Townsend Letter The Examiner of Alternative Medicine
Alternative Medicine Conference Calendar
Check recent tables of contents


From the Townsend Letter
February/March 2008


Literature Review & Commentary
by Alan R. Gaby, MD

Search this site

Acetyl-L-carnitine for fibromyalgia
One hundred and two patients with fibromyalgia were randomly assigned to receive, in double-blind fashion, acetyl L-carnitine (ALC) or placebo for ten weeks. During the first two weeks, patients received daily 1,000 mg orally and 500 mg intramuscularly. During the next eight weeks, the patients received 1,500 mg per day orally. After ten weeks, the improvements in depression, musculoskeletal pain, number of tender points, and total symptom score were significantly greater in the ALC group than in the placebo group. No significant difference was seen between groups after six weeks. ALC was well-tolerated.

Comment: These findings suggest that ALC is an effective treatment for fibromyalgia, although treatment has to be continued for a substantial period of time before improvement is seen. It is probably not necessary to begin treatment with intramuscular injections, as was done in the present study, since orally administered ALC has demonstrated a wide range of beneficial effects, including improvement in memory, fatigue, and Peyronie's disease. While the mechanism of action of ALC is not clear, it appears to function as a neurotransmitter. In addition, the carnitine component of ALC may enhance energy metabolism by promoting the uptake of fatty acids into mitochondria. ALC is generally well-tolerated, although it was reported in one study to cause nausea and vomiting in more than one-quarter of patients with Alzheimer's disease.

Rossini M, et al. Double-blind, multicenter trial comparing acetyl l-carnitine with placebo in the treatment of fibromyalgia patients. Clin Exp Rheumatol. 2007;25:182-188.

Intravenous vitamins and minerals for fibromyalgia
Seven patients with treatment-resistant fibromyalgia, with disease duration of at least eight years, received an intravenous infusion of nutrients once a week for eight weeks. Each infusion contained 400 mg of magnesium chloride hexahydrate, 40 mg of calcium gluconate, 3,000 mg of vitamin C, 1,000 mcg of hydroxocobalamin, 100 mg of pyridoxine hydrochloride, 250 mg of dexpanthenol, 2 mg of riboflavin, 100 mg of thiamine, and 100 mg of niacinamide. The nutrients were administered in 100 ml of normal saline over a period of 20-30 minutes. All patients reported an improvement in pain and fatigue by the second treatment. At the end of the treatment period, there was a 60% reduction in the mean pain severity (p = 0.005) and an 80% decrease in the mean level of fatigue (p = 0.005). No patient reported complete or lasting resolution of pain or fatigue. No side effects were reported.

Comment: In my experience with approximately 30 fibromyalgia patients given a treatment similar to the one described above, some (perhaps 25%) became pain-free (Gaby AR. Altern Med Rev. 2002;7:389-403.). Most of my patients received more magnesium chloride hexahydrate (800 mg vs. 400 mg) and calcium gluconate (200 mg [2 ml of a 10% solution] vs. 40 mg) in their infusion than did those in the present study. In addition, the usual infusion rate for my patients was five to 15 minutes, depending on their tolerance. In contrast, the patients in the present study received the infusion over 20-30 minutes. While there are risks associated with too-rapid infusion of magnesium and other nutrients, the higher peak serum nutrient concentrations that occur with more rapid administration may result in enhanced cellular nutrient uptake and a greater therapeutic effect in some cases.

Massey PB. Reduction of fibromyalgia symptoms through intravenous nutrient therapy: results of a pilot clinical trial. Altern Ther Health Med. 2007;13(3):32-34.

D-ribose for fibromyalgia/chronic fatigue syndrome
Forty-one patients (mean age, 48 years) with fibromyalgia and/or chronic fatigue syndrome received, in open-label fashion, D-ribose at a dose of 5 g, three times per day, for a total of 280 g. Significant improvements were seen in all five visual analog scale categories assessed: energy, sleep, mental clarity, pain intensity, and well-being. The absolute improvement on a 1 to 10 scale for the different parameters assessed ranged from 0.7 to 1.7. Side effects included anxiety (n = 1), lightheadedness (n = 1), and increased appetite (n = 1).

