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Supplements and Drugs That Reduce or Prevent PEM (Post-Exertional Malaise)

frozenborderline

Senior Member
Messages
4,405
Due to TOS I can't say what I am going to do about this, but I certainly is not going to be very pretty indeed. I've had enough of these criminals, and lucky enough not to be bedbound. I like my sleep time. That's all I can say due to terms of service.
There are legal things that are benzos you can buy on theclear net, the regular internet. Like etizolam. Hopefully mods dont censor this bc etizolam has been shown to be safe in many studies , is still legal, will prevent withdrawals , but also there is no reason to do what I can tell you are saying between the lines about "TOS". I mean I respect anyone's decision to do that in general, but there is no reason to do that over benzos supply, it is totally possible to supply yourself. If you can get a passport so many mexican farmacias, at least small ones that aren't chains in cities , will sell valium or clonazepam or any benzo to you. There is lots of info of 5his online . I can link it later. Also if you look further up in the thread , I have listed things like imidazenil that can help.

If you couldn't source etizolam somehow, even though there are websites that still have it, and you didn't want to go to ER but want to prevent seizures or withdrawls, one thing I've done when running out is take phenibut , which you can buy online but is essentially a different kind of gabaergic than benzos, sort of similar to ghb or baclofen mixed with gabapentin. It will almost certainly prevent withdrawals but you want to also watch blood pressure as that can raise in benzos withdrawal and so I'd also take something like clonidine, guanfacine , or a beta blocker ... all things most doctors would give you either for anxiety or sleep or high blood pressure or heart rate or POTS. Seriously man, I realize its grim with doctors. I just talked to a pain doc who wont prescribe my valium and pain meds at the same time even tho I've been dependent on benzos for years and also need the pain meds. But there are avenues for this stuff and you dont need to do anythi ng drastic.

I can help you, or if I'm too tired and in pain, my sister can help you. You can message me , and ask for my phone number to talk off site. This issue of docs not refilling benzod scripts I was dependent on started years ago for me so I found other ways to fill the gaps , I have no shame about it, the withdrawals will kill you otherwise.
 

frozenborderline

Senior Member
Messages
4,405
Also gabapentin can be kind of weak but at bigger doses it can absolutely help a bit with withdrawals, even moreso with lyrica which is stronger version of a similar drug.
 

frozenborderline

Senior Member
Messages
4,405
Everyone should have the agency to decide what quality of life they are willing to dealwith, but my point @Rvanson , is that nothing about your benzo supply needs to be threatened just bc the docs stop filling it , and that doesnt need to be the last straw.
 

seamyb

Senior Member
Messages
560
My insomnia is only controlled by a benzodiazapine. Once that is cut off, and it will be one day, things ain't going to be very pretty. I use a standard, but high dose Rx'ed by a doctor. The government doesn't like people on them,
since they are abused by DRUGGIES (no apologies will ever be given to my use of that term) They crush them up and snort it up their noses to get a high.

So now, we who don't have highs on them, have to pay for their crimes. Due to TOS I can't say what I am going to do about this, but I certainly is not going to be very pretty indeed. I've had enough of these criminals, and lucky enough not to be bedbound. I like my sleep time. That's all I can say due to terms of service.

You don't think people who are taking drugs for a high, ruining their lives and damaging their health are doing so because of an illness? People live in poverty amongst people who have everything and their entire existence is a societal illness, not to mention the myriad of medical illnesses they have an astronomically disproportionate rate of.

Unless we're talking only of those middle class druggies who don't become addicted through social deprivation and just want a bit of a high. Even then, your issue shouldn't be with which methods people choose to enjoy themselves under the conditions they hurt nobody else, it should be with the people who enforce hypocritical laws on which unhealthy chemicals people are allowed to get high on.

Druggies aren't your problem, the war on drugs is.
 

Rvanson

Senior Member
Messages
312
Location
USA
You don't think people who are taking drugs for a high, ruining their lives and damaging their health are doing so because of an illness? People live in poverty amongst people who have everything and their entire existence is a societal illness, not to mention the myriad of medical illnesses they have an astronomically disproportionate rate of.

Unless we're talking only of those middle class druggies who don't become addicted through social deprivation and just want a bit of a high. Even then, your issue shouldn't be with which methods people choose to enjoy themselves under the conditions they hurt nobody else, it should be with the people who enforce hypocritical laws on which unhealthy chemicals people are allowed to get high on.

Druggies aren't your problem, the war on drugs is.

Yes, but did the chicken come before the egg? As I said, and apparently I will have to declare that it was druggies who started the so-called "War on Drugs". If you think I am heartless to them, you'd be quite mistaken. Yet, how is it that I have never snorted up ANY benzodiazepine medication, in all of these years? Not even _ONCE_.

And ,YES, the druggies are hurting me. The psycho-quacks are doling out anti-psychotic medications, like Seroquel, to replace benzodiazepines, and yet I have no psychotic illness whatsoever. As I said, do not expect ANY empathy, remorse or some apologies for my stand on this subject. whatsoever. You can pound sand, pal.
 

frozenborderline

Senior Member
Messages
4,405
Yes, but did the chicken come before the egg? As I said, and apparently I will have to declare that it was druggies who started the so-called "War on Drugs". If you think I am heartless to them, you'd be quite mistaken. Yet, how is it that I have never snorted up ANY benzodiazepine medication, in all of these years? Not even _ONCE_.

And ,YES, the druggies are hurting me. The psycho-quacks are doling out anti-psychotic medications, like Seroquel, to replace benzodiazepines, and yet I have no psychotic illness whatsoever. As I said, do not expect ANY empathy, remorse or some apologies for my stand on this subject. whatsoever. You can pound sand, pal.
"Druggies " didnt start the war on drugs. The government did. They banned opium even when it was an otc medication that wasn't abused by anyone.

By the way, I told you a bunch of things you could do about your situation. That seems more important than whose to blame. Personally I blame the DEA more than the person whose just a consumer and subject to supply and demand.
 

Rvanson

Senior Member
Messages
312
Location
USA
"Druggies " didnt start the war on drugs. The government did. They banned opium even when it was an otc medication that wasn't abused by anyone.

By the way, I told you a bunch of things you could do about your situation. That seems more important than whose to blame. Personally I blame the DEA more than the person whose just a consumer and subject to supply and demand.

You can blame it on the FDA, DEA or whomever, but it'd be nice if they OD'ed on a common street drug. I need my sleep which I am told Heroin does effectively.

