The guaifenesin protocol - Treating fibromyalgia
Fibromyalgia is a legitimate, common entity. It is a cyclic and progressive disease which affects millions of patients, primarily women, regardless of race. Manifested by multiple symptoms that may initially last only a few days, it eventually progresses to affect multiple areas and bodily systems until patients simply cycle from bad to worse. At present, there are no diagnostic laboratory tests for fibromyalgia. Our recent research paper reported several abnormal cytokines that change during the course of our treatment.[1]
Patients are often referred from one doctor to another, and told that they have chronic fatigue, systemic candidiasis, myofascial pain, irritable bowel or vulvar pain syndrome. Too often, physician and patient focus on symptoms and fail to perceive the much larger problem. These dead-end diagnoses result in the treatment of symptoms which is only partially effective and at the same time ignores the underlying cause and the disease that continues to worsen over time.
Fibromyalgia has no set symptoms and many combinations from the following list are interwoven:
Trauma, infection or stress can aggravate or tip susceptible individuals into fibromyalgia but are not the basic causes. It is generally accepted now as an inherited disease and two published papers from our research team at City of Hope have confirmed this. We have treated family members that spanned three generations including four two-year-olds as well as patients who became symptomatic only in their seventies. This age spread strongly suggests a multi-genetic disease in various combinations. Boys and girls suffer equally before puberty but females predominate (85% to 15%) thereafter. Forty percent of our patients recall "growing pains" in childhood that disappeared during the true growth spurt of puberty. Untreated fibromyalgia ultimately leads to a "tartar of joints" that we recognize as osteoarthritis.
Over forty years ago, a patient taking gout medication observed he could peel tartar (calcium phosphate) off his teeth with his fingernail. This observation indirectly led me to study an unrecognized systemic problem reflected by deposits from the disturbed saliva. We now postulate that a defective metabolism, possibly a kidney enzyme, forces a minuscule retention of phosphate, which gradually accumulates to detrimental levels in many tissues. The excess results in inadequate energy formation (ATP), cellular fatigue and other malfunctions that explain all the symptoms of fibromyalgia. For more information about this theory please refer to The Use of Uricosuric Drugs in Fibromyalgia.
We no longer prescribe gout drugs (uricosurics), but use guaifenesin exclusively because it has no side effects and is even safe for children. It is marketed for respiratory mucus problems and is available without prescription in various strengths, though short acting (immediate release) formulas are not effective for fibromyalgia. Currently, we can only advocate three products: the long/short-acting bilayered 600mg Mucinex and a 600mg or 300mg tablet compounded by Marina del Rey Pharmacy, and an extended release single layer tablet manufactured by Perrigo, which is sold as a store-brand generic.
THe 200mg and 400 mg short acting (or immediate release) tablets may be added to boost the basic dose once a patient is taking 1200 mg or more of the long-acting or extended release. (A product marketed under the name Guai-Aid falls into this category and should not be used as a stand alone guaifenesin.)
We begin patients with 300 milligrams of long acting guaifenesin twice a day for one week. Feeling distinctly worse suggests adequate dosage and patients remain on that amount. This suffices for only 20 percent of patients; if symptoms do not worsen, we increase to 600mg. twice daily. Reversal begins for 80 percent of patients at one of these two levels leaving 20 percent who will need more. Dosages should be increased slowly: after one month a patient should begin 1800mg. if no change is seen.
During reversal, symptoms are intensified and new ones may be experienced. These are not side effects, but signal that reversal is underway. Better hours eventually appear and then cluster into days and finally weeks. The palpable lumps and bumps soften, fragment and gradually clear. Recovery is more rapid than the time it took to develop the illness. Newer lesions clear first and the oldest ones last.
The American College of Rheumatology recommends searching for tender points at eighteen predetermined sites on the body to establish a diagnosis of fibromyalgia. However some patients simply have higher pain thresholds so while they complain of body aches or stiffness, they focus mainly on fatigue and cognitive impairments. These so-called Chronic Fatigue Syndrome patients suffer from the same metabolic abnormality. Since pain perception varies greatly, we urge physicians to seek objective evidence instead of the purely subjective response to variably tender points. The confirmation of fibromyalgia is far more secure when using our method of palpation that we call mapping (see below).
Patients are often referred from one doctor to another, and told that they have chronic fatigue, systemic candidiasis, myofascial pain, irritable bowel or vulvar pain syndrome. Too often, physician and patient focus on symptoms and fail to perceive the much larger problem. These dead-end diagnoses result in the treatment of symptoms which is only partially effective and at the same time ignores the underlying cause and the disease that continues to worsen over time.
