Drug Topics - January 28, 2008 - (Page 23) 23 three minutes, or engage in activity for five minutes then rest for 15 minutes. The number of activity minutes can gradually be increased as long as it is followed by rest that is equivalent to three times the number of minutes of exercise. Additional key self-care options include: •Reducing stress, both mental and physical. A daily routine that avoids emotional stress may be beneficial. Adding in a time to relax is also important for CFS patients. •Maintaining good sleep habits and getting adequate sleep. •Maintaining a healthy lifestyle by eating a balanced diet, drinking plenty of fluids, and limiting caffeine intake. •Avoiding alcohol. •Quitting smoking and any substances of abuse. Table 3 CFS resources Chronic Fatigue and Immune Dysfunction Syndrome Association of America (CFIDS). www.cfids.org This association is dedicated to helping patients with CFS as well as providing resources to healthcare professionals who may be treating CFS patients. Centers for Disease Control & Prevention (CDC). www.cdc.gov Information is available under the disease and conditions section at the Web site. Information is provided for patients, caregivers, and healthcare professionals. Pharmacotherapy and other treatment options Several categories of medications may be beneficial in symptomatic relief for the patient. These include, but are not necessarily limited to: analgesics, antidepressants, stimulants, vitamin supplements, and medications for insomnia. There are no defined treatment algorithms specifically for CFS patients. The purpose of implementing pharmacotherapy is to treat the symptoms and any secondary diagnosis such as depression. For pharmacotherapy guidelines, see Table 2. Core principles of pharmacologic treatment for CFS patients, regardless of what symptom is being treated, include: •Minimize the use of multiple medications as some CFS patients are more sensitive to medications. Medications that may help relieve more than one symptom such as depression and sleep may be a better choice for these patients. •Start with a low dose and increase slowly, therefore minimizing any sensitivity reactions commonly experienced by CFS patients. •A systematic approach to medication therapy may be important as CFS patients may require trials of multiple different medications. What works for one CFS patient may not work for another. Considering the above primary pharmacologic treatment goals, the pharmacist should be familiar with the following general areas as common treatments sought by the CFS patient. Many CFS patients experience some sleep disturbances despite feeling very tired. The more common sleep complaints include multiple different symptoms of insomnia including the inability to fall asleep, frequent awakening, vivid dreaming, and periodic limb movement or nocturnal myoclonus. Pharmacists may interact with CFS patients either looking for an over-the-counter remedy or presenting to the pharmacy with a prescription for one of the sleep medications. Pharmacists counseling patients on sleep products should counsel patients on developing a routine of good sleep habits. These include utilizing a consistent bedtime routine with winddown time; avoiding caffeine, alcohol, and tobacco; and controlling noise, light, and temperature. Patients should also try to avoid napping during the day. Ideally, following the sleep habits should minimize the use of medications. The over-the-counter sleep products may be appropriate for these patients if the patient still experiences sleep disturbances despite employing good sleep habits. The initial antihistamine- National Chronic Fatigue Syndrome and Fibromyalgia Association (NCFSFA). www.ncfsfa.org This site provides information to patients and physicians as well as listing some research information. based over-the-counter sleep products may be an adequate choice provided the patient does not have any contraindications to taking these products. It is important to counsel patients on the side effects of the over-the-counter sleep products, particularly as it relates to excess sedation, decreased mental alertness, dizziness, and confusion as CFS patients may already suffer from some of these symptoms. As always it is important to rule out other sleep disturbances such as narcolepsy or sleep apnea. A sleep survey is helpful for not only sleep assessment, but also can assist in monitoring the effectiveness of sleep medications or other non-pharmacologic sleep management interventions. CFS patients can also present with a combination of pain symptoms. These can include different types of musculoskeletal pain symptoms. Patients can present with one or a combination of myalgias, arthralgias, and allodynia. Patients can also complain of headaches and a generalized feeling of hyperalgesia. Nonpharmacologic treatment options include massage, heat, relaxation techniques, stretching, exercise, and hydrotherapy. Some patients have also benefited from acupuncture treatment. Pharmacologic treatment can be initiated with the over-thecounter products including acetaminophen or NSAIDs for mild pain symptoms. Prescription pain relief for CFS patients is not different than treatment for other pain patients and can include sending the patient to healthcare professionals specializing in pain management. Following a pain management algorithm is beneficial in treating and monitoring the patient’s pain management appropriately. Patients with CFS, like other chronic illness patients, may develop depression secondary to CFS. Some reports have indicated that almost 50% of CFS patients developed depres- http://www.cfids.org http://www.cdc.gov http://www.ncfsfa.org
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