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A Novel Nutriceutical Treatment of ME/CFS. Frank Comhaire. Sept 2017

Discussion in 'BioMedical ME/CFS Research' started by Trish, Nov 15, 2017.

  1. arewenearlythereyet

    arewenearlythereyet Senior Member (Voting Rights)

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    Thank you for taking the time to reply and to provide more detail on your views on the disease.

    I think context is definitely key in terms of claims associated with any nutritional supplement.

    I personally take many of these and have got some improvements in symptoms from things like B vitamins and mitochondrial support supplements. However I would say that the use of these are mainly around symptom relief to improve quality of life while I'm sick.

    These treatments haven't moved me forward in terms of improving my capability, they have just eased things like brain fog, and reduced the duration of PEM episodes slightly. I am pretty certain that my energy envelope hasn't increased since I've been measuring heart rate activity and steps before and during taking the supplements.

    It's really important to stress that this is for symptom relief/ quality of life rather than to give people more energy and feeling less fatigued which could be misleading to many desperate sufferers who are looking for a "cure"particularly with the confusion around the name ( as you mention in your paper).

    That is why I hope with future studies you might include the wider aspects of the disease and perhaps use activity and cognitive measurements. It would also be good to see if people's energy envelope did increase or whether it remains unchanged with measures such as constant heart rate monitoring to give an objective measure of activity before and after supplementation. This would also show up PEM episodes so the frequency of these vs activity could then be also captured? I also found that initial supplementation took a while to settle down (6-8 weeks) and in the case of B12 this took a long time (6 months). Longer term studies would be helpful to see what is going on in terms of continuous supplemental therapy. It's also worth noting that pacing activity in a lot of cases will control a lot of symptoms without supplementation so this would need to be a control.

    I hope you find these critiques useful and hope you will post some more of your findings.
     
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  2. Valentijn

    Valentijn Moderator Staff Member

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    Yes, fatigue is nothing to me. It's not pleasant, but I can ignore it. I can't ignore PEM or more immediate muscle weakness and orthostatic intolerance.

    I love it when I get a cold - I feel more fatigued, but my capacity for activity improves a bit, and I can do more than usual. I feel yucky and grumpy due to the cold, but that doesn't stop me from doing anything in the slightest.
     
    Last edited: Nov 21, 2017
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  3. Scarecrow

    Scarecrow Senior Member (Voting Rights)

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    The SF-36 was also used. The author noted:
    This information could only have come from the SF-36 but I don't know how brain function relates to that questionnaire.
     
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  4. Scarecrow

    Scarecrow Senior Member (Voting Rights)

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    For me, the problem with ignoring fatigue is that it inevitably leads to even more fatigue and cognitive incapacity and if I continue to ignore that fatigue, then I can add pain and physical incapacity on top.

    It's difficult not to see the connection.
     
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  5. Wonko

    Wonko Senior Member (Voting Rights)

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    For me there is a difference between fatigues.

    On 2 or 3 occasions in the last few years I have been well enough to get physically fatigued, presumably the type that most people experience after a few hard workouts or several days hard physical work. I remember it, from when I was relatively "healthy" and could do things that caused fatigue. Of course it doesn't take as long to get there these days but this type of fatigue feels good, at least to me.

    Then there's the other type, the ME type.

    The problem, it seems to me, is that there is only one word to describe both, and any attempt at finding other descriptors fails because people hear words, their minds drop into the slot marked "fatigue - I know what that is" and never leaves - it's a "new" concept and people don't do well with them, until they experience them personally. This appears to be the way people are, hardwired, new things can only be referenced in relation to old/known things.

    Then there is PEM.

    If people/researchers/scientists/etc. are simply trying to "fix" the first/normal type of fatigue - this doesn't help us/me, as it's not the problem, it's not what we experience.
     
  6. Scarecrow

    Scarecrow Senior Member (Voting Rights)

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    All the patients you recruited were ill for more than five years. Of those who you considered responders, have any of them been able to resume their former occupations or studies or are they otherwise engaged in any activities that they were unable to do before treatment?
     
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  7. Scarecrow

    Scarecrow Senior Member (Voting Rights)

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    For the avoidance of doubt, I don't think measuring fatigue is ideal, especially when the treatment isn't blinded but as ME/CFS has pointed out this is a preliminary study.

    @ME/CFS, many people have made suggestions about objective measures that you could use in a future trial. Can you say if you intend to incorporate these tools or any others that you may already have been considering?
     
    Last edited: Nov 21, 2017
  8. Trish

    Trish Senior Member (Voting Rights)

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    @ME/CFS, thank you again for engaging with us in discussion about your research. I think you are right to remind us that the published study under discussion here is a very preliminary test of concept, not a claim of efficacy. I am interested to hear that you are now doing a second stage trial with a larger group of patients.
    ...........................

