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Fatigue and AnemiaFatigue and Anemia
           
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Fatigue
Aug 11, 2008

Stimulants... Those used for A.D.D., even ephedrine can these medications help? I am on atripla, for 3 years now. I am having great results with the viral load and my CD-4 being very high! But again, I am so very tired, sleepy.

Has there been a study or is there any one using stimulants to help fight the fatigue.

Response from Dr. Frascino

Hello,

There are many potential causes for HIV-related fatigue. In fact, fatigue is common in HIV-negative folks, but it's much more common in those of us who are virally enhanced. Common potential causes for HIV-related fatigue include anemia, hormonal imbalances, depression, occult infections, medication side effects, etc. You can read about these in detail as well as about some not-so-common causes in the archives of this forum. Have a look! The best treatment for HIV-related fatigue is to identify the underlying cause or causes of the fatigue and specifically treat these conditions. Yes, sometimes stimulants have been used, but side effects are common. If needed, a trial of Provigil could be considered. See below.

Good luck.

Dr. Bob

Provigil Oct 20, 2006

Simple.Whatttay think about the use of the drug Provigil for the fatigue/sleepiness/brain-fog etc,syndromes that we talk about here...It sounds very interesting.Would love to hear your feedback on this. Thanks for all you do. Best Regards Dr.Bob, S.

Response from Dr. Frascino

Hi S,

This topic comes up frequently, as we are all looking for a quick fix for our energy drain. I'll post a few questions from the archives that address Provigil and HIV-related fatigue.

Be well.

Dr. Bob

Tired of HIV, but also just tired Jul 18, 2006

I have looked at a few of your earlier responses to the question of whether or not Provigil is a good drug for HIV fatigue, and you seemed at the time to really not be a fan. Time has passed and it looks like a few studies have shown its effectiveness. What are your thoughts now? I am a 31 year old woman with HIV/AIDS for 14 years. I work full time, take my meds (Truvada and Lexiva), and have done pretty well considering everything. I currently have low level virus and a Tcell count in the 400 range, but I am tired. Not just a little bit, but falling asleep at my desk tired. The fatigue didn't come on suddenly, but has progressed over the last few years. It isn't constant, but is really starting to affect my life. My doctor has ruled out other causes such as hypothyroid, anemia, etc. He suggested medication for 'HIV related fatigue" and offered ritalin type drugs or Provigil. It seems to me like Provigil has fewer side effects and is generally a better tolerated medication than true stimulants. What are your thoughts? Do you still have reservations about the drug? Should I explore other options besides drugs? Thanks for your time.

Response from Dr. Frascino

Hello Tired,

Fatigue in the setting of HIV disease is common and the underlying cause or causes can be difficult to diagnose. I would certainly continue to work closely with your HIV specialist to try to identify any underlying problems that might be contributing to feelings of fatigue, including psychological causes, such as depression; occult unrecognized infections; hormonal imbalances; inadequate sleep, rest, diet or exercise; drug side effects, toxicities or interactions; etc. Review the archives of this forum for additional details about the common, as well as host of not-so-common, causes of HIV related fatigue and discuss these with your HIV specialist.

Regarding Provigil, yes, we do have more experience with this agent and yes, some folks have found it helpful. My biggest concern remains its metabolic pathway (the cytochrome P-450 enzyme system), because many HIV drugs also use these same enzymes. A competent and experienced HIV specialist should be able to make any necessary dose adjustments, if Provigil is tried. In general I, too, would prefer the non-amphetamine drugs, like Provigil, over the amphetamine-type agents, such as Ritalin. I'll post a few questions form the archives that address the use of Provigil for HIV-associated fatigue.

Good luck! If you do try it, let us know if it works for you!