Fibromyalgia has no set symptoms and many combinations from the following list are interwoven:
- Central Nervous System: Fatigue, irritability, nervousness, depression, apathy, listlessness, impaired memory and concentration, anxieties and suicidal thoughts. Insomnia and frequent awakening due to pain result in non restorative sleep.
- Musculoskeletal: Pain and generalized morning stiffness could arise from muscles, tendons, ligaments and fascia of the shoulders, neck, entire back, hips, thighs, knees, ankles, feet, inner and outer elbows, wrists, fingers, and chest. Injured or old operative sites are commonly affected. Though fibromyalgia is described as a “non-articular” disease many know better: Joint pains with or without swelling, redness and heat are frequent. The litany includes foot or calf cramps, numbness and tingling of the face or extremities.
- Irritable Bowel: (Often called leaky gut, spastic colon or mucous colitis). Symptoms include nausea (often brief, repetitive waves), indigestion, gas, bloating, pain, cramps, constipation alternating with diarrhea and sometimes mucous stools.
- Genitourinary: Common are pungent urine, frequent urination, bladder spasms, burning urination (dysuria) with or without repeated bladder infections and interstitial cystitis. Vulvodynia (vulvar pain syndrome) includes vaginal spasms, irritation of the vaginal lips (vulvitis) or opening (vestibulitis) and painful intercourse (dyspareunia). It typically mimics a yeast infection but without the cottage-cheese discharge. Intense PMS and uterine cramping are common. Symptoms of fibromyalgia are worse premenstrual.
- Dermatological: Various rashes may appear with or without itching: Hives, red blotches, itchy bumps or blisters, eczema, seborrheic or neurodermatitis, and rosacea. Nails are often brittle and of poor quality and hair falls out prematurely. Strange sensations are common such as cold, heat (especially palms, soles and thighs), crawling, electric vibrations, prickling, super-sensitivity to touch, and flushing that is sometimes accompanied by sweating.
- Head, Eye, Ear, Nose, and Throat: Headaches (migraines), dizziness, vertigo (spinning) or imbalance; dry eyes as well as itching and burning with or without sticky or crusty discharge upon awakening; blurred vision; nasal congestion and post-nasal drip; painful, burning tongue, mouth and abnormal tastes (scalded, bad or metallic); ringing in the ears (tinnitus) or lower-pitched sounds; ear and eyeball pain; sensitivity to light, sounds and odors.
- Miscellaneous Symptoms: Weight gain; low grade fever; lowered immunity to infections; morning eyelid and hand swelling from fluid retention that gravitates to the lower extremities by evening where it stretches tissues causing the restless leg syndrome.
- Hypoglycemia Syndrome: This is a separate entity. Thirty percent of female and twenty percent of male fibromyalgics suffer both conditions (fibroglycemia). Symptoms greatly overlap those of fibromyalgia, but sugar craving accompanied by tremors, sweating, anxiety, panic attacks, heart pounding, faintness, and frontal headaches, especially if hunger induced, are solid clues to the diagnosis. Hypoglycemics must follow a prescribed diet or recovery will not be complete even with the reversal of fibromyalgia. (See Hypoglycemia for more information.)
Trauma, infection or stress can aggravate or tip susceptible individuals into fibromyalgia but are not the basic causes. It is generally accepted now as an inherited disease and two published papers from our research team at City of Hope have confirmed this. We have treated family members that spanned three generations including four two-year-olds as well as patients who became symptomatic only in their seventies. This age spread strongly suggests a multi-genetic disease in various combinations. Boys and girls suffer equally before puberty but females predominate (85% to 15%) thereafter. Forty percent of our patients recall "growing pains" in childhood that disappeared during the true growth spurt of puberty. Untreated fibromyalgia ultimately leads to a "tartar of joints" that we recognize as osteoarthritis.
Over forty years ago, a patient taking gout medication observed he could peel tartar (calcium phosphate) off his teeth with his fingernail. This observation indirectly led me to study an unrecognized systemic problem reflected by deposits from the disturbed saliva. We now postulate that a defective metabolism, possibly a kidney enzyme, forces a minuscule retention of phosphate, which gradually accumulates to detrimental levels in many tissues. The excess results in inadequate energy formation (ATP), cellular fatigue and other malfunctions that explain all the symptoms of fibromyalgia. For more information about this theory please refer to The Use of Uricosuric Drugs in Fibromyalgia.
