Earlier this week we spoke to a journalist who had written a piece about chronic fatigue syndrome or M.E. for RNZ's online site The Wireless. We received a huge amount of feedback from sufferers and their families about their experiences with the debilitating illness.
Many sent in questions they wanted answers to, some hoping for treatment options. We decided to get an expert in to explain the illness a little more in depth.
Dr Ros Vallings has spent decades dedicated to helping those with CFS, she has a clinic in Howick and has taken a break from patients to respond to our listeners.
Listen to radio interview here.
ME Association Statement: Negative phase III clinical trial result from Norway for Rituximab in ME/CFS | 27 November 2017
By Dr Charles Shepherd, Hon. Medical Adviser, ME Association.
“I was disappointed to learn – while at the Royal Society screening of the documentary, Unrest, in London last Thursday – of the preliminary (but unpublished) results from the phase III clinical trial of Rituximab, that has been carried out in Norway.
“This large, multicentre, ‘gold standard’ clinical trial, involved 152 people with ME/CFS receiving either Rituximab or a placebo, with initial treatment followed by maintenance treatments at 3, 6, 9 and 12 months, and a two year follow up.
“The ME Association has consistently taken the position that Rituximab could be one of the most promising developments in the search for a safe and effective drug treatment that is targeted at the underlying disease process in ME/CFS.
“We also know that the physicians involved in this research – Drs Oystein Fluge and Olav Mella from the Haukeland University Hospital in Norway – have taken great care in the way that they have devised the protocols for the clinical trials that have been carried out and reported.
“Despite the headline negative finding, we believe that this trial will still provide useful insights and contribute to a better understanding of M.E., and we also have the results from the Cyclophosphamide clinical trial to look forward to. We are very pleased that this knowledgeable, and valued, research team will continue with their work, trying to find answers to the M.E. puzzle.
“The ME Association Ramsay Research Fund had set aside around £60,000 to help support this research, or to help fund a clinical trial of Rituximab here in the UK, if such funding was required, and applied for by a reputable research or clinical trials group. No research grant applications have been received.
“It is difficult to comment further on these very basic preliminary results, and my understanding is that no further comment will be made by those involved until the study is published early next year. However, we do believe that it is correct and helpful for the patient community to be notified about the disappointing key conclusions prior to publication.
“Any decision – including if it is going to be sensible for the charity sector to be raising or spending further large sums of money on research involving the theoretical basis to this treatment (i.e. immune system dysfunction, involving the B-cell component of the body’s immune system), or further clinical trials to assess the safety and efficacy of Rituximab – will have to wait until more detailed information becomes available about the outcome of this phase III clinical trial, and the scientists involved have expressed their opinion as to whether further such research is justified.
“Based on the results from the clinical trials that have been published so far – along with the rather mixed evidence from people with M.E. who have been prescribed Rituximab outside formal clinical trials – it does appear that this type of immunotherapy could still be relevant to at least a sub-group.
“If it is agreed by experts in this area of immunotherapeutics (and we will be seeking expert advice), that we should continue to explore the role of Rituximab as a possible treatment for ME/CFS – and try to find immune system biomarkers that could help to identify the sub-group of people with M.E. who are most likely to respond to such treatment – the ME Association will continue to invite applications for research grants to the Ramsay Research Fund.
“Medical journals are less enthusiastic about publishing negative research findings or negative results from clinical trials. However, given the enormous amount of interest in Rituximab, from both people with M.E. and the medical community, I am confident that these results from Norway will be accepted for publication in due course.
“The ME Association is currently considering a number of other research applications – some of them quite large – and trustees will discuss the latest news about the Rituximab clinical trial at their Board meeting in December. A decision will then be made as to whether the £60,000 currently set aside, should remain as a ring-fenced sum for funding Rituximab research, or used for other biomedical research applications.”
Dr Charles Shepherd,
Hon Medical Adviser, ME Association.
The statement from Haukeland University, Bergen from Professor Mella is a major disappointment for people with ME and their families.
What had looked to be a promising line of research that could lead to an effective treatment for a subgroup of patients defined by the Canadian Criteria and major understanding of the pathology of this disease has proven to be inconclusive.
Naturally, at the charity, everyone is disappointed. We are disappointed for all the ME patients and carers and families and friends.
We are especially disappointed for all of our supporters and all who have made such generous and tireless efforts to raise funds and awareness of our campaign.
We are very disappointed also for the Haukeland research team - a wonderful team who have brought hope to all patients - and, importantly, brought new insight into this disease and new interest from other areas.