Dr. Bob

What about Provigil (energy booster)-is it addictive? Jul 5, 2004

two different specialists recommended Provigil to me because i get extremely tired very early. The FDA approves of it for narcolepsy, which i don't think i have. Any how, a month after starting it, I found a flyer at GMHC i think about being a part of a study using Provigil for HIV people. The drug works so well for me and so consistently well, meaning I don't get used to it and so i don't have to increase3 the dosage of 200 mg. (Sometimes, rarely) i take 300 mg. I was worried because i'm in 12-Step programs and thought it was an addictive substance since i felt good and energetic with it (i have insomnia as well). But i researched the heck online about it and could not find anything saying it was addictive. In fact, it is not a triplet prescription (very controlled substance), though it is slightly controlled (but so is everything you need a prescription for). It does not work the same for everyone and most likely you'll need prior approval -- it's $193.00 a month without approval with my HMO and not covered by adap. But $5 after it's approved. It is an amazing drug and was recommended as i said above by both my specialist pain doctor and my psychiatrist. My question is, since it is a relatively new drug, is it addictive. I know that if I stop abruptly, i will be very tired for a few days but that seems to be the only withdrawal effect it has. But i am concerned. Thanks.

Response from Dr. Frascino

Hello,

You mention two different specialists a pain specialist and a psychiatrist recommended Provigil. Have you discussed this with your HIV specialist as well? Since this is an HIV information website and you found the flyer at GMHC, I'm assuming you are HIV positive, correct?

Is Provigil addictive? I have seen some clinical studies that indicate it could be. We know it is "reinforcing," as evidenced by its self-administration in monkeys previously trained to self-administer cocaine. Consequently, misuse and/or abuse of Provigil can potentially occur. However, if you are being monitored closely by your specialists, hopefully that won't be a problem for you. I'll post two questions from the archives that discuss Provigil and again remind everyone that Provigil can interact with some HIV meds.

Dr. Bob

Provigil and fatigue: Posted: Jun 16, 2003

Dar Dr. Bob,

I am an addiction psychiatrist in New York City, and I work with many patients with HIV. I read your comment about the use of Provigil with great interest. Generally, Provigil is a great advancement in "stimulant" medications because it doesn't directly work on dopamine, the neurotransmitter that is responsible for the euphoria or the "hard-wired" repetitive behavior that we see in addiction. For that reason, it's been extremely helpful for many of my addiction patients who suffer from fatigue. However, I do share your concern about using it with patients with HIV. In particular, it is an INDUCER of P450 3A4, which a major pathway of metabolism for medications such as Kaletra. Theoretically, this could lower Kaletra levels and cause sub therapeutic levels of antiretrovirals. These patients may improve fatigue, but they also may worsen their HIV. Unfortunately, there's no published data to support this yet. As far as "psychodelic effects," none of my patients yet have reported this, though some have reported some anxiety, notably much less than with dopaminergic stimulants, such as Ritalin or Dexedrine. But my HIV patients generally require much smaller doses. As with all psychotropics, because HIV affects the CNS in profound and unpredictable ways, we should always use them with some caution. I appreciate your column and look forward to reading more!

Steven

Response:

Hello Steve,

Thanks for writing! I totally agree! The P450 3AY enzyme pathway can be a problem. Improving fatigue at the cost of worsening HIV is generally not a good option. Subtherapeutic drug levels can lead to drug resistance, which then allows HIV to flare while concurrently decreasing potential options for effective future therapies. Fatigue in the setting of HIV is often multifactorial. Certainly psychological causes rank high in the differential diagnosis. I've found that the best approach is to evaluate all potential causes and treat aggressively those most amenable to therapy (anemia, hypothyroidism, depression, infections, etc.). With this approach plus the occasional Starbucks, I haven't needed to use stimulants. Thanks for your insight!

Dr. Bob

Extreme fatique - HIV or depression? Jun 20, 2006

I'm currently taking Reyataz, Zerit, andViread for HIV, and Lexapro and Trazadone for depression. I have been infected for about 20 years. When I was first diagnosed, by CD4 was 8 (eight.) My vral load is currently undetectable, and my CD4 is around 60. I have been fortunate enough to have avoided many of the symptoms, but I have constant fatigue. I constantly feel like I'm walking in molasses. It's very frustrating because I don't know if the fatique is caused by the depression, the HIV, or the meds, but I suspect it to be a combination of the three which are all related. My questions are: How common is this fatigue, and what can be done about it?