We no longer prescribe gout drugs (uricosurics), but use guaifenesin exclusively because it has no side effects and is even safe for children. It is marketed for respiratory mucus problems and is available without prescription in various strengths, though short acting (immediate release) formulas are not effective for fibromyalgia. Currently, we can only advocate three products: the long/short-acting bilayered 600mg Mucinex and a 600mg or 300mg tablet compounded by Marina del Rey Pharmacy, and an extended release single layer tablet manufactured by Perrigo, which is sold as a store-brand generic.
THe 200mg and 400 mg short acting (or immediate release) tablets may be added to boost the basic dose once a patient is taking 1200 mg or more of the long-acting or extended release. (A product marketed under the name Guai-Aid falls into this category and should not be used as a stand alone guaifenesin.)
We begin patients with 300 milligrams of long acting guaifenesin twice a day for one week. Feeling distinctly worse suggests adequate dosage and patients remain on that amount. This suffices for only 20 percent of patients; if symptoms do not worsen, we increase to 600mg. twice daily. Reversal begins for 80 percent of patients at one of these two levels leaving 20 percent who will need more. Dosages should be increased slowly: after one month a patient should begin 1800mg. if no change is seen.
During reversal, symptoms are intensified and new ones may be experienced. These are not side effects, but signal that reversal is underway. Better hours eventually appear and then cluster into days and finally weeks. The palpable lumps and bumps soften, fragment and gradually clear. Recovery is more rapid than the time it took to develop the illness. Newer lesions clear first and the oldest ones last.
The American College of Rheumatology recommends searching for tender points at eighteen predetermined sites on the body to establish a diagnosis of fibromyalgia. However some patients simply have higher pain thresholds so while they complain of body aches or stiffness, they focus mainly on fatigue and cognitive impairments. These so-called Chronic Fatigue Syndrome patients suffer from the same metabolic abnormality. Since pain perception varies greatly, we urge physicians to seek objective evidence instead of the purely subjective response to variably tender points. The confirmation of fibromyalgia is far more secure when using our method of palpation that we call mapping (see below).
An example of a body map filled out.
The original description of fibromyalgia as “rheumatism with hard and tender places” has certainly been forgotten. Tender-point examination limited to a few preordained parts of the body has less value than our totally objective body mapping. We use our finger pads as though we were trying to iron out underlying tissue and thereby find the swollen places within muscles, tendons and ligaments. We record their location, size and degree of hardness on a body caricature that becomes a baseline for future comparisons. Unless swollen, the purely subjective tender spots are excluded in mapping. Subsequent examinations and patient inputs readily determine drug dosages and sequential disease regression. We hide previous maps until we complete the examination and only then compare them to confirm progress. The most important site for confirming the diagnosis and assuring future success is the left thigh. The outside of the quadriceps muscle (Vastus lateralis) and the front part (Rectus femoris) are involved in 100% of adults and clear within the first month upon attaining adequate dosages.
Ignoring the following will guarantee treatment failure. All salicylates including aspirin completely block the benefits of guaifenesin for fibromyalgia. This occurs at a kidney site—something well documented with uricosuric gout medications. Patients must screen all medications (prescription, over-the-counter, supplements, vitamins) and every single product applied to the skin including orally.
Less appreciated is the fact that all plants manufacture them in quantities that vary with genus and from crop to crop. They are stored in bark, leaves, roots, and seeds where they serve to repair damage or as weapons against soil bacteria and fungi. These natural salicylates block guaifenesin as effectively as their synthetic counterparts.
Salicylates are readily absorbed through the skin and intestine when introduced from medications and supplements including plants oils, gels and extracts. Individual genetics determine ease of blocking but all patients should assume a high level of susceptibility and take no risks. New or replacement products should be carefully inspected for changes made by manufacturers. Items on Salicylate-free lists should be double checked for accuracy before purchasing.
The following is a guide to natural and synthetic salicylates that must be avoided:
Medications: (1) Medications where the active ingredient is salicylate or salicylic acid, or contain aspirin: Salflex, Anacin, Excedrin, Disalcid, Pepto Bismol, Asacol, Alka Seltzer or Urised. (2) Herbal medications such as St. John’s Wort, gingko biloba, saw palmetto, Echinacea; vitamin supplements with added plants such as alfalfa or rose hips (3)Bioflavonoids (quercetin, hesperiden, rutin). (4) Topical medications such as wart or callus removers, acne products and dandruff shampoos that contain salicylic acid. (5) Pain creams, balms and lotions such as Ben Gay, Myoflex or Salonpas containing salicylate or plant extracts, gels or oils such as camphor, menthol, tea tree, arnica or eucalyptus.
