BOB MILLER'S HUNGER STRIKE

Advocate Bob Miller has been on a hunger strike to try to convince FDA to approve the experimental drug Ampligen for ME.  He and fellow patient Dr. Janet Smith got a terrific piece of local news coverage in Reno, Nevada. FDA is scheduled to make a decision on Ampligen's fate by tomorrow.  Given that the FDA committee voted no to Ampligen on December 20, odds are slim that the FDA will overturn its committee's decision, but it ain't over until it's over.

Bob Miller posted this on Facebook today:
"Patients who are able can call NBC News at 212-664-4444 and comment on the story [above]. Be sure to tell the person who answers why you are calling, they will put you through to a comment line where you can request for them to please cover this important news story nationally, be sure to tell them where you are calling from."

FDA'S DOUBLE STANDARD

A mad-as-hell Sid Wolfe of the watchdog group Public Citizen sued FDA about the agency's refusal to ban the highest dose of the Pfizer Alzheimer's drug Aricept--and lost. Studies don't show increased efficacy of the 23-milligram pill compared with the lower doses of 5 and 10 milligrams.  However, the higher dose does show increased toxicity, including, Wolfe said, increased mortality.

According to a comprehensive article by reporter Ed Silverman, the director of the FDA’s Division of Neurology Products, Rusty Katz, explained his reasoning for keeping the higher dose by posing a question and then answering it:  “Does the absence of a demonstration of any superiority of the 23 milligram dose to the 10 milligram dose on measures of overall functioning, coupled with the increased incidence of potentially significant adverse events, argue against the approval of this product?” The 23 milligram dose is “clearly superior to the 10 milligram dose” on a cognitive measure.* “In my view, this strongly argues for a conclusion that the 23 milligram dose is very likely to also have an effect on overall functioning, despite this not having been demonstrated directly in this study” [emphasis added].

Reporter Ed Silverman also wrote that given the few Alzheimer's treatments available, FDA believes that physicians may decide the added side effects justify the benefits. 

Following that logic, FDA, Ampligen's side effects are in most cases, minor or manageable, and given that there are no FDA-approved ME treatments, shouldn't Ampligen be approved?  Instead the FDA committee, while endorsing Ampligen's safety, voted that the drug didn't meet FDA's standards for efficacy--though it was "probably effective."  Probably effective sounds an awful lot like the "very likely" of two paragraphs up.

Why the double standard, FDA?  Could it be FDA is throwing the pharmaceutical giant a big bone because the patents on the lower doses are expiring?  Could it be that FDA believes Alzheimer's to be more important than ME?  Could it be, as Sid Wolfe suspects, that FDA doesn't want to admit it was wrong in approving the 23 milligram dose in the first place?

Sid Wolfe also testified at the FDA Ampligen hearing on December 20 that Ampligen shouldn't be approved either.  (And a patient I talked to at the meeting said she overheard him say that cognitive therapy works.) 

Here's Ed Silverman's story, if you want more info.

*In three of the four tests, there was no increase in cognitive function at the higher dose.

An Inappropriate Script

For me, the most problematic thing about the FDA Ampligen committee meeting wasn't Ampligen's nonapproval.  It was a sick ME patient leaning on a cane who showed me the prescription a neurologist had given her—after admonishing her for using a cane.  Gazing at the script for several seconds, I first felt confusion and then the patient's humiliation.  The prescription read:

Tai Chi  

I told this story to a friend who's had ME for more than 20 years, and he said in all seriousness:  At this point, I'd take that cane and bash the doctor's head with it.   

The Oxford Definition It's Baaack

I asked CDC's Unger via email why is CDC using the antiquated Oxford* definition in its partnership with HRSA (Health Resources and Services Administration), along with Fukuda** and Canadian Consensus Criteria*** in its continuing education courses? The Oxford definition requires only fatigue, unlike the other definitions of ME, which require immune, neurologic and autonomic symptoms.

I also asked Unger:

• For most CFS-literate physicians and patients, using all three definitions is a problem. That’s because the Oxford definition requires only fatigue as a symptom. In contrast, Fukuda requires fatigue and four other symptoms.* According to most CFS-literate physicians, the Canadian Consensus Criteria (CCC) is the most accurate and thorough of these three definitions, and requires the following: fatigue, post-exertional malaise and/or fatigue, sleep dysfunction, and pain; two or more neurological/cognitive manifestations and one or more symptoms from two of the categories of autonomic, neuroendocrine and immune manifestations.**

Given the significant differences in definitions, does CDC believe using all three definitions is problematic?  Why or why not?