Why, and more to the point, Where are these people obtaining Benzodiazepines? I've never had a "high" off the one I use so I can get some sleep, and I'm pretty sure it would not last long if I ever shot it up my big snozzola, although that is pure speculation on my part. I don't abuse it. If one is an insomniac like me, you don't do that.
 

frozenborderline

Senior Member
Messages
4,405
Why, and more to the point, Where are these people obtaining Benzodiazepines? I've never had a "high" off the one I use so I can get some sleep, and I'm pretty sure it would not last long if I ever shot it up my big snozzola, although that is pure speculation on my part. I don't abuse it. If one is an insomniac like me, you don't do that.
See this is part of the problem. I am telling you that there are ways to obtain medications, and it's not to abuse them. I dont abuse benzodiazepines, I was in a similar situation S you where I got cut off ... or actually in my case it was dumber, a doctor just continually forgetting to do prompt refills even though I would have physical withdrawals . And so I found other sources of benzodiazepines as well as looking for other ways to attenuate withdrawals... things that are found in the literature. And now it seems you're insinuating that this means abuse or I'm abusing benzodiazepines, when in fact I'm a patient who needs them and gets no high, like you, and I'm saying I can help you avoid withdrawals and get what you need, and that seems more important than apportioning blame.

There are always going to be addicts it's simple supply and demand. On the other hand the DEA and all three letter orgs besides the EPA maybe (environmental protection is good, but the CIA and FBI do evil things) is an evil organization that hurts not just addicts, who you dont need to have sympathy for but are often normal people with aproblem, but additionally they arrest docs who prescribe pain meds or controlled substances even if they did nothing wrong. Your doctor is probably scared bc of the DEA or something so if you want someone to blame look at them.

Also maybe addicts do snort benzodiazepines but they're not water soluble so that makes no sense... additionally , some people who are labeled "addicts" in government statistics aren't addicts... they may be someone who got cut off a benzo supply without 6tapering and needed to continue to take benzos to live... or they had adhd and couldn't function --most adhd people report trying adderall or something like that before eventually deciding to get formally evaluated and legally prescribed those meds. That's another problem with being mad at addicts is that it's a term thrown around very loosely by government agencies that are full of dumb cops who aren't doctors and have no medical degree or ability to determine if someone is indeed an "addict".

So , by your response, I'm still not sure if you would like help with avoiding withdrawal, or would rather just be angry at me or wallow in self pity. This disease sucks, doctors suck, etc etc but as far as I'm concerned we have to emotionally compartmentalize and keep moving.
 

frozenborderline

Senior Member
Messages
4,405
. I need my sleep which I am told Heroin does effectively.
Well, because of the war on drugs lowering heroin supply and destroying poppy fields in afghanistan, I'm pretty sure, now all "heroin" is just baby powder with fentanyl, which is far more unsafe, can hardly blame people for preferring pharmaceuticals --although there are many pharmaceutical fake pills with fentanyl as well.

You realize that because of the DEAs policy, lots of people who were legitimately prescribed meds end up being lumped in as "addicts" bc when they have a spinal fusion and get cut off pain meds they have to turn to street meds or something. Agencies like that Nd also most doctors dont care about the fine distinctions between having a legitimate reason for your medication , self or otherwise.
 

frozenborderline

Senior Member
Messages
4,405
Why, and more to the point, Where are these people obtaining Benzodiazepines? I've never had a "high" off the one I use so I can get some sleep, and I'm pretty sure it would not last long if I ever shot it up my big snozzola, although that is pure speculation on my part. I don't abuse it. If one is an insomniac like me, you don't do that.
Oh I misread this. So, more to the point , I made an earlier post saying there are ways you can obtain these meds safely and regularly so that you dont die when cut off. and you dont need to do this forever necessarily, if you use the Ashton taper plus something like imidazenil, which is a non tolerance forming , novel, and very miraculous substance, you could probably get off the meds. Or not. You could take them for as long as you want. But you definitely can't stop cold Turkey. However, I'm tired of discussing "addicts" and who is at fault for this problem, I'm trying to offer you a solution, but if you'd rather not take it, I really could care less... I dont have the energy to try and convince people to accept help lol.
 

Rvanson

Senior Member
Messages
312
Location
USA
Oh I misread this. So, more to the point , I made an earlier post saying there are ways you can obtain these meds safely and regularly so that you dont die when cut off. and you dont need to do this forever necessarily, if you use the Ashton taper plus something like imidazenil, which is a non tolerance forming , novel, and very miraculous substance, you could probably get off the meds. Or not. You could take them for as long as you want. But you definitely can't stop cold Turkey. However, I'm tired of discussing "addicts" and who is at fault for this problem, I'm trying to offer you a solution, but if you'd rather not take it, I really could care less... I dont have the energy to try and convince people to accept help lol.

My psychiatrist would have no way to prescribe Imidazenil. It is not in the medication list of any US medication. Furthermore, although I DO appreciate your help, but the search says that is does not cause the sedation, which I need for sleep.

Alprazolam works quickly, giving me 6-7 hours of sleep with NO side effects, like feeling groggy, when I wake up. It is very sort acting, unlike the only Benzodiazepine medication, Klonopin, which is used much,which has a half-life too long for me, and it simply takes too long to put me to sleep. Ativan is also not taken by me, as it affects memory. The others have no such effect at all.
 

frozenborderline

Senior Member
Messages
4,405
My psychiatrist would have no way to prescribe Imidazenil. It is not in the medication list of any US medication. Furthermore, although I DO appreciate your help, but the search says that is does not cause the sedation, which I need for sleep.

Alprazolam works quickly, giving me 6-7 hours of sleep with NO side effects, like feeling groggy, when I wake up. It is very sort acting, unlike the only Benzodiazepine medication, Klonopin, which is used much,which has a half-life too long for me, and it simply takes too long to put me to sleep. Ativan is also not taken by me, as it affects memory. The others have no such effect at all.
You misread bc imidazenil isnt the only thing I discussed. And btw even if you need this meds for sleep, imidazenil will help with tolerance and avoiding the life threatening effects ts of withdrawal like seizures! It also doesnt need to be prescribed by a psychiatrist , I learned where to buy it safely and legally online from someone in a discord group that started with this forum. I also know how to obtain diazepam, known as valium, which I'm sure you would want. I know where to obtain etizolam , which is as short lasting as xanax so not as good as valium for sleep or tapering but definitely works as well as xanax. Even better maybe if anything. I know where to obtain clonazolam. I know where to obtain clonazepam, known as klonopin. And probably ativan and all the other things you mentioned. Etizolam btw is not like imidazenil and would absolutely help with sleep. But the reason I suggested imidazenil is it helps with benzo tolerance and withdrawals and seizures from that's which it sounds like you may be at risk for. Plus it never hurts to lower tolerance

Look, you may not appreciate my offer or help, but my point is jts preferable to have to do a little bit of extra work to buy a medication than to give up entirely.
 

