Abstract:
The present invention relates to methods and compositions comprising ribose for the treatment of fibromyalgia syndrome. The methods and compositions of the invention are especially suitable for oral administration and are useful for alleviating the symptoms of pain, fatigue, and irritable bowel syndrome in fibromyalgia syndrome.

Description:
CROSS REFERENCE TO RELATED APPLICATION 
     This application claims benefit of U.S. Provisional Application Ser. No. 60/161,841, filed on Oct. 27, 1999. 
    
    
     BACKGROUND OF THE INVENTION 
     Fibromyalgia syndrome is a common yet mysterious condition with symptoms of widespread pain and fatigue. The syndrome afflicts five to ten million Americans, women 20 times more often than men. It occurs worldwide with no particular ethnic correlation. It has been proposed by various researchers that the syndrome is caused by such diverse causes as: growth hormone deficiency, relaxin hormone deficiency, autoimmune (rheumatoid) disorder, spinal cord compression, viral infection (heptatisC virus), injection with rubella vaccine, idiopathic nociceptive dysfunction, silicone implants, and other causes. It has even been suggested that fibromyalgia is a psychosomatic symptom of depression. 
     Nonetheless, the specificity of symptoms indicates a true syndrome, although primary cause versus side-effects remains unknown. In 1994, it became officially recognized as a diagnosis by the Copenhagen Declaration. The two criteria for the diagnosis of fibromyalgia as defined by the American College of Rheumatology (ACR) are: 1) diffuse widespread pain, and 2) the presence of multiple tender points. The latter comprise 18 points that are extremely painful on palpation. These specific sites are at the base of the occiput, the cervical anterior, the trapezius, the supraspinatus, the second rib, the epicondyle on the elbow region, the greater trochanter, the gluteus, and the fat pad on the knee. It should be noted that many of these tender points are not muscle tissue. In fact, some researchers believe that skin, tendons or the subcutaneous fascia are the primary nociceptive dysfunctional tissues. Accordingly, the syndrome is sometimes referred to as Myofascial Pain Syndrome. Although many patients report joint pain, unless those patients also have rheumatoid or osteoarthritis, the pain in the joints is referred pain from nearby skin, tendons or muscles. Typically, joints are not swollen as in arthritis. 
     In addition to pain and tender points, patients may experience a disturbed sleep cycle, tension headaches, irritable bowel syndrome, premenstrual tension syndrome, cold intolerance, deconditioning, reduced exercise tolerance and restless leg syndrome. Diagnosis is based on reporting pain in at least 11 of the 18 tender points. Pressure over one of these areas can cause referred pain in peripheral locations. 
     The symptoms of pain and fatigue are chronic and the intensity varies unpredictably. Patients may find that they are so severely affected that they are unable to work in their professions or perform daily tasks. There is no known cure for fibromyalgia. Among the suggested therapies are:steroids, analgesics, hormone administration, antidepressants, physical therapy, xylocaine injections into the tender points to allow for exercise and education on coping with chronic pain. Most patients can expect to have the symptoms lifelong. The common analgesics seem to have minimal effect. While strong analgesics such as codeine can diminish pain, these cannot be taken for long periods of time. Patients who are able to exercise routinely can experience improvement. Xylocaine injections may give enough temporary relief so that the patients can exercise, but these injections are inconvenient for daily use. For some patients, antidepressants also seem to help. Most doctors treating fibromyalgia patients suggest a combination of medical treatment, moist heat, and exercise. Because of the varied responses to treatment, patients are encouraged to make careful observation of any treatments that seem to offer some alleviation of symptoms and, based on their observations, to devise a personalized regimen. Otherwise, those who are afflicted must learn to live with the symptoms and a greatly reduced quality of life. 
     The need remains for compositions and methods of alleviating the symptoms of fibromyalgia, without inducing deleterious side effects. 
     SUMMARY OF THE INVENTION 
     The present invention relates to methods and compositions for the treatment of fibromyalgia. The present invention provides ribose, alone or in combination with minerals, vitamins, malic acid or ornithine to alleviate pain and fatigue as well as irritable bowel syndrome due to fibromyalgia. 
    