Comment: Fibromyalgia and chronic fatigue syndrome are associated with impaired cellular energy metabolism. D-ribose has been shown to increase energy production in the heart and skeletal muscle by providing a substrate for the synthesis of adenine nucleotide, which is, in some circumstances, a rate-limiting factor for the production of ATP. While the results achieved with ribose supplementation were modest, this compound might be useful when used as a component of a comprehensive treatment program.

Teitelbaum JE, et al. The use of D-ribose in chronic fatigue syndrome and fibromyalgia: a pilot study. J Altern Complement Med. 2006;12:857-862.

Folinic acid for chronic fatigue syndrome and fibromyalgia
Forty-two patients (aged 19-64 years) with chronic fatigue syndrome, with or without fibromyalgia, received 25 mg of folinic acid three to four times per day for one to two months. Thirty-four patients (81%) reported a significant increase in energy level and a reduction in pain within two months. No adverse effects were reported. Responses were seen both in patients with primary fibromyalgia and fatigue and in those whose condition was associated with other diseases such as rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, or multiple sclerosis.

Comment: Folinic acid (5-formyl tetrahydrofolate) is an activated form of folic acid. In certain circumstances, when the conversion of folic acid to its active forms is blocked, folinic acid is an effective treatment even though folic acid is not. In addition, some people have a defect in the transport of folic acid across the blood-brain barrier into the brain, because they make antibodies that block the folate receptors in the choroid plexus. In those people, treatment with folinic acid corrects cerebral folate deficiency by bypassing the folic acid transport mechanism. There is no clear evidence that people with fibromyalgia or chronic fatigue syndrome have a defect in folic acid absorption, transport, or utilization. However, considering the apparent effectiveness of folinic acid in the treatment of these conditions, such a possibility should be investigated. Controlled trials are needed to confirm the efficacy of folinic acid.

Lundell K, et al. Clinical activity of folinic acid in patients with chronic fatigue syndrome. Arzneimittelforschung. 2006;56:399-404.

Preventing complex regional pain syndrome with vitamin C
Four hundred and sixteen patients with 427 wrist fractures were randomly assigned to receive, in double-blind fashion, placebo or vitamin C (200, 500, or 1,500 mg/day) for 50 days. The incidence of complex regional pain syndrome was 76% lower in the vitamin C group than in the placebo group (2.4% vs. 10.1%; p = 0.002). All of the affected patients were elderly women. The incidence was 4.2% in the 200-mg vitamin C group, 1.8% in the 500-mg group, and 1.7% in the 1500-mg group. Thus, vitamin C in doses of at least 500 mg/day decreased the incidence of complex regional pain syndrome by 82%.

Comment: Complex regional pain syndrome (previously called reflex sympathetic dystrophy) is characterized by chronic burning pain, often accompanied by trophic skin changes. It results from injury to a peripheral nerve. The condition is difficult to treat and results in significant morbidity and lost time from work. Previous studies have shown that supplementation with vitamin C reduces microvascular leakage of fluid and proteins following skin burns. Circumstantial evidence suggests that microvascular abnormalities may also be involved in the pathogenesis of complex regional pain syndrome. The results of the present study confirm a previous report that vitamin C supplementation following trauma can prevent complex regional pain syndrome. The authors of this study recommend a dose of 500 mg/day for 50 days, although their data suggest that a higher dose might be slightly more effective. Flavonoids also improve capillary integrity, so supplementation with flavonoids might enhance the preventive effect of vitamin C.

Zollinger PE, et al. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. 2007;89:1424-1431.

Thyroiditis as a cause of chronic fatigue
Two hundred and nineteen patients with a history of chronic fatigue for more than one year underwent fine-needle aspiration of the thyroid gland. Forty percent of the patients had definite histological evidence of chronic lymphocytic (autoimmune) thyroiditis. In the patients with autoimmune thyroiditis, Thyroid Stimulating Hormone (TSH) levels were widely scattered, with a median value of 3.8 mU/L (range, < 0.9 to > 15 mU/L). Administration of levothyroxine to the patients with autoimmune thyroiditis resulted in clinical improvement, irrespective of the initial TSH level. Of note, only about half of the patients with histologic evidence of autoimmune thyroiditis had elevated serum levels of thyroid autoantibodies (peroxidase or thyroglobulin).

