Lots of people are speculating as to why we might be better, other than HAART, including me of course. Maybe it’s our genetics. Maybe Lyme treatment worked:). Maybe quitting Lyme and other palliative treatments worked. Maybe we’re taking something else that did it.

All the drugs cause an intensification reaction in most patients. It generally subsides in weeks, but is persisting in a few patients. Except for us and a 16 year old that hasn’t been ill for long whose mother reported on this blog, results are so far not as encouraging as hoped. The most obvious difference between us and the others is that we have been on all three drugs for a few months. Also Deplin may be a factor for us, as discussed later in this post. Actos has helped Ali and may have made it easier to get on the drugs, which haven’t bothered her at all, clearly an exception to the rule. I had a hard time getting on them, but was very motivated. It wasn’t worse in any way than where I’ve been before, but it required a willingness to suffer.

AZT seems to be the easiest to start, but may have the least clinical effect. I haven’t seen or heard any indication that all the fear about AZT exacerbating the existing mitochondrial defect has any basis in clinical reality. It is the broadest spectrum drug we have; it inhibits transcription of HIV, HTLV, FeLV, MLV’s and XMRV. It also has the best CNS penetration of the three available drugs. There are some potential long-term consequences of taking it that hopefully we will be able to avoid when new, specific drugs are developed. This happened with HIV disease, in which AZT is generally not needed anymore for effective treatment, at least in the developed world.

The inflammatory flare that follows starting the drugs may have to do with an increase in unintegrated viral DNA exacerbating the existing pathological response. It is an intensification of existing symptoms. I will resist the impulse to call it a ‘herx’. We don’t have a handle on the pathogenesis of X related disease yet, so we can’t know what the drugs are doing specifically with respect to this virus. With HIV, patients stay healthy until the virus activates, then die pretty quickly if not treated. X smolders without killing. Many of us are very far down the road and it isn’t surprising to me that the established pathological processes don’t just turn themselves off, since provirus is present in existing cells and probably still doing damage. Recovery likely depends upon the formation of new, uninfected cells, so it is a slow process.

The biggest reason I can think of not to try these drugs now is the potentially serious consequence of exposing drug naive virus to a regimen that doesn’t really do it. It’s possible that it will be better in the long run to wait. It’s a very personal decision that has to do with quality of life now and ability to temporize, or not. It should be made in consultation with a knowledgeable physician. But as things are, many patients are unable to find help and a few are trying antiretrovirals without supervision. This is of great concern, given that the drugs are not easy to take and need to be managed. There is so little information to go on that anyone who chooses to go ahead now must know that they are taking a big chance. Each person’s assessment of risk to potential benefit is going to be different. The risk of doing nothing needs to be carefully evaluated in light of the information available, as our understanding of what’s going on medically is changing all the time right now. Unfortunately, clinical medicine is all we have. It doesn’t look like science is going to save us for a while. Also I think one should probably not start antiretrovirals without a willingness to take them forever.

Although it goes a bit against the grain to post this information publicly, some have asked and my intention is to inform about what seems relevant. So, in addition to HAART, here are our current daily meds, once a day unless otherwise noted.

Me:
Cozaar 100mg
     switched from Benicar 6 months ago; have been taking an ARB for 15
     years
Norvasc 5mg prn severe hypertension
Deplin 7.5mg x 6 months
Low dose aspirin x 6 months
Armour thyroid 30mg for years
High dose cyclical topical estradiol and estriol
    since menopause two years ago
High dose topical testosterone
     have been taking testosterone since ’97
Prometrium 200-400mg (since ’97)
Topical selegilene .5mg x 8 months
Topical D3 10,000 units x 6 months
     had to slowly increase dose; didn’t tolerate previously due to
     increased pain
Meriva SR (curcumin extract) 2 capsules BID, added recently

Ali:
Actos 7.5mg BID x 6 months
Fortamet 500mg BID x 4 months
Cortef 5mg for years
Deplin 15mg x 1 year
Topical progesterone 200mg 12 days per month during luteal phase
Topical D3 10,000 units x 6 months
Meriva SR 2 capsules BID, added recently

There are also many things we are not taking anymore, including antibiotics, Klonopin, pain medicine, anticonvulsants, psychoactive drugs and truckloads of supplements.

Ali has PCOS, as do more than a few second generation women in my ‘clinic without walls’. PCOS is a very common, though under-diagnosed syndrome characterized by LH and insulin insensitivity. The LH insensitivity interferes with normal ovulation and there is impaired formation of the corpus luteum cyst and therefore, inadequate progesterone. PMS in this group looks like an exacerbation of the illness. Atypical reactive hypoglycemia is seen in male patients as well, as are hormone deficiencies.

Actos has been quality of life changing for Ali. The treatment for PCOS is usually metformin, sometimes with Actos. Treatment encourages normal ovulation. In addition to the luteal phase defect, PCOS is associated with insulin insensitivity. Ali became so sugar sensitive that she didn’t tolerate any carbs at all. Two physician friends suggested Actos at the same moment for her, for completely different reasons, so the lightbulb went on for me. Actos (a TZD or thiazolidinedione, like Avandia) works by binding to PPARγ which are receptors on the membrane of the cell nucleus. TZDs enter the cell, bind to the nuclear receptors, and affect the expression of DNA. Activating PPARγ decreases insulin resistance, inhibits VEGF (vascular permeability factor), dropping levels of certain cytokines. Here are links to a few Medscape articles and pertinent papers:
Medscape: Insulin–sensitising drugs for Polycystic Ovary Syndrome
Medscape: Antidiabetic Agents for Treatment of PCOS
Medscape: Pharmacologic Treatment of Polycystic Ovary Syndrome
Treat Endocrinol. 2006;5(3):171-87.
PPAR Res. 2006; 2006: 73986. 
J Endocrinol Invest. 2005 Dec;28(11):1003-8.
Reprod Toxicol. 2007; 23(3): 438–448.

