Ok, so a patient comes in to check what the naturopath is doing. Should patient really take this?
The naturopath has put P on a raft of pills, containing high dose vitamins and herbs. Also cow thymus. I don't know why cow thymus is so popular with naturopaths. I still don't know what the thymus does. We're a bit fuzzy about the spleen, too.
But also hydrocortisone. This is a steroid. Damn it, why a steroid? It is a low dose, but still.
Chronic fatigue, myalgic encephalomyelitis. Chronic fatigue for twenty years after nearly bleeding out twice and needing an emergency surgery and getting transfused buckets of blood.
Hmmm. So the naturopath is trying to "stimulate the adrenals". Except my medical training is that when you give steroids, you suppress the body's natural steroids. If you give steroids for more than a week, we always taper, because otherwise the person can get sick or die if their adrenals don't kick in and make steroids. That is called an Addison's crisis: I have never seen one and hope never to see one.
Further discussion. Lifelong migraines. Tend to come in cycles. A few months of horribly horribly worse and then a few months of better. The only thing that has ever worked for the migraines is a benzodiazepine. And of course she's going to the doctor who hates benzodiazepines.... but that is the clue that leads to our next plan.
I think of chronic fatigue as a sort of crash switch in the brain. Something really bad happens, infection or trauma, the person nearly dies, and the brain throws a switch. It is to force the person to rest and recuperate. Some people heal: I pretty much have, though I still have to pay attention and be careful. My crash symptoms involve 3:30 am nausea, severe headache, vertigo when I stand up, vomiting and diarrhea. It used to last for three days and now is pretty much down to half a day.
So benzos help. So did alcohol but P quit that 30 years ago. P's body wants to be sedated. How do we do a non-addictive sedation? Also, hydrocortisone does the opposite: P feels it's wrong and me too. I have the Ramones song playing in my head. Think. High cortisone and high adrenaline are the sympathetic nervous system and she feels energetic on benzos. So: we will go after the adrenaline instead. Beta blocker: propranolol low dose, 10mg twice a day. And guess what: propranolol is used for migraine prophylaxis, usually starting at 40mg twice a day and titrating up. P has some propranolol but has not really tried it. I want P to do a week of 10 at twice a day and then go to 20 if it's not enough.
Propranolol is wonderful. The dose for hypertension is 400-600mg a day, but it comes in a 10mg tablet. In low dose it is used for anxiety and for stage fright. It's non-addictive! And because it has this massive dosing range, the low dose can be used in people with really low blood pressure and it doesn't drop it. It just blocks adrenaline receptors. Yee-ha, a drug that I love! Praise to propranolol, old, cheap and useful as hell.
P is in agreement. P has taken three days of the hydrocortisone but will go off. I tell P to ask the naturopath if any of the other six pills are stimulating and get the hell off them. Dunno if this will work, but P and I feel hopeful. And then I play the Ramones on the laptop.
The Ramones: I wanna be sedated.