Rvanson

Senior Member
Messages
312
Location
USA
See this is part of the problem. I am telling you that there are ways to obtain medications, and it's not to abuse them. I dont abuse benzodiazepines, I was in a similar situation S you where I got cut off ... or actually in my case it was dumber, a doctor just continually forgetting to do prompt refills even though I would have physical withdrawals . And so I found other sources of benzodiazepines as well as looking for other ways to attenuate withdrawals... things that are found in the literature. And now it seems you're insinuating that this means abuse or I'm abusing benzodiazepines, when in fact I'm a patient who needs them and gets no high, like you, and I'm saying I can help you avoid withdrawals and get what you need, and that seems more important than apportioning blame.

There are always going to be addicts it's simple supply and demand. On the other hand the DEA and all three letter orgs besides the EPA maybe (environmental protection is good, but the CIA and FBI do evil things) is an evil organization that hurts not just addicts, who you dont need to have sympathy for but are often normal people with aproblem, but additionally they arrest docs who prescribe pain meds or controlled substances even if they did nothing wrong. Your doctor is probably scared bc of the DEA or something so if you want someone to blame look at them.

Also maybe addicts do snort benzodiazepines but they're not water soluble so that makes no sense... additionally , some people who are labeled "addicts" in government statistics aren't addicts... they may be someone who got cut off a benzo supply without 6tapering and needed to continue to take benzos to live... or they had adhd and couldn't function --most adhd people report trying adderall or something like that before eventually deciding to get formally evaluated and legally prescribed those meds. That's another problem with being mad at addicts is that it's a term thrown around very loosely by government agencies that are full of dumb cops who aren't doctors and have no medical degree or ability to determine if someone is indeed an "addict".

So , by your response, I'm still not sure if you would like help with avoiding withdrawal, or would rather just be angry at me or wallow in self pity. This disease sucks, doctors suck, etc etc but as far as I'm concerned we have to emotionally compartmentalize and keep moving.

I am not angry at you at all. Yeah doctors suck, but you can be imprisoned for buying controlled substances, so I obtain my medications legally. Until a decent anti-insomnia medication is invented, I will stick to my Benzo. The current "non-addictive" ones are useless, so until they come up with a better one I am NOT going to withdrawal.

Ive been down the road of completely not having a benzodiazepine before.Cut off cold turkey. It was very unpleasant to say the least. No I didn't have a seizure, but not being able to sleep was very tiring. Insomnia makes expert driving impossible after a few days.
 
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frozenborderline

Senior Member
Messages
4,405
I am not angry at you at all. Yeah doctors suck, but you can be imprisoned for buying controlled substances, so I obtain my medications legal
it's a reasonable fear even if overblown. A) etizolam. clonazolam, are both legal and can be purchased on normal websites without using the darknet.

B) the darknet is an option but if you think it's too risky, there is c) purchasing in mexico. This could be technically legal actually, especially if you go to a doctor there that works with the farmacia yo generate scripts and business. And quickly just say what the problem is. They will write a script and you can take a certain percentage across the border.

But the only reason I brought up doing it illegally or grey area like etizolam., Is bc u said you're getting cut off and you're going to do [the thing that the TOS say we cant talk about] . If you really plan to do that, why would you care more about legal risk which is minor doing this the smart way, than making a drastic decision you cant undo? At that point what do you have to lose.
Until a decent anti-insomnia medication is invented, I will stick to my Benzo. The current "non-addictive" ones are useless, so until they come up with a better one I am NOT going to withdrawal.
Phenibut is an excellent medication for sleep. And provides better deep sleep and REM than benzos... it's not unpleasant like anti psychotics. You can get it online , NOT ON THE DARKNET ITS NOT ILLEGAL. Just google liftmode phenibut.

Insomnia can be hellish, but I do think there are drugs better than benzodiazepines for it. but to each his own. It should be allowed to take whatever you want. I dont see why you wouldn't5try somethi g legal like phenibut tho. Just dont mix it with benzos or be careful and take very low benzo dose when combining , as it's a powerful sedative.

I'm not stupid I know a lot about pharmacology and have had to biohack and figure my own way out if these situations as doctors rarely help.

Anyway, @Hip knows lots of good stuff for insomnia I'm sure.

But my other point about imidazenil, and this is the last thing I'll say. Is that helping lower benzo tolerance, which imidazenil does, obviously means you get more efficacy from your benzo dose without having to up the dose. I'm on oxycodone for pain but bc of tolerance it doesnt work as well for pain. If someone said I have a drug here and it lowers oxycodone tolerance but doesnt directly help pain I'd be ecstatic bc lowering tolerance helps the drug work better and there are few things that do that. But again--to each his own. And imidazenil is not scheduled as far as I know and should be totally legal. Like phenibut and etizolam .
 

frozenborderline

Senior Member
Messages
4,405
Cut off cold turkey. It was very unpleasant to say the least. No I didn't have a seizure, but not being able to sleep was very tiring.
You Could have a seizure the next time though. And all the things I mentioned , including the gabapentin or lyrica, which can be bought from clear net overseas pharmacies which @Hip has found that are reputable and not scams, and are never prosecuted, or the clonidine , could maybe help with both sleep and preventing seizures. So I dont see why not try that. It's not like buying more controlled meds on the darknet. Gabapentin and lyrica are not considered narcotics or drugs of abuse, and buying them on online pharmacies is easy and poses no legal risk. It's the same as buying allergy meds. Clonidine same thing. Worst case scenario seized by customs money lost but I've gotten about 20 packages go through and they're labelled medications by the pharmacy. Again it's yourchoice but I thought you were in danger of death or something. Obviously if you're fine and getting prescribed your meds and theres no problem dont take any unnecessary risk but I thought you were in a crisis bad enough the risks I suggested would be nothing in comparison. Obviously misread the situation.
 

keenly

Senior Member
Messages
814
Location
UK
Cheney and levine regularly prescribe it for PEM. (Well, Cheney used to, when he was alive ). Levine still does. wouldn't argue about it being dependence forming , and maybe it doesnt work for you, but it's been known to help PEM , energy envelopes, sound sensitivity, and fatiguability , which are all related.

Seems to help whitney's PEM.