    
     DESCRIPTION OF THE DRAWING 
     FIG. 1 summarizes the clinical protocol to be followed. 
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     While it is not known whether the pain and fatigue in fibromyalgia are due to neuronal, endocrine, physiological, or genetic factors, an approach that would alleviate some or all of the symptoms of the condition would be an improvement in the current treatment regime. Applicants have disclosed in U.S. patent application Ser. No. 09/290,789, now U.S. Pat. No. 6,159,942, that ribose is useful in raising the energy levels of healthy individuals during intense exercise. In addition, Applicants have also disclosed in pending U.S. patent application Ser. No. 09/405,462, now U.S. Pat. No. 6,339,716, that ribose can prevent and alleviate muscle soreness and cramping in healthy exercising humans and patients with emphysema. However, it is believed that these effects are due to the energy-stimulating effects of ribose administration to subjects with a higher than usual energy demand or lower than usual oxygen availability. We have now unexpectedly found that ribose also alleviates symptoms of pain and fatigue as well as painful irritable bowel syndrome in fibromyalgia patients, who do not have a higher than usual energy demand and who experience constant pain in both muscular and non-muscular tissue. 
     This invention provides ribose for the alleviation of pain and fatigue and irritable bowel syndrome experienced by patients with fibromyalgia. The alleviation of pain and fatigue in turn is reflected in an increased feeling of well-being and energy. By “alleviation” is meant the definition as set forth in Webster&#39;s Ninth New Collegiate Dictionary: “alleviate . . . ” to make (as suffering) more bearable.” In this case, a noticeable reduction in the levels of pain, achiness, fatigue and a noticeable improvement in bowel function, as reported subjectively by the patient. A convenient composition comprised of ribose, magnesium, malic acid, vitamins C, B 3  and B 6 , tryptophan, calcium, zinc and ornithine or arginine is also provided. Preferably, this composition is mixed in eight ounces of water and taken orally two to four times a day. This invention also provides doses and protocols for maximum beneficial effect. 
     Ribose is a simple 5-carbon sugar, with a slightly sweet taste. It is a white to light yellow crystalline powder. The amount necessary to alleviate symptoms of fibromyalgia can be between 2 and 50 grams per day depending on severity of the condition and the individual response to ribose ingestion. The preferred dose is around 20 grams per day taken in 10 gram doses twice a day or 5 gram doses 4 times per day. The ribose can be ingested directly, sprinkled on food, or mixed in a liquid such as water, juice, coffee, or tea. Ribose could also be ingested as part of an energy bar or other functional food. In the most serious cases, ribose could also be administered by other methods such as intravenous, intraperitoneal, or transmucosal delivery. 
     We have found that the steady ingestion of ribose two to four times per day over the course of a week is enough to observe noticeable improvement in the level of fatigue, achiness, pain, and energy, and alleviation of irritable bowel syndrome. Continued ingestion leads to greater improvement, in turn allowing the patient to endure the much needed regular exercise to further relieve the painful symptoms. 
     A convenient premixed composition containing the recommended dose of ribose plus other ingredients that address other symptoms of fibromyalgia may provide added benefit. 
     The following examples are included to demonstrate the preferred embodiment of the invention. D-ribose is the preferred embodiment, however, to those skilled in the art it is known that certain pentoses such as xylitol and ribulose are readily converted to D-Ribose in vivo. Therefore, the term “ribose” is intended to include D-Ribose and such precursors thereof. It should be appreciated by those skilled in the art that the methods and dosages in the examples that follow represent methods and dosages discovered by the inventors to function well in the practice of this invention, and thus can be considered to constitute preferred modes for its practice. However, those skilled in the art should, in light of the present disclosure, appreciate that many changes can be made in the specific embodiments that are disclosed and still obtain a like or similar result without departing from the concept and scope of the invention. All such changes are considered to be within the spirit, scope, and concept of the invention as defined by the appended claims. 
     EXAMPLE 1 
     Alleviation of Symptoms in a Fibromyalgia Patient 
     A female patient diagnosed with fibromyalgia had been experiencing extreme muscle pain and fatigue as well as irritable bowel syndrome, disturbed sleep, and cognitive dysfunction. She had been told by her physician that she was in the worst stage of the condition and could end up in a wheel chair within a year. She began taking ribose, one teaspoonful (about 5 grams), 4 times per day. She felt an immediate improvement in her symptoms and noticed that she had more energy and fewer flare ups of muscle soreness. She continued taking it for a week then decided to observe the effects of stopping the doses of ribose, so she discontinued the protocol for one week. The symptoms returned to their previous level. She resumed taking one teaspoonful 4 times per day and after 4 weeks reported that it not only alleviated her pain, fatigue and morning stiffness, but also improved her irritable painful bowel syndrome. She stated that “It is without a doubt the best product I have ever been on.” 
     EXAMPLE 2 
     Pilot Study on the Effect of Ribose in Alleviating the Symptoms of Fibromyalgia 
     Four women subjects ranging in age from 45 to 55 were given ribose and instructed to take at least 20 grams per day, preferably divided in four doses. The recommended mode of administration was one heaping teaspoon, about five to seven grams, mixed in six to eight ounces of water, taken preferably with meals and before planned activity. Subjects were encouraged to vary the dosage according to their perceived needs. Each subject was given a health status profile (SF-36) to complete. The profile was to be filled out both before and after four weeks of ribose administration. Two of the subjects complied with filling out the profile. 
     Health Status Profile (SF-36): 
     1) General health compared to one year ago: 1=much better, 2=somewhat better, 3=about the same, 4=somewhat worse, 5=much worse 
     2) Energy, 2 questions, from peppy all of the time to none of the time. 
     3) Activities, 12 examples from vigorous to mild, scored as: limited a lot, limited a little, not limited 
     4) Pain: 1=none, 2=very mild, 3=mild, 4=moderate, 5=severe, 6 =very severe The results of each subject&#39;s before and after ratings are summarized in Table I. 
     
