulation Problems This is diagnosed with a specialized laboratory test that includes soluble fibrin monomer, prothrombin fragment 1 +2, fibrinogen and thrombin/antithromb in complex. Defects are typically treated with heparin and vascular enzymes such as lumbrokinase and serapeptidase to stop the excessive production of soluble fibrin monomers and to help clean up the fibrin already laid down. Eradication of chronic infections is also important, as there is often a chronic infection as the underlying stimulus of the abnormal activation of coagulation. Low Thyroid CFS and FM patients almost always have low tissue levels of thryoid hormones due to hypothalamic and pituitary dysfunction and thyroid resistance, which has been documented in a number of studies. Unfortunately, this hypothyroidism is missed 80% to 90% of the time because standard thyroid tests and TSH [thyroid-stimuating hormone] levels are usually normal, and this is what 90% of doctors are accustomed to using to diagnose low thyroid. Currently, the best method to diagnose low thyroid in these conditions is to look at the T3/reverseT3 ratio. [TSH causes the thyroid gland to produce two hormones: triiodothyronine (T3) and thyroxine (T4).] When CFS and FM patients are treated with thyroid, they are almost always under-dosed because their pituitary dysfunction results in their TSH becoming quickly suppressed, which normally indicates too much thyroid. Because these patients have pituitary dysfunction, one must not rely on the TSH, and not treat based on this parameter. In addition, due to the thyroid resistance, T4 preparations such as Synthroid and Levoxyl cannot provide adequate tissue levels of the active hormone. T4/T3 combinations such as Armour thyroid can be of benefit, but many patients also find that these preparations also do not provide adequate relief. Straight timed released T3 is often the best preparation to obtain adequate tissue levels. Adrenal Insufficiency Standard blood testing will almost always miss this deficiency. Studies show that with sophisticated testing, close to 100% of CFS and FM have adrenal dysfunction and treatment can be very beneficial. To diagnose, we typically use symptoms and a combination of blood sugar, free cortisol, and HgA1C%. Again, one must have a high clinical suspicion and not just think in terms of 'normal' and 'abnormal'. These normal levels are determined for healthy individuals, not the chronically ill, so the cortisol levels should be higher with this illness. 24-hour urine and saliva tests can be done, but these can also result in false positive and false negative results. Growth Hormone Deficiency Many CFS and FM patients are low in growth hormone. This hormone is produced in the pituitary, and with the documented pituitary dysfunction in CFS and FM, it is not unexpected that there is such a deficiency in these illnesses. Treatment can sometimes make a tremendous impact and because the cost has come down significantly in recent years, it is a viable treatment for more patients. IGF-1 is the best indication for growth hormone levels, but again, one cannot use the standard laboratory normal ranges to diagnose. * * * * * Question: Once you've determined which problems a CFS or FM patient has, do you prescribe both traditional and alternative treatments, or do you focus on a single method at a time? Dr. Holtorf: In order to treat these diseases adequately, one must simultaneously use both traditional and so-called alternative treatments. If one treatment were used at a time it would take many years before the patient feels better. Many treatments can be withdrawn as the patient improves. * * * * * Question: Please tell us a little bit about the Holtorf Medical Group, Inc: The Center for Hormone Imbalance, Hypothyroidism and Fatigue (http://www.HoltorfM ed.com) where you practice. Dr. Holtorf: I started the Holtorf Medical Group to concentrate on the treatment of complex endocrine dysfunction, hypothyroidism, fatigue, CFS and fibromyalgia. Eighty percent of our practice is for patients complaining of fatigue, with CFS and FM probably being the biggest part of the practice. * * * * * Question: What are the biggest challenges you face with treating CFS and FM patients? Dr. Holtorf: Although we have good success with CFS and FM, these are challenging cases that require doctors to spend significant time with the patient. It cannot be accomplished with seven-minute office visits. * * * * * Question: What are the biggest successes you've experienced in treating CFS and FM? Dr. Holtorf: Many of these patients are very sick and have given up. It is so gratifying to get these patients back to having a life. They are just so grateful. Many have been unable to work and/or have been on disability and now, following treatment, are happy, functional and productive. * * * * * Question: Are you working on any promising new treatments at this time – either through research or through a trial and error process with your patients? Dr. Holtorf: We are continually working on and implementing new treatments every day in practice. We have been using and refining many of the so-called "new" treatments for many years. For instance, Valcyte is considered a new, novel treatment for CFS, but we have been using it for 4 years, since it was first approved. * * * * * Question: What are the most exciting developments you've seen recently in treatment options for CFS and FM? Dr. Holtorf: Recent developments are taking place in a stepwise manner, but I do not believe it will be through the so- called `mainstream' medicine one-drug cures. I think these are very treatable conditions, and advances will only continue to improve treatment. I do believe, however, that the incidences of CFS and FM will significantly increase and at some point will be considered an epidemic because they are very poorly treated through the standard healthcare delivery system. ____ * For more information about the Holtorf Medical Group's Center for Hormone Imbalance, Hypothyroidism and Fatigue, visit their website at http://www.HoltorfM ed.com or phone 310-375-2705 ** To review Dr. Holtorf's earlier summary article on the effective treatment of CFS and FM, archived in the ImmuneSupport. com library, click here. Note: This information has not been evaluated by the FDA. It is not intended to prevent, diagnose, treat, or cure any illness, condition, or disease. It is very important that you make no change in your healthcare plan or regimen without researching and discussing it in collaboration with your professional healthcare team.
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