However, we have found, throughout 12 years of trying to change the way that ME is perceived, researched and treated that it is never easy.
It would be easy to give up, to resign oneself to nothing changing, to accept the status quo.
But we think differently.
At the 2017 Colloquium/Conference we invited Karolinska Institutet in Stockholm to present negative results. Because it is important to use negative results for positive effects. Negative results are data and the Norwegian rituximab trial has generated a lot of data that needs to be looked at very carefully.
When we first engaged Professor Jonathan Edwards into research into ME one of the earliest comments he made was that he was pleased to note that our conference did contain negative results.
We see the positives in this research which has been performed by researchers of the utmost integrity who have not made headlines for the sake of it but have thoroughly conducted outstanding research, and still retained a humility that is to their credit and that of their colleagues and team.
We have an excellent research team in Norway which has served the ME patient community and their families with honesty, integrity, professionalism, determination and an empathy which had never been seen before in this field.
We have established good working relationships between the Norwegian researchers and the UK Centre with input from UCL and UEA/Quadram Institute.
We have data now – more than before.
We have research which IiMER has established and a foundation for the Centre of Excellence for ME.
We have international collaboration in research into ME that will continue.
And we have new plans – already in the making.
The researchers from Haukeland will give more detail on their results and publish a paper or two which will benefit all studying ME.
For us, we have invited the Haukeland team to Norwich to discuss the way forward.
We remain positive. Another setback, another day.
We have already been in discussion with our advisors and with the Norwegian team and we will meet to clarify the best way forward in the near future with our major funder and researchers.
We still have much good research being funded and being planned and feel our stategy is, and will pay off and lead to the most rapid route to finding cause(s) of ME and effective treatments.
In another age, and in another struggle which has some parallels to that which is forced upon people with ME, these words strike a chord -
“ We must accept finite disappointment, but never lose infinite hope. ”
- Dr Martin Luther King
No Isolation for ME
November 15, 2017–
With myalgic encephalomyelitis (ME), one of the most insidious consequences of this devastating and disabling disease that affects patients can be the isolation experienced.
This is especially true for younger patients and the consequences of this can extend far into adulthood and beyond and lead to unnecessary departure from society.
Already, due to the consequences of a lack of a sensible and standardised pathway to care, patients are stigmatised and excluded from society.
This need not be so and much could be done to avoid this by tackling this issue early on for young children affected by ME.
Earlier this year Invest in ME Research was contacted by a Norwegian company who were interested in demonstrating a product that was aimed at reducing the isolation experienced by many younger people who were unable to attend school, or were cut-off from social contact due to illness.
Obviously, the charity immediately saw the parallels with ME and the possibility of raising awareness of one of the least publicised side effects of this disease on patients, and their families.
Our immediate reaction was how we can help use this to publicise awareness of the effects of ME on children.
We then invited the company – No Isolation – to take a table at our 12th International ME Conference in London (IIMEC12) and offered to work further to support this campaign.
The charity felt this to be a worthwhile cause that could help alleviate some of the unnecessary suffering that careless or ignorant education systems inflict on sick children and their families.
The company’s product - AV1 robot - helps children and youths with ME to continue to be connected to their peers at school despite not being present for all or some of the time due to illness.
The robot is now available in the UK and together, with No Isolation, we are hoping to set up trials.
Invest in ME Research will be contacting local education authorities to trial AV1.
Initially, a trial of three AV1 robots will be set up involving families who currently have a child with ME who is unable to attend school, or whose regular attendance is compromised by ME.
Children and youths with long-term illness such as ME do not need to be excluded from their friends’ activities and progress and schools have a responsibility not to ignore them – something which can lead to long term discrimination.
The robot, called AV1, acts as the students’ eyes, ears and voice in the classroom on days where they cannot be physically present. With AV1 the student controls the robot with an app on a tablet. When the student raises their hand, a light flashes on AV1’s head. The robot can be turned 360 degrees, so the student can see the entire classroom and talk to other students. If the student does not feel like actively participating, they communicate it by turning on a blue light on AV1’s head. AV1 is designed to withstand Childs play, and can join classmates in the playground or on after school visits.
AV1 is already helping ME-patients across Scandinavia, the Netherlands and UK.
Children and youths suffering from ME is the largest user group – a salient point and one that ought to be a red flag for any education system.