    I hope you understand that we are wary of trials where questionnaires are used as the primary, or only, outcome measures.

    Fatigue is not the core symptom of ME/CFS. PEM is the core symptom.
    PEM is what prevents us being more active, not fatigue.

    The SF-36 physical functioning scale is also of limited value, as our symptoms fluctuate, and there is a subjective element in how it is filled in.

    Subjective improvement is of very limited value to ME/CFS sufferers unless there is also objective improvement in energy capacity, as measured by either actometer or a biomedical measure of cellular energy metabolism.

    We have suffered, as you are aware, from a long history of CBT/GET trials that falsely claimed improvement and even recovery using subjective 'fatigue' and 'physical functioning' questionnaires as primary outcome measures.

    It is therefore not surprising that any unblinded trial with subjective outcome measures, whether of a psychological therapy, nutriceutical or drug, will be judged as of very limited value by this well informed, science/evidence focused patient community.

    .................................

    I do not understand why, when there are objective measures like actometers available, some researchers choose not to use them. We have been hurt badly by this in the past, particularly in the PACE trial, where the approved protocol specified actometers to be worn by patients at the start and end of the trial, and this was dropped by the researchers without adequate justification. (Other smaller trials have shown that subjective improvement was not matched by actometer measured improvement. We suspect this influenced the PACE decision).
    .....................................

    It might help us understand your approach if you could spell out whether you are seeking to develop:

    a) a symptomatic treatment for subjectively measured symptoms such as fatigue,

    or

    b) a treatment that reverses the energy deficit and significantly increases the energy envelope in ME/CFS patients while preventing or significantly reducing PEM.

    If it is the former, it is worth being open about this. It doesn't make the treatment worthless as a symptomatic treatment, alongside pain medication and sleep medication that some patients use, but it could not be claimed to reverse ME/CFS.

    If it is the latter then it seems to me to be imperative that you use a primary outcome measure that actually measures the patient's ability to make and use energy sustainably and without triggering PEM. Wearing actometers that measure pulse rate and steps throughout the trial seems the logical way to do this. Blood tests to look for alterations in the energy metabolism of cells would add to the strength of your evidence.

    Even if in a final stage trial you then move on to using double blinding, the case for your treatment would be hugely strengthened by the use of objective outcomes.
     
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  9. Valentijn

    Valentijn Moderator Staff Member

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    I didn't realize the file you uploaded was a different study you co-authored. I appreciate that you seem to view ME as an immune disease and reject the psychosomatic paradigm and treatments. Though I don't think your beliefs regarding the influence of psychosocial factors such as stress, emotion, profession, socioeconomics, personality, education, or stress management skills are supported by quality research:
    cromhaire diagram.jpg

    I'm glad you reject CBT, but I think you overestimate the role which stress-management can play as a treatment:
    And exercise of any sort is rarely helpful, especially as patients by definition must have exercise intolerance. If that exercise intolerance is noticable enough to be diagnosed, they probably don't have spare energy for swimming or other activities. Any exercise added comes at the expense of other activities, typically ones essential for daily living. If I were well enough to do water aerobics at all (I'm not), it would mean I wouldn't be able to cook dinner, shower that weak, or sit down on one of my garden beds to do 10 minutes of weeding. I also note a lack of citations to support your following statements:
    You also use that paper (described as an opinion piece) to market several supplements from a single website. Some already exist, and apparently the new one is to be called "Improve". Looking at the ingredients from other supplements there, algae does indeed seem likely to be the secret ingredient not mentioned in your newer paper :p

    This is an extraordinary claim, and I have seen no evidence at all to support it any of it:
     
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  10. TiredSam

    TiredSam Moderator Staff Member

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    @ME/CFS are you working on anything to help ME sufferers whose stress management skills are just fine, who like the occasional glass of wine, and who avoid all exercise so that they don't make their condition worse? That would be great.

    By the way, I have absolutely no interest in mindfulness, Zen-yoga, Zen-anything, transcendental meditation (is that the one where you bounce up and down and delude yourself that you're levitating - seriously? For ME sufferers?) or positive thinking or anything else like that. I have a fairly grumpy outlook on life. I hope this doesn't reduce my chances of benefitting from your research. It's certainly never stopped my bones mending, colds going, or any other ailments getting better.
     
  11. Sid

    Sid Established Member

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    I'm surprised to see water aerobics recommended for ME/CFS. Personally, no activity makes me weaker and more orthostatically challenged than being in a bath, jacuzzi or swimming pool, presumably due to vasodilation and thus severe worsening of orthostatic intolerance, a very common and disabling symptom of ME/CFS.
     
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  12. Perrier

    Perrier Established Member

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    This is well articulated. Fatigue is NOT the central symptoms. Doctors please take note.
     