I would guess the mechanism is simple, anything that lowers brain and spinal glutamate could help PEM. Includes NMDA antagonists

Honestly, the reason this list is so long isnt bc everything on it works really well it's probably bc theres a bigger variance in what works for people than we can pin down without more rigorous study.
Cheney is no longer with us?
 
Messages
7
List of "PEM Buster" Supplements and Drugs Which Can Reduce PEM

Several supplement and drugs appear to be able to reduce or prevent post-exertional malaise (PEM), by either preventing PEM from physical or mental exertion occurring in the first place, or helping to relieve any PEM that has already appeared.

PEM can be caused both by physical exertion, and also by mental exertion (such as hectic social activity). The mechanism of mental exertion-induced PEM may be different to the mechanism of physical exertion-induced PEM.

The PEM reducers (aka "PEM busters") on this thread were compiled from other forum threads detailing ME/CFS patients' experiences with supplements and drugs they observed reduced or eliminated their PEM.



PEM Reducer Supplements and Drugs

The following are the supplements, drugs and other treatments that ME/CFS patients have found reduce PEM, given in approximate order of efficacy (best or most promising PEM reducers at the top of the list):

Corticosteroids — taken before exertion can completely prevent PEM; see the corticosteroids section. below.
Mestinon (pyridostigmine) 10-180 mg daily— helps some patients entirely avoid PEM.
Cannabis — taken just as PEM begins to appear prevents PEM from fully manifesting; see the cannabis section below.
D-ribose — 5 grams, three times daily.
Branched-chain amino acids (BCAA) — 5 grams.
Co-enzyme Q10 — 800 mg to 1800 mg (this is a very high dose of Q10).
Sodium bicarbonate (baking soda) — 2 grams (half of a level teaspoon).
Citrate supplements — 3 grams.
Creatine hydrochloride — 2 grams.
Citrulline — 1000 mg.
Catalase — 600 mg (taken after exercise).
Cold therapy — such as a cold bath.
Cumin (Cuminum cyminum) — level teaspoon of cumin powder; effects last for 3 days.
Chinese skullcap root (Scutellaria baicalensis) — 3 to 6 grams, taken two to three times daily

These anti-PEM supplements and drugs are further detailed below.

You can try one or more of the above supplements and drugs during PEM itself, or in advance of any physical or mental exertion that you suspect is going to trigger PEM, and see if they relieve or prevent your PEM.

Most experienced ME/CFS patients know roughly how long their PEM periods tend to last for, so will certainly notice if a supplement can dramatically shorten the severity or duration of their PEM.



PEM Shielders vs PEM Relievers

A PEM reducer supplement or drug may fall into one (or both) of the following two categories:

PEM shielders — help prevent PEM from occurring in the first place. PEM shielders only work properly when taken as a preventative medication before you engage in physical or mental exertion.

PEM relievers — mitigate the severity and duration of PEM only when taken after the exertion has occurred, where the PEM may already have begun to manifest.

It is important to know whether a supplement or drug is a PEM shielder or a PEM reliever, because the former only work when taken before the exertion, and the latter only work when taken after the exertion.

As an example of the difference, @hamsterman found that the corticosteroid drug prednisolone 20 mg is an excellent PEM shielder for both physical and mental exertion, but found that such corticosteroid drugs do not work at all as PEM relievers.

Whereas @hamsterman found that BCAA, Q10, creatine and baking soda work more as PEM relievers, rather than PEM shielders.

Though @TravelChimp said in this post that creatine works for him as both a PEM shielder, as well as a PEM reliever.

And @SOC said Q10 works both as a PEM reducer when taken at a one-off very high dose of 2400 mg (two 1200 mg doses on the same day), but also found Q10 had some mild PEM shielding effects when taken at a dose of 800 mg daily.

Note that this study found 3000 mg of Q10 daily for 8 months was safe.

If you are going try these high doses of Q10, you may be better off taking the ubiquinol form, not the more common and cheaper ubiquinone form. This is because blood levels of ubiquinol will continue to rise with increasing dose levels; by contrast, if you take ubiquinone, the blood levels of Q10 will eventually begin to flatten out with increasing dosage. Ref: here.

@msf found that Chinese skullcap root is a good PEM shielder, at a dose of 3 to 6 grams, taken two to three times daily.

One review paper says both baicalin and baicalein (found in Chinese skullcap) and protect mitochondria from oxidative stress. And one study found baicalin restored the infection-triggered decrease in mitochondrial complex V (aka: ATP synthase, or ATPase). Mitochondrial complex V (ATP synthase) has been found deficient in ME/CFS. This might explain the anti-PEM effect of Chinese skullcap root.

Chinese skullcap root contains 8 to 16% of baicalin, and 0.2% to 1.2% of baicalein. Ref: 1 So 5 grams of root corresponds to about 500 mg of baicalin. Note that you can buy 95% pure baicalin from LifeMode, costing $19 for 20 grams. Baicalin bioavailability in rats 2.2%, and half-life around 10 hours. Ref: 1 In the body, baicalin converts into baicalein. Ref: 1

@Wishful finds that cumin (Cuminum cyminum) effectively blocks physical exercise from causing PEM, as well as reducing any PEM that is already present. So cumin appears to be both a PEM shielder and PEM reliever. He finds just 1 level teaspoon of cumin powder blocks PEM for 3 days. This spice contains cuminaldehyde, which has known mitochondrial effects. Unfortunately @Wishful says that no other ME/CFS patients so far seem to have benefited from cumin. See also this thread.

Cannabis appears to be a good PEM shielder/reliever, when taken just as the first signs of PEM appear. See the cannabis section below for more details.

Some ME/CFS patients find Mestinon (pyridostigmine) taken in doses of 10-180 mg daily eliminates PEM from physical exercise, see here. Dr David Systrom has a clinical trial of pyridostigmine for ME/CFS.

Nothing however seems to be quite as powerful as corticosteroids for total PEM shielding.



Biochemical Theory of PEM: How the PEM Busters Work

The above PEM reducer supplements and drugs were discovered by various ME/CFS patients on this forum, who observed that a supplement or drug they were taking had anti-PEM effects.

Interestingly, many of these PEM buster supplements —namely creatine, citrulline, BCAA, Q10, bicarbonate and glutathione — are shown in studies to inhibit exercise-induced lactate. See the athletic exercise performance studies in this post. So lactate inhibition may be the mechanism of action of these PEM busters. Lactate inhibition probably does not apply to D-ribose, cannabis or corticosteroids, which likely reduce PEM by other mechanisms.

D-ribose may work by helping to replace ATP molecules that may be lost during significant exertion: in the theory of PEM proposed by Myhill, Booth and McLaren-Howard (briefly explained in this post), it is suggested that PEM is caused by the loss of ATP molecules that occurs when ME/CFS patients exercise.

