I was at FDA this week to testify for approval of Ampligen for ME. I was surprised when several people, including a representative of Hemispherx—the company that makes Ampligen— felt assured that Dr. Beth Unger, head of CFS research at CDC, would vote for approval.
In my view, Beth Unger—who should know the suffering that millions experience with ME better than most FDA committee members—would vote for Ampligen approval when pigs fly.
Like most of the committee (9 to 4), Unger voted no, when it came to evidence of Ampligen's efficacy. She also voted with the majority (9 to 4) that the company did not supply adequacy of safety data. She voted with the majority (8 to 5) that the company did not provide sufficient efficacy and safety data to bring the drug to market. However, she also voted with the majority of members (8 to 5) who said that the drug's safety profile overall was acceptable.
Vodka and Beets
Granted there were issues with the studies—but there are issues with all studies, and side effects with all drugs, and on and on. Of course you can make a strong argument for not approving a drug with problematic trials when there are other drugs on the market, but when there aren't any? For a disease that afflicts 1 million Americans and 20 million worldwide? When there are no drugs in the pipeline? When the majority of the committee says it's safe? Ampligen has a near 30-year history of helping patients, and there haven't been any
fatalities from the drug. How many FDA-approved drugs have that track
record?
At FDA, Unger also said in her
decision that more needs to be known about this "subset" of ME patients
who responds to Ampligen. If Unger, the late William Reeves and the rest
of the sham scientists at CDC had bothered to investigate the disease seriously for the past 30 years, those "subsets" would have been defined by now and drugs would have been approved. Now, CDC is finally running the study. What are the odds CDC will discover anything useful? Pleassssssssse.
Muddle, Muddle
Of course, when you muddle the definition of ME or CFS or whatever you want to call it for 30 years, when CDC lumps its CFS studies in with "idiopathic fatigue" and "unwellness," when CDC is looking for personality disorders in patients instead of viruses and retroviruses, when CDC cold calls depressed women in Georgia and Kansas and tells them they have CFS when they didn't know they had anything wrong with them—believe me, if you have this disease, you know absolutely, the way you know if you like liver or chocolate or vodka or beets, that something is terribly wrong with you—is it any wonder that the patient population gets muddled?
Of course not, since that's the idea: Muddle everything, so that there's no data to hang your hat on, so that ME remains a mystery forever and ever, so that you have job security until retirement. Muddle, muddle, toil and trouble.
FDA: More Studies
FDA also said it believes the data is interesting and the panel wants to see another Ampligen study. From what I've learned, the company doesn't have money for another study now. So how is that going to happen?
Alaine Perry
One other point, before I bring you the main point—I buried the lead—of my post.
The FDA committee seems to think that the fantastic, and I mean fan-frigging-tastic presentations by patients—including several beyond-articulate patients who are also physicians—are outliers, in other words, in the committee's eyes, they're far sicker than the average patient.
Thank God for Alaine Perry, a brave scientist on the Ampligen committee who has ME and voted for approval. Perry, 52, senior adviser for Disability and Special Need Population, CMS Center for Strategic Planning, said that the average patient is very sick. And when committee members were grousing about the problematic side effects of Ampligen—the flu-like symptoms, the headaches—Perry also made clear, in her determined, resonant voice, that those are everyday symptoms of ME. She explained that she works at FDA, but that's all she can do. She went caroling one day—she said she loves to sing—but knew she couldn't sing in a choir every week. She doesn't have the energy after work. Perry broke down, and so did many people in the audience.
Why does the committee think most ME patients aren't that sick? Could it be the name CFS that CDC coined? Could it be the useless research perpetuated by same? Laurence Fishburne, where are you? Where the hell is the CDC of the movie Contagion? Not doing ME research, that's for sure.
Oxford Definition
But there's more. A couple of weeks ago 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
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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.