Cosmetic and Topical Products including but not limited to: (1) Skin cleansers or exfoliants that use salicylic acid or plants such as witch hazel or chamomile. (2) Hair products with plant extracts, oils or salicylic acid (3) Bubble baths and lotions containing plant oils such as coconut oil or extracts from aloe or other plants. (5) Products with sunscreens containing octisalate, homosalate, mexoryl or meradimate. (6) Lipsticks, balms, etc. with ingredients such as salicylic acid, aloe, camphor, menthol, or castor oil. (7) Deodorants with castor or other plant oils or extracts. (8) Toilet paper and wipes with aloe or other plant oils, gels or extracts.
Shaving Aids: (1) Shaving creams with aloe, mint, menthol or mentholatum will block. (2) Razors with aloe strips adjacent to the cutting edge deliver salicylates through microscopic cuts. Vitamin E, lanolin, cocoa/shea butter and mineral oil are all acceptable.
Oral Agents: (1) Most mouth washes contain mint, wintergreen or salicylate (Listerine). (2) Toothpastes contain salicylates, as well as fresh or artificial mint, often unlisted. Use Cleure toothpastes, the non-mint ones made by Tom’s of Maine. Baking soda and/or peroxide provide good cleansing and whitening. The non-mint pre-brushing rinses are acceptable as are Cleure Mouthwashes. (3) Use no lozenges, dental floss, breath fresheners or chewing gums with any mint flavor, including menthol, wintergreen, peppermint or spearmint. (Fruit/Cinnamon flavors may mask mint hidden by the stronger flavors.).
Gardening: Sticky plant juices or saps adhere to the skin while gardening or weeding. Patients should wear waterproof gloves.
The QUICK CHECK here on the website will detail exactly how to check your products.
PHYSICIANS CANNOT BE EXPECTED TO RECOGNIZE OR KNOW ALL THE INGREDIENTS IN YOUR TOPICAL PREPARATIONS. DOCTORS WILL ASSUME GUAIFENESIN HAS FAILED IF PATIENTS DO NOT COMPLETELY PURGE SALICYLATES. IT IS YOUR RESPONSIBILITY TO FOLLOW OUR PROTOCOL EXACTLY.
No diet is required for fibromyalgia since the liver alters food salicylates. The only exception to this is that we ask patients not to drink tea. The camellia plant is very high in salicylates and steeping makes it stronger. (There is no problem with coffee and with plants other than those in the tea or mint family.)
Do not use decongestants or cough medicines to get guaifenesin. There are potential side effects from various additives. Single ingredient guaifenesin has no side effects (save rarely mild, but transient nausea) and no known drug interactions. Using it with salicylates causes no ill-effects, it simply negates the drug’s effectiveness for fibromyalgia.
Pain medications such as acetaminophen (Tylenol), Ultram, Imitrex, non-steroidal drugs such as Advil, and Aleve, will not block guaifenesin.
Our treatment is not for those lacking courage. It calls for patient skills and, hopefully, physician assistance. Remember, reversal of the disease reproduces past symptoms and may cause new or long-forgotten ones to re-surface. The intensity of these early cycles often causes concern during the initial weeks of treatment. Such symptoms are not guaifenesin side effects. Patients realize they were getting steadily worse long before starting our protocol despite medicinal Band-Aids used to mask symptoms. We offer hope to those with determination to try once more despite previous failures. This is a highly-effective protocol.
R. Paul St. Amand, M.D.
Associate Clinical Professor of Medicine
Endocrinology--Harbor-UCLA
Claudia Craig Marek
Medical Assistant
[email protected]
Important: Do not assume fibromyalgia is the cause of all symptoms. When in doubt or confronted with new problems, please consult your personal physician or appropriate specialist.
Ignoring the following will guarantee treatment failure. All salicylates including aspirin completely block the benefits of guaifenesin for fibromyalgia. This occurs at a kidney site—something well documented with uricosuric gout medications. Patients must screen all medications (prescription, over-the-counter, supplements, vitamins) and every single product applied to the skin including orally.
Less appreciated is the fact that all plants manufacture them in quantities that vary with genus and from crop to crop. They are stored in bark, leaves, roots, and seeds where they serve to repair damage or as weapons against soil bacteria and fungi. These natural salicylates block guaifenesin as effectively as their synthetic counterparts.
Salicylates are readily absorbed through the skin and intestine when introduced from medications and supplements including plants oils, gels and extracts. Individual genetics determine ease of blocking but all patients should assume a high level of susceptibility and take no risks. New or replacement products should be carefully inspected for changes made by manufacturers. Items on Salicylate-free lists should be double checked for accuracy before purchasing.