       
         
               
               
               
               
               
             
           
               
                 TABLE I 
               
               
                   
               
               
                   
                 General 
                   
                   
                   
               
               
                   
                 health 
                   
                   
                   
               
               
                   
                 compared to 
                   
                 Activities (12 
                 pain 
               
               
                   
                 last year 
                 Energy 
                 total) 
                 before/ 
               
               
                 Subject, age 
                 before/after 
                 before/after 
                 before/after 
                 after 
               
               
                   
               
             
             
               
                 #1 45-54 
                 much worse 
                 little of 
                 8 of 12 limited a 
                 very 
               
               
                 Fibromyalgia 
                 
                   ————— 
                 
                 the time 
                 lot —————   
                 severe 
               
               
                 for 15 years 
                 somewhat 
                 
                   ————— 
                 
                 1 of 12 limited a 
                 
                   ————— 
                 
               
               
                   
                 better 
                 all of the 
                 lot 
                 moderate 
               
               
                   
                   
                 time 
               
               
                 #2 50-55 
                 somewhat 
                 none of the 
                 2 of 12 limited a 
                 severe 
               
               
                 Fibromyalgia 
                 better 
                 time 
                 lot —————   
                 
                   ————— 
                 
               
               
                 for several 
                 
                   ————— 
                 
                 
                   ————— 
                 
                 0 of 12 limited 
                 moderate 
               
               
                 years 
                 much better 
                 some of the 
                 activities 
               
               
                   
                   
                 time 
               
               
                   
               
             
          
         
       
     