According to this theory, you only get over PEM once the body re-manufactures the lost ATP molecules, which can take many days or weeks — hence why PEM can last for days or weeks. D-ribose speeds up the process of re-manufacturing the lost ATP molecules, thus curtailing the duration of PEM.

Myhill, Booth and McLaren-Howard's theory also proposes that a build up of lactic acid during exercise exacerbates and worsens PEM (since lactic acid requires a lot of energy to clear from the body); so that might explain why the above supplements which reduce exercise-induced lactate are PEM relievers: they can help ME/CFS patients get over PEM more quickly.

Their theory suggests that lactic acid is not the initial cause of PEM (that's due to a shortage of ATP molecules which deliver energy), but lactic acid build-up from exercise further compounds the energy shortage problem of PEM, because to clear lactic acid by converting it back to glucose, it requires considerably more energy than was originally gained from the conversion of glucose to lactic acid.



Patient Accounts of The Anti-PEM Effects of The Supplements

This post details how D-ribose powder, at the standard dose of 5 grams taken three times daily, consistently curtails PEM from its usual 3 or 4 days, down to just 12 to 24 hours, for ME/CFS patient @arewenearlythereyet.

This post details how for ME/CFS patient @SOC, a very high one-off dose of 2400 mg of co-enzyme Q10 (taken as two 1200 mg doses on the same day) dramatically eliminated a PEM period with 24 hours, a PEM that would normally have lasted 10 to 14 days. The patient also found that 800 mg of Q10 taken daily noticeably raised their PEM threshold (see this post). Cheap sources of bulk Q10 powder are found on purebulk.com.

This post details how regular supplementation with creatine monohydrate 10 grams daily increased energy, and allowed ME/CFS patient @TravelChimp to do much more physical exercise before the PEM was triggered; in other words, this patient found the creatine raised their PEM threshold. Not only that, but when they did get PEM by overdoing it, they noticed their PEM was reduced in severity as a result of the creatine supplementation.

Note that creatine hydrochloride 2 grams daily may be a much better form of creatine to use than creatine monohydrate, as creatine HCl does not cause stomach aches or fluid retention (as the monohydrate form can), and also is much more water soluble and absorbable in the gut, and so you only need to take around ⅕ of the dose (so 10 grams of creatine monohydrate = 2 grams of creatine hydrochloride; ref: 1).

Here is a thread detailing the anti-PEM effects of branched-chain amino acids (BCAAs). @Mary says later in this thread that BCAAs reduce her PEM duration from 2 days to 1 day. It may be the isoleucine in BCAAs that is responsible for the bulk of the anti-PEM affects, as isoleucine significantly increases glucose uptake. See this post. BCAAs have been proposed to alleviate exercise-induced fatigue. Ref: 1

Here is a thread detailing the anti-PEM effects of sodium bicarbonate, catalase, glutathione and others. In the thread, @Mya Symons says that sodium bicarbonate taken just before exercise, and 600 mg of catalase taken just after exercise, has the best anti-PEM effect.

Citrate supplements (such as sodium citrate or potassium citrate) may be an alternative to sodium bicarbonate; see @Mel9's post below. I would think you need to use doses around 3 grams or so (the sort of dose used for alkalizing). Citrate has the advantage that you can take in on a full stomach, and it will not reduce stomach acid levels (bicarbonate is best not taken when you are digesting food).

Here is a post detailing the anti-PEM effects of cold therapy (cold baths or swimming in cold water). @helen1 finds PEM symptoms decrease significantly after cold therapy, especially nausea and weak legs, and finds it is most effective if you catch the PEM early.




Studies on these PEM Buster Supplements

Athletic performance studies which demonstrate how these PEM reducing supplements also generally improve exercise performance are given in this post. These studies are also listed in Cort's excellent resource about PEM reducers found here.

These athletic performance studies found that the very same supplements that ME/CFS patients on this forum have found prevent or relieve PEM also reduce the recovery period after athletic exercise in healthy people. Several of these studies found that the athletic performance-enhancing supplements work via neutralizing exercise-induced lactate circulating in the blood, and this is probably one of the mechanism by which they reduce PEM.



Cannabis as a PEM Shielder/Reliever

Several ME/CFS patients have reported that cannabis is a good PEM shielder/reliever: they find if cannabis is taken just when the first signs of PEM appear, at the first PEM "danger signals", then cannabis will prevent the PEM from fully manifesting.

Cannabis seems to prevent PEM caused by both physical or mental exertion. Patients report that when they have done too much physical or mental activity, and start to sense the "danger signals" that PEM is about to appear, taking cannabis pulls them out of the danger zone, so that they can escape PEM before it manifests.

Interestingly, some ME/CFS patients report that moderate doses of cannabis do not produce any high at all. This observation is interesting in itself, as cannabis will normally get people high; but the fact that in ME/CFS, moderate doses of cannabis often do not cause any high is intriguing. And this is good news for patients who would like to benefit from the anti-PEM effects of cannabis, but do not want to experience a high just in order to gain these benefits.

To help ensure only moderate doses are taken, Cannabis indica may be the best choice, rather than Cannabis sativa. Indica has less of the THC that gets you high, and more of the CBD which acts to counter some of the effects of THC. Whereas by comparison, sativa has more THC and less CBD.

Of course, the legality of cannabis varies from region to region, but this option of using moderate dose of a mild cannabis like Indica to prevent PEM is another useful addition to the list of medications that reduce PEM.

In terms of why cannabis has this anti-PEM effect, this article says the THC and CBD active principles in cannabis can affect mitochondria: cannabinoid type 1 receptors (CB1) are found on mitochondria, and THC is an agonist of the CB1 receptor, whereas CBD is an antagonist of this receptor. So maybe that is how cannabis helps avoid PEM, by modulating mitochondrial function.



Corticosteroids as Potent PEM Shielders

Corticosteroids such as prednisone, prednisolone and hydrocortisone are reported to be potent PEM shielders. When normal doses of these corticosteroids are taken around one or two hours before any physical or mental exertion, they can totally prevent any PEM from later appearing.

But these drugs were found to be useless if taken after the exertion. That is, they do not help if you are already experiencing PEM from a previous period of exertion.

Note that it is normal doses of corticosteroids (eg, prednisolone 20 mg, or hydrocortisone 80 mg) that can prevent PEM, not the low doses (eg, prednisolone 5 mg, or hydrocortisone 20 mg) that some ME/CFS patients take daily.