Research fellow Jorun Børsting and senior lecturer Alma Leora Culén at the Institute for Informatics, University of Oslo, are researching the technology needs of ME-patients. Having studied the use of AV1 among nine children and youths suffering from ME they see a big advantage in the fact that the robot is designed with ME-patients in mind. Børsting stresses that the robot cannot fully replace normal attendance at school or home teaching, but act as a supplement.
We invite support for this campaign to help younger children – in the hope and knowledge that it could lead to fewer problems in the future for young people affected by ME.
“Of the children I followed several had not attended school in a long time when they first received the robot.
Some had been out of school for over six months.
After they received AV1, all of them participated regularly, on their own terms”
- Jorun Børsting, Research fellow and senior lecturer Alma Leora Culén at the Institute for Informatics, University of Oslo.
Invest in ME Research will receive no financial reward for this campaign.
The charity does this in order to highlight and overcome a major consequence of becoming ill with ME.
We invite support for this initiative by assisting us with contact to local schools and education authorities.
The advantage in participating in class through a tablet is that they have full control over sound levels, light and movement. In a normal classroom they do not have the option to control sensory inputs in this way. Furthermore, they can participate exactly when they feel like it, taking into account that symptoms can fluctuate over the course of the illness, even from hour to hour
Invest in ME Research is a major UK charity which campaigns for biomedical research into ME and for proper education of healthcare staff and support for ME patients.
The charity has been instrumental in initiating a UK Centre of Excellence for ME and there are now five PhD student positions involved in researching ME.
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If you would like more information about this topic, please contact Invest in ME Research at 02380 643736 or email at firstname.lastname@example.org.
If you would like to be one of the families trialling AV1 and would be prepared to report back during the trial and work with us, No Isolation and the school/school authority then we would be very keen to hear from you.
The London Med Ed Workgroup is a new initiative formed during the 11th Invest in ME International ME Conference 2016 (IIMEC11), held in London on June 3, 2016.
Solve ME/CFS Initiative’s vice president for research and scientific programs, Dr. Zaher Nahle, was tasked by meeting organizers to assemble a starter team of Med Ed experts from conference participants to examine national and international medical educational efforts in ME/CFS and explore areas for potential collaboration.
The goals of the London Med Ed Workgroup are to 1) create effective vehicles for improving current medical information on ME/CFS, 2) improve the dissemination and exchange of medical information, and 3) develop educational materials building on existing tools and relevant literature.
On June 4, 2016, the team held its first meeting in London, followed by a teleconference in July. In addition to Dr. Nahle, the team thus far is comprised of several prominent patient advocates and ME/CFS experts including Mary Dimmock, Dr. Rosamund Vallings, Dr. James Baraniuk, and Dr. Vicky Whittemore. Regular updates will be provided on the work of this team as well as its ongoing efforts and expansion.
“This collaborative work is yet another way in which we are trying to create momentum on all fronts of ME/CFS,” said Dr. Nahle. “When it comes to a complex, poorly understood disease like this, it is critical that every medical health professional, all medical school curricula, and every governmental agency site is up to date and equipped with the right information and tool kits; this is feasible in this day and age.”
Notably, Dr. Nahle is also part of the CDC Technical Development Workgroup (TDW) that provides input on the accuracy and effectiveness of the CDC website and the dissemination of correct information to healthcare providers as well as the general public. There are many aspects of the current CDC website that provide insufficient or incorrect information to the public; we are actively engaged in working to correct this serious deficiency.
We are grateful for the opportunity to provide input to the Trans-National Institutes of Health (NIH) ME/CFS Working Group as they develop strategies to guide NIH's research efforts and priority setting for research on ME/CFS. Our mission at the Stanford Chronic Fatigue Syndrome Research Center is to discover causes, a molecular diagnosis, and treatment options for ME/CFS. Through our research efforts, collaborations with the ME/CFS research and clinical community, and extensive engagement with patients, we have defined several elements of importance for future ME/CFS research programs.
A key consideration in ME/CFS research efforts is the complex and multisystemic nature of this disease, and we are happy to see the involvement of several NIH institutes in developing this plan. Because the causative factors driving the disease remain unknown, and because work from our team and others has indicated effects on neurology, metabolism, immunity, and more, it will be crucial that calls for proposals allow for open, unbiased, multifaceted, and systematic research. Broadening the scope of ME/CFS research will create opportunities for engaging researchers in other disciplines. Similarly, investigating numerous organ systems and biological pathways perturbed in ME/CFS may well reveal informative parallels to other diseases – for example, we and others have observed symptomatic, transcriptomic, and metabolic overlap between ME/CFS and neurodegenerative disorders like Parkinson's Disease. It is important not to limit research to single organs like the brain, and to integrate results from many different organs and molecular processes so that they can be understood at the systems level. Big data approaches and high-throughput, large-scale molecular profiling should therefore be prioritized. Such efforts hold promise to identify key genes or pathways underlying ME/CFS. Similarly, large-scale in vitro drug screening efforts would help point to a variety of molecules and molecular processes as therapeutic targets.