Comment: These findings indicate that chronic autoimmune thyroiditis is common among people with chronic fatigue; that patients with autoimmune thyroiditis improve after treatment with levothyroxine, even if their laboratory tests for thyroid function are normal; and that measuring thyroid autoantibodies in the blood will fail to detect thyroiditis in half of these individuals. I have found that clinical evaluation can identify, with a reasonable degree of reliability, those patients with normal thyroid function tests who are likely to show a positive response to thyroid hormone. A careful medical history and physical exam may obviate the need for an invasive thyroid biopsy in many patients in whom hypothyroidism is suspected. (For additional information, see Gaby AR. "Sub-laboratory" hypothyroidism and the empirical use of Armour thyroid. Altern Med Rev. 2004;9:157-179.).

Wikland B, et al. Fine-needle aspiration cytology of the thyroid in chronic fatigue. Lancet. 2001;357:956-957.
Wikland B, et al. Subchemical hypothyroidism. Lancet. 2003;361:1305.

Allergy to folic acid
In a case report, a woman had three episodes of allergic reactions, including anaphylaxis, after ingesting synthetic folic acid. Intradermal testing with folic acid was positive. A graded, blinded challenge with a folic acid solution led to widespread urticaria at a dose of 160 mcg. The patient appeared to tolerate dietary folates (pteroylpolyglutamates).

Comment: Although allergy to synthetic folic acid is rare, it is likely to become a more common clinical entity now that grains are being fortified with this vitamin. Folic acid allergy should be considered in the differential diagnosis of idiopathic anaphylaxis and in patients with suspected grain allergy.

Smith J, et al. Recurrent anaphylaxis to synthetic folic acid. Lancet. 2007;370:652.

Can vitamin D help you live longer?
The risk of dying from any cause was examined in a pooled analysis of 18 randomized trials (including a total of 57,311 participants) of vitamin D2 or vitamin D3 supplementation. In most of the trials, the primary outcome measure was related to the prevention or treatment of osteoporosis or the prevention of falls. The mean vitamin D dose in the trials was 528 IU/day. During a mean follow-up period of 5.7 years, 4,777 deaths occurred. The pooled relative risk for mortality from any cause was 0.93 (95% CI, 0.87-0.99). The relative risk was not influenced by the inclusion of calcium supplements in the trial.

Comment: The results of this study indicate that supplementation with relatively modest doses of vitamin D can decrease the risk of death from any cause by seven percent. Some of this reduction in mortality may be due to prevention of hip fractures, which are associated with a relatively high five-year mortality rate. There is evidence that vitamin D may also reduce the incidence of certain types of cancer. In addition, vitamin D supplementation appears to improve glucose metabolism in people with diabetes and might therefore reduce the risk of fatal diabetic complications such as renal failure and heart disease. In addition to keeping you alive, extra vitamin D may help you maintain a sunny disposition ("Sunshine on my shoulder makes me happy").

Autier P, Gandini S. Vitamin D supplementation and total mortality: a meta-analysis of randomized controlled trials. Arch Intern Med. 2007;167:1730-1737.

by Alan R. Gaby, MD



Consult your doctor before using any of the treatments found within this site.

Subscriptions are available for Townsend Letter, the Examiner of Alternative Medicine magazine, which is published 10 times each year.

Search our pre-2001 archives for further information. Older issues of the printed magazine are also indexed for your convenience.
1983-2001 indices ; recent indices

Once you find the magazines you'd like to order, please use our convenient form, e-mail, or call 360.385.6021 (PST).


Who are we? | New articles | Featured topics |
Tables of contents
| Subscriptions | Contact us | Links | Classifieds | Advertise | Alternative Medicine Conference Calendar | Search site | Archives |
EDTA Chelation Therapy | Home


© 1983-2008 Townsend Letter for Doctors & Patients
All rights reserved.
Website by Sandy Hershelman Designs
March 16, 2008

Order back issues
Advertise with TLDP!

Visit our pre-2001 archives