And note that normal doses of corticosteroids should only be used occasionally in ME/CFS, perhaps as a maximum of once a week. If normal doses are used every day on a long term basis, this can lead to worsening of ME/CFS (possibly because the corticosteroid Th1 immune suppression may allow any underlying viral infections to proliferate).


Examples of ME/CFS patients using corticosteroids to prevent PEM:

▶︎ @Patrick* found that prednisone at a dose of 20 mg taken a just before a mentally exerting event (such as socializing) was effective at relieving ME/CFS symptoms. Sometimes he would take another 20 mg later in the day. Other ME/CFS patients have vouched this works effectively and reliably (though others report ill effects from this corticosteroid drug). Note that this dosing is only used as a one-off, not regularly every day.

▶︎ @hamsterman found hydrocortisone at a one-off dose of 80 mg (or alternatively and equivalently prednisolone 20 mg) taken 30 minutes before a mentally or physically exerting event very effective for preventing PEM due to physical and mental exertion:

Correction: @hamsterman told me he was actually using prednisolone and not prednisone as he stated in the quote above. The former takes effect faster.

Note that @hamsterman said he has the autoimmune disease Crohn's, which causes has extreme fatigue, though thinks he may have ME/CFS as well.

▶︎ @gregh286 found prednisone will block PEM from appearing.


How long for the corticosteroid PEM shield to kick in? Prednisone takes around 2.6 hours for the drug to reach peak levels in the bloodstream, whereas prednisolone is faster, taking only around 1.3 hours. Hydrocortisone takes around 1 to 2 hours. Ref: 1

So when taking any of these corticosteroids in advance to prevent PEM from a physical or mental exertion you are about to perform, give these drugs enough time to kick in before starting the exertion, else your PEM shield will not be in place. CAUTION: note that there are also timed release versions of prednisone, which only slowly release the drug into your system over several hours, so it might be best to avoid these.


What is the dose equivalence of different corticosteroids? Difference corticosteroid drugs have different strengths: hydrocortisone 80 mg = prednisone 20 mg = prednisolone 20 mg = methylprednisolone 16 mg = triamcinolone 16 mg = dexamethasone 3 mg = betamethasone 2.4 mg. Source: here.


How long does the corticosteroid PEM shield last? In terms of how long the "PEM shield" lasts, the plasma half-life of prednisone and prednisolone is 3 to 4 hours, and the plasma half-life of hydrocortisone is 2 hours. So once your "PEM shield" is active it will last for say one or two half-lives, ie, your PEM shield may last about 4 to 8 hours for prednisone and prednisolone, and last around 2 to 4 hours for hydrocortisone.

When taking prednisone 20 mg, @hamsterman found its PEM protection lasted for as long as 8 hours; but when he tried exercising 13 hours after his prednisone, then he crashed. So for a single 20 mg dose of prednisone, around 8 hours would seem the limit of its protective effects. Of course you could take a second 20 mg dose at the 8 hour point, and get another 8 hours of protection.


Efficacy of the corticosteroid PEM shield. This is how effective @hamsterman found a one-off dose of prednisolone 20 mg to be at completely eliminating PEM from a major physical workout at the gym:

Note that @hamsterman was using prednisolone and not prednisone as he stated in the quote above. Interestingly enough, after doing this intense cardiovascular exercise once weekly for a year, courtesy of the PEM shielding provided by corticosteroids, @hamsterman was able to completely cure his POTS (see here). But his ME/CFS has not improved through exercise. POTS is known to responds well to exercise, whereas ME/CFS does not.


Corticosteroids may lead to major problems if taken daily for weeks in a row. If corticosteroids are used every day on a long term basis of weeks, this can lead to worsening of ME/CFS, perhaps because the immune suppression from the corticosteroids may allow any underlying infections to proliferate (corticosteroids reduce the antiviral Th1 response, reduce T-cell function, and increase the antibacterial Th2 response).

See the warning in this post, which cautions against using prednisone for any extended period of time, and warns that the PEM protective effects do not work for the whole day, they seem to wear off after about 6 to 8 hours. Prednisone is a strong drug, and has sometimes caused adverse events in ME/CFS patients.

Dr Chia says two ME/CFS patients who took prednisone daily for two weeks remarkably improved; but when they tapered off they got much worse, and ended up in the hospital. He believes it such extended use of corticosteroids allows enterovirus to proliferate.


The mechanism by which corticosteroids provide a potent PEM shield may relate to their effects on energy metabolism and mitochondrial oxidative phosphorylation. Mitochondria possess a glucocorticoid receptor, and that receptor regulates oxidative phosphorylation. Refs: 1 2


Interestingly, the over-the-counter drug theophylline greatly potentiates the anti-inflammatory effects of corticosteroids. Ref: 1 In this study of adding theophylline to the corticosteroid regimen of asthma patients, they used a dose of 250 mg of theophylline daily. Theophylline also has a vasoconstriction effect, and is thus useful for POTS, to reduce blood pooling in the legs on standing. Whether theophylline would help ME/CFS patients get the same anti-PEM effects from lower doses of corticosteroids remains to be seen.


Hello fellow searchers.

I have tried both citrulline and baking soda. The citrulline doesnt really work and gives me flu-like symptoms the next day. I even had chest crampa recently. The baking soda removes the PEM but gives me some frequent urination for a couple of hours as well
List of "PEM Buster" Supplements and Drugs Which Can Reduce PEM

Several supplement and drugs appear to be able to reduce or prevent post-exertional malaise (PEM), by either preventing PEM from physical or mental exertion occurring in the first place, or helping to relieve any PEM that has already appeared.

PEM can be caused both by physical exertion, and also by mental exertion (such as hectic social activity). The mechanism of mental exertion-induced PEM may be different to the mechanism of physical exertion-induced PEM.

The PEM reducers (aka "PEM busters") on this thread were compiled from other forum threads detailing ME/CFS patients' experiences with supplements and drugs they observed reduced or eliminated their PEM.



PEM Reducer Supplements and Drugs

The following are the supplements, drugs and other treatments that ME/CFS patients have found reduce PEM, given in approximate order of efficacy (best or most promising PEM reducers at the top of the list):

Corticosteroids — taken before exertion can completely prevent PEM; see the corticosteroids section. below.
Mestinon (pyridostigmine) 10-180 mg daily— helps some patients entirely avoid PEM.
Cannabis — taken just as PEM begins to appear prevents PEM from fully manifesting; see the cannabis section below.
D-ribose — 5 grams, three times daily.
Branched-chain amino acids (BCAA) — 5 grams.
Co-enzyme Q10 — 800 mg to 1800 mg (this is a very high dose of Q10).
Sodium bicarbonate (baking soda) — 2 grams (half of a level teaspoon).
Citrate supplements — 3 grams.
Creatine hydrochloride — 2 grams.
Citrulline — 1000 mg.
Catalase — 600 mg (taken after exercise).
Cold therapy — such as a cold bath.
Cumin (Cuminum cyminum) — level teaspoon of cumin powder; effects last for 3 days.
Chinese skullcap root (Scutellaria baicalensis) — 3 to 6 grams, taken two to three times daily

These anti-PEM supplements and drugs are further detailed below.