• By focusing on fatigue, the Oxford definition neglects other important symptoms embraced by CCC, as well as other symptoms in the original Fukuda definition. Fatigue is characteristic of many illnesses, from cancer and heart disease to depression.  Thus, with the Oxford definition, CFS morphs into a vague disease—it’s only vague by the Oxford definition, not by CCC.  Using the Oxford definition makes it more difficult for doctors to distinguish pathological fatigue of CFS from ordinary fatigue and from illnesses that have fatigue as a symptom—and that’s most illnesses. For all these reasons, Oxford is, in the view of most patients and CFS-literate physicians, a woefully inadequate and inaccurate definition.  Does CDC understand the problems with the Oxford definition?

• Does CDC want there to be confusion about the disease?  

• If CDC doesn’t want there to be confusion, why does it use all three vastly different definitions in the HRSA CME courses?

• Over and over again, CDC states in meetings and in its medical articles that CFS is a poorly understood disease. Other researchers and clinicians look to CDC for guidance. Does CDC understand that by using all three of these vastly different definitions, CDC is causing the disease to be poorly understood?

• The CCC definition describes the illness that most patients and CFS-literate physicians understand to be CFS. Given that using multiple definitions results in confusion and heterogeneous populations, why not make this critical change and use only CCC? Please explain why CDC won’t do this.

CDC’s Response
Through its press office, CDC—I assume it was Unger, since I directed my questions to her—replied:

CDC has developed several CFS CME courses, including Diagnosis and Management of Chronic Fatigue Syndrome (see http://www.cdc.gov/cfs/education/diagnosis/index.html) which was prepared in collaboration with other CFS subject matter experts, including non-CDC clinicians in private practice and academic settings. Among other things, this CDC CME course provides information about multiple CFS case definitions, such as those mentioned in your query. CDC uses the 1994 case definition, but recognizes there are additional case definitions that can be useful. CDC is committed to providing accurate, evidence-based CFS information that is relevant to various audiences, including CFS patients, clinicians who treat CFS patients, researchers, and others.
 
I believe this information addresses the questions you asked.  You may wish to contact HRSA directly about questions regarding CME courses produced by that agency.
 
Thank you for your interest in CDC’s CFS research program.

This article is copyright CFS Central 2012. All Rights Reserved. You may quote up to 150 words from this article as long as you indicate in the body of your post (as opposed to a footnote or an endnote) that the excerpt is by Mindy Kitei for CFS Central. You may not reprint more than 150 words from this article on blogs, forums, websites or any other online or print venue. Instead, refer readers to this blog to read the article. 
 

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*Oxford definition
fatigue as the main symptom; definite onset and not lifelong; fatigue is severe, disabling and affects physical and mental function; fatigue should persist for 6 months or more and be present 50% of the time; other symptoms, especially myalgia, sleep and mood disturbance may be present.

**Fukuda definition:
Patients must have four of the following:

Self-reported impairment in short term memory or concentration severe enough to cause substantial reduction in previous levels of occupational, educational, social, or personal activities; sore throat; tender cervical or axillary lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern or severity; unrefreshing sleep; post-exertional malaise (PEM) lasting more than 24 hours.


*** Canadian Consensus Criteria:
Neurological/Cognitive Manifestations: Two or more of the following: confusion, impairment of concentration and short-term memory consolidation, disorientation, difficulty within formation processing, categorizing and word retrieval, and perceptual and sensory disturbances—e.g., spatial instability and disorientation and inability to focus vision. Ataxia, muscle weakness and fasciculations are common. There may be overload phenomena: cognitive, sensory—e.g., photophobia and hypersensitivity to noise—and/or emotional overload, which may lead to crash periods and/or anxiety.

One or more symptoms from two of the categories of autonomic, neuroendocrine and immune manifestations:

Autonomic Manifestations: orthostatic intolerance neurally mediated hypotension (NMH), postural orthostatic tachycardia syndrome (POTS), delayed postural hypotension; light-headedness; extreme pallor; nausea and irritable bowel syndrome; urinary frequency and bladder dysfunction; palpitations with or without cardiac arrhythmias; exertional dyspnea.

Neuroendocrine Manifestations:  loss of thermostatic stability—subnormal body temperature and marked diurnal fluctuation, sweating episodes, recurrent feelings of feverishness and cold extremities; intolerance of extremes of heat and cold; marked weight change—anorexia or abnormal appetite; loss of adaptability and worsening of symptoms with stress.

Immune Manifestations: tender lymph nodes, recurrent sore throat, recurrent flu-like symptoms, general malaise, new sensitivities to food, medications and/or chemicals.