Post
by Paper_Nanny » Wed Aug 03, 2011 10:00 am
Thanks for the condolences on the death of my dog.
I have completed one of the aforementioned homework assignments- the review of my medications by a sharp pharmacist. I modified the assignment, though, and had my medications reviewed by a sharp rheumatologist.
I had a very long, very interesting appointment with my rheumatologist (MR) yesterday. He is the physician treating my fibromyalgia and also the one who had sent me in for my sleep study. I had him do a thorough review of my medications, focusing on the question: What is this medication doing to my sleep?
Before I get into what he said, I need to give a brief summary of his explanation of fibromyalgia. FM is a disorder involving two key features. The first is that FM involves a disorder of sleep architecture, most significantly, a lack of deep sleep. The second is that a brain affected with FM does not process pain signals in the same way that a nonaffected brain does. The question of which is the cause and which is the effect is a question that has been widely debated amongst those specialising in FM.
MR and I talked some yesterday about the REM suppressing effects of some of the medications I take. His position on that is that from a practical stand point, it doesn’t really matter. If people are deprived of REM sleep, he said, they will eventually start hallucinating and that seems to be the only significant problem of REM deprivation. Obviously, my REM sleep deprivation hasn’t crossed that line In other words, since I am not experiencing symptoms of REM deprivation, we need not be particularly concerned with that.
What we do need to be concerned with is the lack of deep sleep. During stage 4 sleep, the pain regulatory part of the limbic system is rested. Functional MRI studies have shown that during stage 4 sleep, that area of the brain is inactive. Through mechanisms we don’t yet understand, it is being restored. When the pain regulatory part of the limbic system is discharging at night, it underperforms during the day. The pain component of FM is a sign of the underperformance.
MR said there is no way to restore or correct the abnormal sleep architecture in someone with FM. So, treatment focuses on decreasing pain and correcting the abnormal brain chemistry- the levels of serotonin and norephinephrine (NE). Those two factors are intertwined with each other, so separating them is somewhat artificial.
Flexeril, cymbalta, klonopin, neurontin, trazadone, and zanaflex, along with the soma and ultram I take prn, all decrease the pain level. Because there is more than one inhibitory pathway, a combination of medication is needed for effective pain management.
Some of those medications also work to normalize brain chemistry by working on the serotonin and NE pathways. Some of them may be suppressing REM sleep, but, more importantly, none of them are interfering with stage 4 sleep.
He did suggest one medication change for me, which is a change from cymbalta to savella. Cymbalta increases serotonin and NE at a ratio of 3:1. Savella increases at a ratio of 1:3. He said it is possible that since savella has a higher increase in NE, it may work better for fatigue. If this is true, it may allow me to reduce or completely eliminate the methylphenidate and provigil that I take.
MR is also going to set up a referral to a sleep specialist in another part of the state who has used xyrem to help normalize the sleep architecture in people with FM. Because of the potential for abuse and misuse with xyrem, physicians much have specific training to prescribe it. The sleep specialist to whom I will be referred is the only one MR knows of in this area who is able to prescribe it.
I was so focused on finding a pharmacist to give me information about my medications that I had completely forgotten about MR as a resource in that area. In my opinion, he is an excellent physician. He is very knowledgeable about all aspects of FM. He takes time to answer all my questions. He gives as much detail as needed for me to be satisfied with the answers. He also explains any parts of his answers that I don’t completely understand, filling in whatever background information is needed. He has a good sense of humour and he is easy to talk to.
Deborah
PR System One BiPAP Auto SV Advanced