Understanding the molecular etiology of ME/CFS is another important opportunity. A long-standing belief in the field is that an infectious agent causes the disease, and that the pathogenicity of the as-yet-undiscovered organism is responsible for the severity of the illness. An equally plausible explanation is that a stressor such as trauma, infection, or genotoxic stress may trigger a series of events that lead to a hypometabolic state. This model is observed in children with congenital mitochondrial disorders, where the phenotype does not present itself until after a serious viral infection. This shift in thinking opens up the possibility that ME/CFS has strong genetic and environmental associations, which may also explain the extensive heterogeneity in its presentation, progression, and recovery across patients. The search for novel infectious agents should continue, but research efforts should also focus on understanding individual host susceptibility and response to infection. For example, it may not be a particular infectious agent that results in the disease, but rather a particular host state as a function of numerous biological and external factors that governs an individual’s susceptibility. This perspective mirrors the NIGMS-funded Glue Grant on Inflammation and Host Response to Injury, which used an integrated omics approach to define variable responses to infection and trauma. Characterizing host responses to infection and understanding the mechanisms of the long-term sequelae may reveal insights into ME/CFS that are relevant to numerous other diseases of infectious origin, such as Chronic Lyme Disease and Post-Ebola Syndrome (Mattia et al., 2016). Moreover, such precision medicine approaches would build a more comprehensive understanding of ME/CFS and offer richer opportunities for therapeutic intervention.
Another major challenge is our lack of understanding of the prevalence and landscape of ME/CFS, which is largely due to the difficulty in diagnosing the disease. The search for precise molecular biomarkers is a great opportunity afforded by this research program, which would be accelerated through multi-omics approaches in large patient cohorts. Current estimates of the prevalence of ME/CFS vary widely (800,000 to 2.5 million cases in the US) due to varying diagnostic and data collection methods. There is an opportunity here to improve these estimates based on modernized methods and community-defined standards, including criteria specified in the 2015 Institute of Medicine Report, and by considering questionnaire-based responses like the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort in the United Kingdom (Collin et al., 2016).
Because of these complex scientific challenges, ME/CFS research presents an excellent opportunity for developing and piloting novel methods and technologies in discovering biomarkers, elucidating disease mechanisms, and revealing therapeutic possiblities. The methods we need to understand this complex disease may very well not exist yet. Engineering and technology development efforts towards highly sensitive, quantitative molecular profiling and/or measuring novel cellular properties, as well as novel computational analyses that integrate multiple datatypes to define disease mechanisms, should be encouraged. Again, it is highly likely that such efforts will prove useful in the study of other diseases, be they infectious, genetic, or complex in origin.
Beyond scientific considerations, we would like to note several programmatic considerations that we believe are key for rapid progress. Long-term studies of patients are absolutely essential. Such a mechanism has proven effective in the NIGMS Glue Grants described above. Moreover, maintaining an open structure in RFAs will allow scientists to develop and refine their hypotheses as research progresses, as appropriate for the unknown/uncertain nature of the field. As highlighted in several places above, the opportunities for collaborative efforts within and beyond the ME/CFS research community to understand and treat this disease are numerous. There are numerous experts spread across the world, each taking their own approaches based on their own expertise. We believe future funding programs should not only encourage, but establish frameworks for highly collaborative data sharing and strategizing that bring together researchers and clinicians. All data should be made publicly available as early as possible (even before publication), in both raw and accessible formats. This will not only facilitate collaboration (for example by encouraging biocomputing experts to engage with the data) and integrative analyses, but also empower patients to understand more about their disease and what progress is being made. As we have all seen, the ME/CFS patient community is extremely active, engaged, and eager for actionable results.
We thank you once again for the opportunity to provide input on this matter, and look forward to the new strategies for ME/CFS research efforts put forth by this working group.
Ronald W. Davis, Ph.D. Professor of Biochemistry and Genetics, Stanford University
Director, Stanford Chronic Fatigue Syndrome Research Center and Stanford Genome Technology Center
Director, Scientific Advisory Board, Open Medicine Foundation