You can try one or more of the above supplements and drugs during PEM itself, or in advance of any physical or mental exertion that you suspect is going to trigger PEM, and see if they relieve or prevent your PEM.

Most experienced ME/CFS patients know roughly how long their PEM periods tend to last for, so will certainly notice if a supplement can dramatically shorten the severity or duration of their PEM.



PEM Shielders vs PEM Relievers

A PEM reducer supplement or drug may fall into one (or both) of the following two categories:

PEM shielders — help prevent PEM from occurring in the first place. PEM shielders only work properly when taken as a preventative medication before you engage in physical or mental exertion.

PEM relievers — mitigate the severity and duration of PEM only when taken after the exertion has occurred, where the PEM may already have begun to manifest.

It is important to know whether a supplement or drug is a PEM shielder or a PEM reliever, because the former only work when taken before the exertion, and the latter only work when taken after the exertion.

As an example of the difference, @hamsterman found that the corticosteroid drug prednisolone 20 mg is an excellent PEM shielder for both physical and mental exertion, but found that such corticosteroid drugs do not work at all as PEM relievers.

Whereas @hamsterman found that BCAA, Q10, creatine and baking soda work more as PEM relievers, rather than PEM shielders.

Though @TravelChimp said in this post that creatine works for him as both a PEM shielder, as well as a PEM reliever.

And @SOC said Q10 works both as a PEM reducer when taken at a one-off very high dose of 2400 mg (two 1200 mg doses on the same day), but also found Q10 had some mild PEM shielding effects when taken at a dose of 800 mg daily.

Note that this study found 3000 mg of Q10 daily for 8 months was safe.

If you are going try these high doses of Q10, you may be better off taking the ubiquinol form, not the more common and cheaper ubiquinone form. This is because blood levels of ubiquinol will continue to rise with increasing dose levels; by contrast, if you take ubiquinone, the blood levels of Q10 will eventually begin to flatten out with increasing dosage. Ref: here.

@msf found that Chinese skullcap root is a good PEM shielder, at a dose of 3 to 6 grams, taken two to three times daily.

One review paper says both baicalin and baicalein (found in Chinese skullcap) and protect mitochondria from oxidative stress. And one study found baicalin restored the infection-triggered decrease in mitochondrial complex V (aka: ATP synthase, or ATPase). Mitochondrial complex V (ATP synthase) has been found deficient in ME/CFS. This might explain the anti-PEM effect of Chinese skullcap root.

Chinese skullcap root contains 8 to 16% of baicalin, and 0.2% to 1.2% of baicalein. Ref: 1 So 5 grams of root corresponds to about 500 mg of baicalin. Note that you can buy 95% pure baicalin from LifeMode, costing $19 for 20 grams. Baicalin bioavailability in rats 2.2%, and half-life around 10 hours. Ref: 1 In the body, baicalin converts into baicalein. Ref: 1

@Wishful finds that cumin (Cuminum cyminum) effectively blocks physical exercise from causing PEM, as well as reducing any PEM that is already present. So cumin appears to be both a PEM shielder and PEM reliever. He finds just 1 level teaspoon of cumin powder blocks PEM for 3 days. This spice contains cuminaldehyde, which has known mitochondrial effects. Unfortunately @Wishful says that no other ME/CFS patients so far seem to have benefited from cumin. See also this thread.

Cannabis appears to be a good PEM shielder/reliever, when taken just as the first signs of PEM appear. See the cannabis section below for more details.

Some ME/CFS patients find Mestinon (pyridostigmine) taken in doses of 10-180 mg daily eliminates PEM from physical exercise, see here. Dr David Systrom has a clinical trial of pyridostigmine for ME/CFS.

Nothing however seems to be quite as powerful as corticosteroids for total PEM shielding.



Biochemical Theory of PEM: How the PEM Busters Work

The above PEM reducer supplements and drugs were discovered by various ME/CFS patients on this forum, who observed that a supplement or drug they were taking had anti-PEM effects.

Interestingly, many of these PEM buster supplements —namely creatine, citrulline, BCAA, Q10, bicarbonate and glutathione — are shown in studies to inhibit exercise-induced lactate. See the athletic exercise performance studies in this post. So lactate inhibition may be the mechanism of action of these PEM busters. Lactate inhibition probably does not apply to D-ribose, cannabis or corticosteroids, which likely reduce PEM by other mechanisms.

D-ribose may work by helping to replace ATP molecules that may be lost during significant exertion: in the theory of PEM proposed by Myhill, Booth and McLaren-Howard (briefly explained in this post), it is suggested that PEM is caused by the loss of ATP molecules that occurs when ME/CFS patients exercise.

According to this theory, you only get over PEM once the body re-manufactures the lost ATP molecules, which can take many days or weeks — hence why PEM can last for days or weeks. D-ribose speeds up the process of re-manufacturing the lost ATP molecules, thus curtailing the duration of PEM.

Myhill, Booth and McLaren-Howard's theory also proposes that a build up of lactic acid during exercise exacerbates and worsens PEM (since lactic acid requires a lot of energy to clear from the body); so that might explain why the above supplements which reduce exercise-induced lactate are PEM relievers: they can help ME/CFS patients get over PEM more quickly.

Their theory suggests that lactic acid is not the initial cause of PEM (that's due to a shortage of ATP molecules which deliver energy), but lactic acid build-up from exercise further compounds the energy shortage problem of PEM, because to clear lactic acid by converting it back to glucose, it requires considerably more energy than was originally gained from the conversion of glucose to lactic acid.



Patient Accounts of The Anti-PEM Effects of The Supplements

This post details how D-ribose powder, at the standard dose of 5 grams taken three times daily, consistently curtails PEM from its usual 3 or 4 days, down to just 12 to 24 hours, for ME/CFS patient @arewenearlythereyet.

