Brief Answer:
Fatigue and its origins

Detailed Answer:
Please consider finding a physician who is interested in working up your symptom of FATIGUE which is a complex state of both physical and mental dynamics that are poorly understood in terms of how this comes about in the face of having obtained good amounts of sleep, eating good amounts of foods, being well hydrated, etc. etc. Asking for a single medication is not as likely to give you long term relief as a thorough workup looking for the cause. This will require someone with some creativity and skill sets to investigate how fatigue is manifest from the perspective of neurological deficits as well as how fatigue manifests and is brought to the surface by other bodily systems and metabolic factors.

This is very likely one explanation why Nuvigil is not as effective

Therefore, if I were your treating physician I would put you through a solid history then, physical examination trying to determine when this symptom complex began and how it's actually evolved. I'm sure that you are aware that MS, FIBROMYALGIA, AND RHEUMATOID ARTHRITIS all are known to contain as part of their clinical picture FATIGUE as a major symptom. Nobody is really sure where this fatigue comes from in any one of those 3 entitiies and to them all at the same time, I'm sure must certainly do nothing but magnify the problem.

But have you been put through the metabolic checks and reviews to be sure that your THYROIDS are in good working order...and by THYROIDS I am talking about at the very least FT4, Total T4, TSH, and T3 (Total and Free). I would also include a standard CBC looking for any forms of anemia and if found I would run a full IRON PANEL with a SERUM ZINC since even iron is low in the body and causing anemia you may never correct the problem unless you also have adequate levels of zinc so I always check both at once before deciding on recommending iron supplementation.

Of course, Vitamin D's and B12 are always talked about and even though I am not one who believes in taking EXCESSIVE amounts of either vitamin for "energy" purposes.....I certainly do promote having the right amounts for normal health and well being, especially in someone who has 3 autoimmune diseases. That means that in my patients I also look to get their Vitamin D's into a range of 60-80 and with Vitamin B12- I'm looking for a MINIMUM of 400....450 is better. I would also do a Vitamin C assay in serum since that element is known to be highly integral to normal functioning of the IMMUNE SYSTEM thought to be making mistakes in the 3 progressive entities you've talked about. And if you can give better support to your immune system with Vitamin C INFUSIONS (talking about 25-30,000 mg. per bag) then, it is theoretically possible to put a bigger damper on the NEGATIVE EFFECTS of the 3 immune complex diseases that you are currently battling and it seems likely therefore, that the major symptoms they produce such as fatigue may be brought under better control.

I would also ask you to get on an exercise program which would be custom tailored to your needs with RA, MS, and FM so as to benefit you from a physical and stamina perspective. The Arthritis Foundation has an excellent website where exercise programs are outlined for people with a variety of arthridites.

Exercise is the single MOST EFFICIENT and LONG TERM solution to increasing stamina and reducing fatigue in most cases of metabolic or other disorders that cause people to be chronically tired and low on energy. In your case aqua-therapy would be outstanding to help stimulate you, your muscles, and your brain to gain more stamina throughout the day AND you'll sleep better at night.

I would also measure cortisol levels in serum as well as levels of metanephrines to get an idea of how your body is producing and metabolizing stress hormones since these play an integral role in a person's state of alertness and levels of tiredness. An endocrinologist would be the best person to consult for a full and complete set of appropriate tests along these lines.

I will suggest one medication which I believe can actually contribute more to making your nervous system at the very least more "awake" if not all your systems since every cell in your body both produces this substance as well as REQUIRES good quantities of it to function properly and that is NICOTINAMIDE DINUCLEOTIDE. It used to be referred to as Vitamin B8 but that designation was taken away since in fact, we produce it in our bodies. However, I've found in my patients that NAD tablets (more than any other dietary or prescription medication) in GENERALIZED CASES of fatigue and stress has the ability to get people feeling much better physically if not to some extent emotionally. There are some potential side effects that NAD possesses if taken in excess quantities so I might try it first at a low dose of 10mg. daily and then, slowly uptitrate on a weekly or biweekly basis to see how you feel. I would stop at 25mg. twice daily (total daily dose of 50mg.) and see how that makes you feel. The good news is that NAD doesn't really interact with other medications to any significant extent and it is neither habit forming nor will it cause rebound symptoms if at some point you decide to stop taking the medication. It will take time to get in to your system if you're going to take my advice and slowly uptitrate over several weeks.

Another medication I have found that can have a stimulatory effect but yet not itself be habit forming or dangerous in anyway in terms of drug to drug interactions or other unexpected side effects is the drug called AMANTADINE. Now, this is a prescription drug but I will also say that when we use amantadine (generally in Parkinson's patients or other neurodegenerative movement disorders) the effect seems to be much less prolonged. NAD on the other hand seems not to have the ceiling effect as much as prescription medications.

But once again, I URGE you to take the time, effort, and spend the money necessary to have a doctor thoroughly look into the possible ROOT CAUSE of your fatigue and then, if no specific causes can be identified look to using medications...but consider something SYSTEMIC like NAD as opposed to something highly specific such as Nuvigil since without knowing that's the major contributor you may be really pigeon holing yourself into a corner unnecessarily.

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This query has utilized a total of 112 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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