     Each of these subjects reported a drop in energy and increase in aching within a day of suspending ribose administration. 
     Subject #3, age 52, who was compliant with the protocol but did not complete the profile, reported that she experienced an improvement in her fatigue level and less achiness. She began to feel more energetic, but did not feel a decrease in severe pain at the tender points. Cessation of administration resulted in next-day loss of energy. 
     Subject #4, age 50-55, who did not complete the profile, also did not follow the protocol. Nonetheless, she reported that when she felt exhausted, she would take ribose and feel more energetic. 
     As can be seen, no subject reported total relief from all symptoms of fibromyalgia, but all reported some alleviation. 
     EXAMPLE 3 
     Treatment of Fibromyalgia With Oral Ribose 
     Following the informal studies in five subjects, a protocol was written to determine whether oral ribose administration in patients with fibromyalgia (FM) can reduce symptoms of fatigue and pain and improve the subjects&#39; quality of life. The study endpoints will be: (1) the patient&#39;s visual analog (PVA) scale for pain, (2) the patient&#39;s analog scale for fatigue, (3) the physician&#39;s global assessment (GA phs ), (4) the patient&#39;s global assessment (GA PT ), (5) the Western Ontario MacMaster Questionaire (WOMAC) index, (6) SF-36 quality of life form, (7) the patient&#39;s&#39;s daily activity/events log and (8) the number of days to study discontinuation, if the patient chooses to do so, based upon his/her improved condition. 
     The details of the WOMAC index and the PVA are as follows:                           
     Following is a study Event Schedule to be used for protocol compliance and patient monitoring during the clinical study. 
     
       
         
               
             
               
             
               
               
             
               
               
               
               
               
               
             
               
             
               
             
               
               
             
               
               
               
               
               
               
             
               
             
               
             
               
               
               
               
               
               
             
               
             
               
               
               
               
               
               
             
               
             
               
               
               
               
               
               
             
           
               
                   
               
             
             
               
                 SECTION C 
               
             
          
           
               
                 INSTRUCTIONS: 
               
               
                 The following questions concern your physical function. By this we mean 
               
               
                 your ability to move around and to look after yourself. For each of the 
               
               
                 following activities, please answer each question with an “X” in the 
               
               
                 appropriate box to indicate the degree of difficulty you have experienced 
               
               
                 during the last 48 hours due to pain or fatigue. 
               
             
          
           
               
                   
                 What 
               
               
                   
                 degree of difficulty did you have with... 
               
             
          
           
               
                 QUESTION: 
                 None 
                 Mild 
                 Moderate 
                 Severe 
                 Extreme 
               
               
                   
               
               
                 1.Descending stairs. 
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                 2.Ascending stairs. 
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                 3.Rising from sitting. 
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                 4.Standing 
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                 5.Bending to floor. 
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                 6.Walking on flat surface. 
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                 7.Getting in/out of car. 
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                 8.Going shopping. 
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                 9.Putting on sock/stockings. 
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                 10.Rising from bed. 
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                 11.Taking off sock/ 
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                 stocking. 
               
               
                 12.Lying in bed. 
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                 13.Getting in/out of bath. 
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                 14:Sitting. 
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                 15.Getting on/off toilet. 
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                 16.Heavy domestic duties. 
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                 17.Light domestic duties. 
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                 WOMAC INDEX 
               
               
                 SECTION A 
               
             
          
           
               
                 INSTRUCTIONS: 
               
               
                 Answer each question with an “X” in the appropriate box, based on 
               
               
                 fatigue or the amount of pain you experienced in your muscles. For each 
               
               
                 situation, enter the amount of pain experienced doing the last 48 hours. 
               
             
          
           
               
                   
                 How much pain do you have? 
               
             
          
           
               
                 QUESTION: 
                 None 
                 Mild 
                 Moderate 
                 Severe 
                 Extreme 
               
               
                   
               
               
                 1. Walking on a flat 
                 □ 
                 □ 
                 □ 
                 □ 
                 □ 
               
               
                 surface. 
               
               
                 2. Going up or down stairs. 
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                 3. At night while in bed. 
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                 4. Sitting or lying. 
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                 5. Standing upright. 
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                 SECTION B 
               
             
          
           
               
                 INSTRUCTIONS: 
               
               
                 Answer each question with an “X” in the appropriate box, based on the 
               
               
                 amount of muscle pain you experienced during the last 48 hours. 
               
             
          
           
               
                   
                 None 
                 Mild 
                 Moderate 
                 Severe 
                 Extreme 
               
             
          
           
               
                 1. How severe is your pain after first awakening? 
               
             
          
           
               
                   
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                 2. How severe is your pain after sitting, lying or resting later in the day? 
               