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  13. ME/CFS

    ME/CFS New Member

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    when reading further comments, I notice that everyone is looking at his own story. I have given general recommendations based om my clinical experience in a rather important number of patients, many of whom I follow and try to help since several years. The nutriceutical suggestions made in my previous paper (on Systemic Immune Disorder) do NOT concern the new development described in my recent paper. It is hard to discuss if the commentators do not read the publications carefully.
     
  14. Wonko

    Wonko Senior Member (Voting Rights)

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    @ME/CFS

    It's hard to read the publications carefully. and I presume you also mean understand them, if cognitive impairment is an issue, which it is, for many.

    It is not currently possible for me to read either of the papers posted, either by Trish, or by you, they may be the same paper, they may not, I cannot determine even that ATM. From a quick visual scan neither is particularly friendly from a cognitive point of view.

    So I am forced to go off what others say about it, this is not unusual, either for myself or for others on an ME forum.

    We have some members who do not have as severe cognitive issues, they dumb things down for me, and others, so we can get an idea of what's going on.

    I wouldn't let it discourage you

    edit - they are not the same paper.
     
    Last edited: Nov 21, 2017
  15. Trish

    Trish Senior Member (Voting Rights)

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    Hi @ME/CFS, I think you have to allow us a bit of leeway. We are, after all, individual patients who have close knowledge of our own story and like to share this. That's the nature of patient forums.

    We also, as ME sufferers, have limited ability to concentrate and read scientific papers.

    Any thread in the forum is open to any member to comment in any way they like, it is not a controlled discussion between scientists.

    Some members have scientific training, and vast experience of reading ME research papers, others are not scientifically trained or have less knowledge of how science works. We try to help and support each other in learning together.

    We are always grateful when scientists join us in discussion, but hope they will understand both our wide variation in experience and our limitations.
     
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  16. TiredSam

    TiredSam Moderator Staff Member

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    Filling in a subjective questionnaire is just someone looking at their own story. Collecting lots of subjective questionnaires is collecting a lot of own stories. If you assign numbers to a lot of people's subjective reported feelings and then perform operations on those numbers it doesn't raise anything above the level of a bunch of subjective own stories.

    Once you start making objective measures you can start taking the scientific high-ground if you like.

    Without objective measurements that is a subjective interpretation of a bunch of annecdotes.

    And really, the fact that you have recommended transcendental meditation in any paper does affect how seriously readers of any of your other papers are likely to take you.

    This is not medicine:



    It is a belief system.

    Surely you don't recommend that any ME patient should ever try this:



    Because it wouldn't relieve stress (on the offchance that ME patients need to, which I don't accept), it would make them crash.

    As a result of the feedback on this thread, can you tell me which objective measures you'll be planning to use in your future studies? It really is a kind of pre-requisite.
     
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  17. strategist

    strategist Established Member (Voting Rights)

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    Are you able to document improvement of PDH or mitochondrial function in responders? There's a device called a Seahorse flux analyzer which has been able to show abnormal energy metabolism in ME/CFS, and I'm guessing that some university in your area might have one.
     
  18. Barry

    Barry Senior Member (Voting Rights)

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    Agreed. In my wife's case a key symptom that I observe in her is lack of power - energy not available to her at the rate her body needs it to be delivered at; like a car with a partly blocked fuel pipe. She can walk slowly, for a while, but gets slower and slower the more she tries. There comes a point if she isn't careful, she doesn't have energy enough left to stand. Through all this process she goes from her "best", of feeling unwell, to much worse, feeling horribly ill. She then needs a day or two to recover again.

    It's not necessarily walking that does it of course. We had our daughter and grandchildren with us recently, which was wonderful, but no matter how careful we tried to be, there were a few days my wife ended up feeling really ill, because her normal pacing routine was disturbed.

    And this is real physical function I'm talking about here, (i.e. as measured objectively), not perceived physical function (i.e. subjective), which PACE, GETSET, etc glibly and misleadingly refer to as "physical function".
     
  19. Barry

    Barry Senior Member (Voting Rights)

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    Trouble with the SF-36 is it only deals with subjective measures, even though naming conventions seem to imply otherwise. e.g. Physical function subscale sounds like it closely reflects actual physical function, but it is of course perceived physical function. The PACE FOI data showed, unsurprisingly, a huge disconnect between the two, but failed to aknowledge that. It would be good for any further trials to not fall into the same trap.
     
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  20. Scarecrow

    Scarecrow Senior Member (Voting Rights)

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    Yes but that's the nature of self-reports.

    The phase III rituximab trial also relied on subjective reports but people were generally happy with the design because the treatment was blinded.

    This is a preliminary study so there isn't a placebo. However, the results help inform the investigators in future trials.

    I don't think we should get too hung up about what we perceive as flaws in this research. Yes there is a patent pending but nothing is being sold off the back of this initial study. Let's see what happens in the future.
     
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