As for the fear of exposing the virus to a hormone activator with physiologic progesterone, testosterone or hydrocortisone replacement, nothing new is being added. My gut says it is safer to cover young women for progesterone deficiency to prevent an estrogen dominant state, especially given the concern with respect to X and oncogenesis, but we cannot know at this time. All the steroid hormones, including sex hormones, cortisol and the mineralocorticoids are metabolized via common pathways link; note that progesterone is metabolized to androgens and aldosterone, and that there are bidirectional pathways. Replacement tries only to tip the ratios. It’s nothing like taking birth control pills, which is how the gynecologists treat PCOS. Birth control pills are synthetic estrogen and progesterone-like drugs (that may or may not activate virus, time will tell). With bioidentical hormones (same molecular structure as the hormones the body makes on it’s own), you are not taking over the cycle, but supporting it, normalizing it. You’re not exposing the virus to anything that isn’t there anyway. A menstruating woman’s body makes some progesterone, but women with PCOS don’t make enough. Unless you want to take out ovaries, the virus is going to see some progesterone. They use ablation for hormone dependent cancers, but it’s extremely destructive to quality of life. So, for the record, Ali and I have both improved despite taking hormones, in my case full bioidentical HRT, including testosterone.

Endocrinologists as a group seem to be particularly clueless with respect to managing CFS/Lyme patients, even though hormone depletion is probably pretty universal. Because the ‘bioidentical’ hormones are naturally occurring substances, they can’t be patented. Therefore they have not been studied and doctors generally don’t know how to use them.

Deplin is L-methylfolate, a medical food, the only active form of folate that crosses the blood brain barrier. It is a regulator of synthesis of monoamines (serotonin, norepinephrine and dopamine). In the face of deficiency, it is useful for depression. Ali added it to potentiate Cymbalta about a year ago, and it allowed her to wean from the drug. I tried Deplin because it had such a profound effect for Ali. I didn’t notice anything going on it, but have tried to stop it a few times and had difficulty with irritability and sleep disruption, so continue to take it. Because sufficient levels of all B-complex vitamins is important, B12 supplementation (sublingual or parenteral) is worth considering with Deplin, hydroxocobalamin probably being the preferred form.

People have questioned me as to whether Ali and I really have CFS. We meet the Canadian criteria for CFS, but not the ridiculously inadequate CDC case definition. In my experience, most chronic Lyme patients meet Canadian criteria for the disease. My early symptoms, in hindsight, were related to sensory and cranial nerve dysfunction, and vasospasm – classic, atypical and intestinal migraines, hypertensive crises, sensory disturbances. We are both hyper, not hypo, immune. Ali has had vasculitis. I was diagnosed with Crohn’s on surgical path. I am more of an atypical MS picture (radiculopathies, +Rhomberg, +Babinski). Ali is more classic CFS with POTS being a big part of her symptom complex. My orthostatic intolerance is superimposed on hypertension, so I don’t get tachycardic unless I’m over-medicated and hypotensive, but gravity is still an obstacle for me for more obscure reasons. Neither of us is particularly MCS or drug intolerant.

Ali has persistent IgM specific bands for Borrelia burgdorferi. I have fleeting IgG specific bands. We both had positive FISH test for Babesia microti. We both had postive PCR’s for Mycoplasma fermentans and high IgG titers for Bartonella henselae. I had high titers for Bartonella quintana.

One of my few positive tests, besides the usual TBD suspects, is a low positive nucleolar ANA and very high circulating immune complexes. Also very low alpha MSH and mildly elevated VEGF. I have never been tested for HHV-6, etc. I tend to run a borderline high white count with normal differential and I have slightly low globulins. Ali has elevated IgG titers for EBV, but hasn’t been extensively tested for other activated viruses. She has had a low IgG subunit.

As for the genetic component, Dr. Shoemaker says we have HLA profiles that put us at risk. I am an Ashkenazi Jew, a group which has a variety of genetic diseases, including Familial Dysautonomia. I am probably an Ehlers-Danlos variant, becoming more flexible with age and exacerbations of illness. My husband has Marfan’s Syndrome. My husband and Ali are positive for the V Leiden gene. So a genetic hodgepodge.

Historically, Ali and I go up and down together, but I think that has to do with stress and cortisol activation. Our triggers have been hormonal shifts (puberty and childbirth), sustained stress and a concussion once for me. That fits with X having glucocorticoid and androgen receptor elements. 

All I really know for sure is that we are X+, we’ve been on antiretroviral treatment since March, on three drugs since May and we are a lot better. Lyme Disease was a big piece for Ali, probably not for me. We’ve each gone up at least 30 KPS points since starting HAART. I don’t think it’s possible that antiretrovirals haven’t helped us. Nothing else we’ve tried in the last few years has worked, except for Deplin and Ali’s Actos, and I think we can all agree that we were unlikely to get this kind of improvement from those interventions. But it is possible that the other things we are taking are potentiating the effects of the drugs or ameliorating the side effects of treatment. Neither of us feels completely well, especially me. But we are both hugely more functional. We can only hope it continues.

P.S. Ali wants me to disclose the things about her in this post, because she thinks they are so important.