             
          
           
               
                   
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     The study will include 16 patients with a confirmed diagnosis of FM using a double-blind crossover design. All patients who meet entrance or screening criteria will be randomly assigned to either treatment #1 (oral dextrose as a placebo) or treatment #2 (oral ribose) at a dose of 20 gm per day (10 gm bid), as a first treatment modality. Both physician and patient will be blinded to the treatment modality. Informed consent will be obtained prior to enrolment. Patients will be administered either treatment, as randomly assigned. All endpoint parameters will be assessed at baseline prior to treatment, after 4 weeks of treatment one, at the end of the workout period, and again following 4 weeks of treatment 2 (“crossover” treatment modality). FIG. 1 is a summary of the protocol. 
     Patients will be included in the study if they present with a confirmed diagnosis of FM, as defined by the ACR criteria. All FM patients must have a PVA score of 40 or greater and have at least 11 of 18 tender points. Patients will be excluded from the study if (1) they do not meet ACR criteria for FM, (2) are diagnosed with rheumatoid or osteo-arthritis or gout, (3) suffer from coronary artery disease or recent myocardial infarction of less then three months, heart failure, diabetes mellitus, chronic obstructive/restrictive lung disease, hepatic or renal disease, cancer, or other metabolic disorders. In addition, all pregnant or lactating women will be excluded. 
     It is expected that, as in the pilot study, most of the patients will experience some alleviation of achiness, fatigue and/or pain at the tender points. 
     4. Convenient Composition for Administration of Ribose and Other Ingredients 
     Although ribose is the primary ingredient for alleviating pain and fatigue, other compounds have been found beneficial in alleviating other symptoms of fibromyalgia. Magnesium, as magnesium carbonate, oxide, sulfate or citrate, has been found to enhance muscle energetics. Malic acid has shown some advantage in treating fibromyalgia. Calcium and zinc tend to relieve sleeplessness. Tryptophan, vitamins B3 and B6 are thought to be beneficial in the synthesis of serotonin, which affects mood. Omitine and/or arginine are precursors to growth hormone, low levels of which may be among the causes of fibromyalgia. Vitamins C is often borderline deficient in fibromyalgia patients and may be added to the composition. It is convenient for a patient to be able to administer these compounds in a single preparation. Table II shows a dry composition to be dissolved in eight ounces of water and administered twice daily. 
     
       
         
               
               
               
               
             
               
               
               
               
               
               
             
           
               
                   
                 TABLE II 
               
               
                   
                   
               
               
                   
                   
                 Preferred 
                 Acceptable 
               
               
                   
                   
                 daily dosage 
                 daily range 
               
               
                   
                   
               
             
             
               
                   
               
             
          
           
               
                   
                 Ribose 
                 10 
                 grams 
                 2 to 50 
                 grams 
               
               
                   
                 Magnesium citrate 
                 500 
                 mg 
                 200-1000 
                 mg 
               
               
                   
                 Calcium carbonate 
                 500 
                 mg 
                 200-1000 
                 mg 
               
               
                   
                 Zinc citrate 
                 10 
                 mg 
                 5-15 
                 mg 
               
               
                   
                 Malic acid 
                 1300 
                 mg 
                 800-1500 
                 mg 
               
               
                   
                 Ornithine* 
                 2 
                 mg 
                 1-10 
                 mg 
               
               
                   
                 Vitamin C 
                 500 
                 mg 
                 200-1500 
                 mg 
               
               
                   
                 Vitamin B 3   
                 10 
                 mg 
                 5-30 
                 mg 
               
               
                   
                 Vitamin B 6   
                 120 
                 mg 
                 50-200 
                 mg 
               
               
                   
                   
               
               
                   
                 *Arginine or citrulline may be substituted for ornithine.  
               
             
          
         
       
     
     The ingredients are triturated as a powder and can be conveniently administered in capsules, tablets or dissolved in any carrier, such as water or juice. If the solvent is water, many patients will prefer a sweeter composition with added flavor. The sweetener is most preferably sucrose. It is also convenient to prepare concentrated solutions which may be diluted to taste. It is most convenient to provide a drink with the composition of Table II dissolved in eight to ten ounces of water. 
     It will be understood by those skilled in the art that many subsitutions and additions may be made to the above invention without departing from the spirit and scope of the invention. Therefore, such substitutions and addtions are considered to be within the scope of the invention as herein claimed.