Response from Dr. Frascino

Hello,

Fatigue is one of the most common and annoying symptoms associated with HIV disease. Its cause often turns out to be multifactorial, i.e. multiple underlying causes all working in tandem, just as you surmised. So could your fatigue be related to your depression, medications and HIV itself? Yes. Not only that, but there are many other potential contributing factors as well, including anemia; inadequate sleep, rest, exercise or diet; occult infections; hormonal imbalances; etc.; etc.; etc.

What can be done about it? The first thing is to identify as many of the underlying problems as possible and then to treat each of these conditions aggressively. To do that, I would suggest you begin by reading the archives of this forum and familiarize yourself with the common and not-so-common causes of HIV-associated fatigue. Make a list of these and then bring it to your HIV specialist and develop a plan to evaluate and treat your specific underlying problems. This process may well take some collaborative detective work to isolate the problems. But it's worth the effort, because HIV-associated fatigue can often be significantly improved if appropriate attention is given to this very important quality-of-life problem! Once all the underlying causes have been attended to, if you remain exhausted, you could try Provigil (modafinil). It's a non-amphetamine, pick-me-up-type pill that was initially approved to treat narcolepsy, but which is being increasingly used for fatigue. However, because Provigil is processed in your liver by an enzyme system also used by many HIV medications, there is some risk of drug interactions, especially with Norvir and Fortovase, so discuss this with your HIV specialist as well.

Good luck!

Dr. Bob

Provigil for fatigue/Ritalin Jun 4, 2008

I saw in some of the postings where you talked about Provigil and wanted to share this because others may have the same situation. I was checked for everything that has been mentioned about causes of fatigue to see why and everything was OK. Finally the HIV specialist I go to prescribed Provigil. I have great insurance coverage and they turned down the request saying fatigue from HIV and meds is not the intended use of Provigil. My doctor even countered the decision and still lost. In 15 years of having this coverage this is the first drug they ever turned down. I guess its expensive so if they can get out of approving it they will. So he prescribed Ritalin. I have been taking this for a month now and I feel great. I'm exercising and eating healthy foods. I lost weight.My blood pressure is even lower probably attributed to the cardio exercising. I have spent the last 10 years going to work and totally dragging thru the day. I would get home and get in bed and watch TV. I just existed, period. I was on anti-depressants for 5 years which I got off because I thought they were causing or adding to the fatigue and the weight gain. But after a year of being off of anti-depressants I was still exhausted. I have a top level high stress job too that doesn't help the situation. I have been on EPZICOM and VIRAMUNE for years and always maintained an undetectable level. At 55 years old I don't feel like I'm dying anymore. Dealing with fatigue is horrible because it affects so much or your life and causes chain reactions affecting your whole lifestyle.

Response from Dr. Frascino

Hi,

It's always a worry when "great insurance coverage" decides they understand the practice of medicine better than a trained physician! I doubt I would refer to your insurer as "great." Your physician was correct to fight this decision. Chances are if he persisted, ultimately they would have covered the cost of Provigil (it's not excessively expensive compared to most prescription drugs!). It works on an entirely different mechanism than Ritalin and is in some ways safer to use. Nonetheless, you seem to be remarkably improved on Ritalin, so we certainly can't argue with success. Thanks for taking the time to write in and share your story. I'm delighted your batteries are recharged. I should also mention for our readers that I have never had difficulty getting insurance coverage for Provigil for use in the treatment of HIV-associated fatigue when indicated.

Dr. Bob

heart issues with provigil Nov 23, 2007

I am newly diagnosed hiv+. I am considering asking my doctor to let me try provigil for fatique and difficulty concentrating. Since Provigil is a stimulant does it have any negative impact on the heart. I am 65 years old and had some fibrillation problems in the past but this is no longer a current problem.

Response from Dr. Frascino

Hello,

Provigil should be avoided by people with certain types of heart problems, such as mitral valve prolapse. Your past history of fibrillation should not be a problem; however, as with all prescription medications, your physician will evaluate you for potential complications before prescribing any medications.

Good luck.

Dr. Bob


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