The following is a guide to natural and synthetic salicylates that must be avoided:
Medications: (1) Medications where the active ingredient is salicylate or salicylic acid, or contain aspirin: Salflex, Anacin, Excedrin, Disalcid, Pepto Bismol, Asacol, Alka Seltzer or Urised. (2) Herbal medications such as St. John’s Wort, gingko biloba, saw palmetto, Echinacea; vitamin supplements with added plants such as alfalfa or rose hips (3)Bioflavonoids (quercetin, hesperiden, rutin). (4) Topical medications such as wart or callus removers, acne products and dandruff shampoos that contain salicylic acid. (5) Pain creams, balms and lotions such as Ben Gay, Myoflex or Salonpas containing salicylate or plant extracts, gels or oils such as camphor, menthol, tea tree, arnica or eucalyptus.
Cosmetic and Topical Products including but not limited to: (1) Skin cleansers or exfoliants that use salicylic acid or plants such as witch hazel or chamomile. (2) Hair products with plant extracts, oils or salicylic acid (3) Bubble baths and lotions containing plant oils such as coconut oil or extracts from aloe or other plants. (5) Products with sunscreens containing octisalate, homosalate, mexoryl or meradimate. (6) Lipsticks, balms, etc. with ingredients such as salicylic acid, aloe, camphor, menthol, or castor oil. (7) Deodorants with castor or other plant oils or extracts. (8) Toilet paper and wipes with aloe or other plant oils, gels or extracts.
Shaving Aids: (1) Shaving creams with aloe, mint, menthol or mentholatum will block. (2) Razors with aloe strips adjacent to the cutting edge deliver salicylates through microscopic cuts. Vitamin E, lanolin, cocoa/shea butter and mineral oil are all acceptable.
Oral Agents: (1) Most mouth washes contain mint, wintergreen or salicylate (Listerine). (2) Toothpastes contain salicylates, as well as fresh or artificial mint, often unlisted. Use Cleure toothpastes, the non-mint ones made by Tom’s of Maine. Baking soda and/or peroxide provide good cleansing and whitening. The non-mint pre-brushing rinses are acceptable as are Cleure Mouthwashes. (3) Use no lozenges, dental floss, breath fresheners or chewing gums with any mint flavor, including menthol, wintergreen, peppermint or spearmint. (Fruit/Cinnamon flavors may mask mint hidden by the stronger flavors.).
Gardening: Sticky plant juices or saps adhere to the skin while gardening or weeding. Patients should wear waterproof gloves.
The QUICK CHECK here on the website will detail exactly how to check your products.
PHYSICIANS CANNOT BE EXPECTED TO RECOGNIZE OR KNOW ALL THE INGREDIENTS IN YOUR TOPICAL PREPARATIONS. DOCTORS WILL ASSUME GUAIFENESIN HAS FAILED IF PATIENTS DO NOT COMPLETELY PURGE SALICYLATES. IT IS YOUR RESPONSIBILITY TO FOLLOW OUR PROTOCOL EXACTLY.
No diet is required for fibromyalgia since the liver alters food salicylates. The only exception to this is that we ask patients not to drink tea. The camellia plant is very high in salicylates and steeping makes it stronger. (There is no problem with coffee and with plants other than those in the tea or mint family.)
Do not use decongestants or cough medicines to get guaifenesin. There are potential side effects from various additives. Single ingredient guaifenesin has no side effects (save rarely mild, but transient nausea) and no known drug interactions. Using it with salicylates causes no ill-effects, it simply negates the drug’s effectiveness for fibromyalgia.
Pain medications such as acetaminophen (Tylenol), Ultram, Imitrex, non-steroidal drugs such as Advil, and Aleve, will not block guaifenesin.
Our treatment is not for those lacking courage. It calls for patient skills and, hopefully, physician assistance. Remember, reversal of the disease reproduces past symptoms and may cause new or long-forgotten ones to re-surface. The intensity of these early cycles often causes concern during the initial weeks of treatment. Such symptoms are not guaifenesin side effects. Patients realize they were getting steadily worse long before starting our protocol despite medicinal Band-Aids used to mask symptoms. We offer hope to those with determination to try once more despite previous failures. This is a highly-effective protocol.
R. Paul St. Amand, M.D.
Associate Clinical Professor of Medicine
Endocrinology--Harbor-UCLA
Claudia Craig Marek
Medical Assistant
[email protected]
Important: Do not assume fibromyalgia is the cause of all symptoms. When in doubt or confronted with new problems, please consult your personal physician or appropriate specialist.
Guaifenesin PRotocol resources
| Blank "Body Map" Template |
| Fibromyalgia Paper - For Patients (PDF) |
| physicians_paper_-_march_2014.pdf |