This post details how for ME/CFS patient @SOC, a very high one-off dose of 2400 mg of co-enzyme Q10 (taken as two 1200 mg doses on the same day) dramatically eliminated a PEM period with 24 hours, a PEM that would normally have lasted 10 to 14 days. The patient also found that 800 mg of Q10 taken daily noticeably raised their PEM threshold (see this post). Cheap sources of bulk Q10 powder are found on purebulk.com.

This post details how regular supplementation with creatine monohydrate 10 grams daily increased energy, and allowed ME/CFS patient @TravelChimp to do much more physical exercise before the PEM was triggered; in other words, this patient found the creatine raised their PEM threshold. Not only that, but when they did get PEM by overdoing it, they noticed their PEM was reduced in severity as a result of the creatine supplementation.

Note that creatine hydrochloride 2 grams daily may be a much better form of creatine to use than creatine monohydrate, as creatine HCl does not cause stomach aches or fluid retention (as the monohydrate form can), and also is much more water soluble and absorbable in the gut, and so you only need to take around ⅕ of the dose (so 10 grams of creatine monohydrate = 2 grams of creatine hydrochloride; ref: 1).

Here is a thread detailing the anti-PEM effects of branched-chain amino acids (BCAAs). @Mary says later in this thread that BCAAs reduce her PEM duration from 2 days to 1 day. It may be the isoleucine in BCAAs that is responsible for the bulk of the anti-PEM affects, as isoleucine significantly increases glucose uptake. See this post. BCAAs have been proposed to alleviate exercise-induced fatigue. Ref: 1

Here is a thread detailing the anti-PEM effects of sodium bicarbonate, catalase, glutathione and others. In the thread, @Mya Symons says that sodium bicarbonate taken just before exercise, and 600 mg of catalase taken just after exercise, has the best anti-PEM effect.

Citrate supplements (such as sodium citrate or potassium citrate) may be an alternative to sodium bicarbonate; see @Mel9's post below. I would think you need to use doses around 3 grams or so (the sort of dose used for alkalizing). Citrate has the advantage that you can take in on a full stomach, and it will not reduce stomach acid levels (bicarbonate is best not taken when you are digesting food).

Here is a post detailing the anti-PEM effects of cold therapy (cold baths or swimming in cold water). @helen1 finds PEM symptoms decrease significantly after cold therapy, especially nausea and weak legs, and finds it is most effective if you catch the PEM early.




Studies on these PEM Buster Supplements

Athletic performance studies which demonstrate how these PEM reducing supplements also generally improve exercise performance are given in this post. These studies are also listed in Cort's excellent resource about PEM reducers found here.

These athletic performance studies found that the very same supplements that ME/CFS patients on this forum have found prevent or relieve PEM also reduce the recovery period after athletic exercise in healthy people. Several of these studies found that the athletic performance-enhancing supplements work via neutralizing exercise-induced lactate circulating in the blood, and this is probably one of the mechanism by which they reduce PEM.



Cannabis as a PEM Shielder/Reliever

Several ME/CFS patients have reported that cannabis is a good PEM shielder/reliever: they find if cannabis is taken just when the first signs of PEM appear, at the first PEM "danger signals", then cannabis will prevent the PEM from fully manifesting.

Cannabis seems to prevent PEM caused by both physical or mental exertion. Patients report that when they have done too much physical or mental activity, and start to sense the "danger signals" that PEM is about to appear, taking cannabis pulls them out of the danger zone, so that they can escape PEM before it manifests.

Interestingly, some ME/CFS patients report that moderate doses of cannabis do not produce any high at all. This observation is interesting in itself, as cannabis will normally get people high; but the fact that in ME/CFS, moderate doses of cannabis often do not cause any high is intriguing. And this is good news for patients who would like to benefit from the anti-PEM effects of cannabis, but do not want to experience a high just in order to gain these benefits.

To help ensure only moderate doses are taken, Cannabis indica may be the best choice, rather than Cannabis sativa. Indica has less of the THC that gets you high, and more of the CBD which acts to counter some of the effects of THC. Whereas by comparison, sativa has more THC and less CBD.

Of course, the legality of cannabis varies from region to region, but this option of using moderate dose of a mild cannabis like Indica to prevent PEM is another useful addition to the list of medications that reduce PEM.

In terms of why cannabis has this anti-PEM effect, this article says the THC and CBD active principles in cannabis can affect mitochondria: cannabinoid type 1 receptors (CB1) are found on mitochondria, and THC is an agonist of the CB1 receptor, whereas CBD is an antagonist of this receptor. So maybe that is how cannabis helps avoid PEM, by modulating mitochondrial function.



Corticosteroids as Potent PEM Shielders

Corticosteroids such as prednisone, prednisolone and hydrocortisone are reported to be potent PEM shielders. When normal doses of these corticosteroids are taken around one or two hours before any physical or mental exertion, they can totally prevent any PEM from later appearing.

But these drugs were found to be useless if taken after the exertion. That is, they do not help if you are already experiencing PEM from a previous period of exertion.

Note that it is normal doses of corticosteroids (eg, prednisolone 20 mg, or hydrocortisone 80 mg) that can prevent PEM, not the low doses (eg, prednisolone 5 mg, or hydrocortisone 20 mg) that some ME/CFS patients take daily.

And note that normal doses of corticosteroids should only be used occasionally in ME/CFS, perhaps as a maximum of once a week. If normal doses are used every day on a long term basis, this can lead to worsening of ME/CFS (possibly because the corticosteroid Th1 immune suppression may allow any underlying viral infections to proliferate).


Examples of ME/CFS patients using corticosteroids to prevent PEM:

▶︎ @Patrick* found that prednisone at a dose of 20 mg taken a just before a mentally exerting event (such as socializing) was effective at relieving ME/CFS symptoms. Sometimes he would take another 20 mg later in the day. Other ME/CFS patients have vouched this works effectively and reliably (though others report ill effects from this corticosteroid drug). Note that this dosing is only used as a one-off, not regularly every day.

▶︎ @hamsterman found hydrocortisone at a one-off dose of 80 mg (or alternatively and equivalently prednisolone 20 mg) taken 30 minutes before a mentally or physically exerting event very effective for preventing PEM due to physical and mental exertion:

Correction: @hamsterman told me he was actually using prednisolone and not prednisone as he stated in the quote above. The former takes effect faster.

Note that @hamsterman said he has the autoimmune disease Crohn's, which causes has extreme fatigue, though thinks he may have ME/CFS as well.

▶︎ @gregh286 found prednisone will block PEM from appearing.


How long for the corticosteroid PEM shield to kick in? Prednisone takes around 2.6 hours for the drug to reach peak levels in the bloodstream, whereas prednisolone is faster, taking only around 1.3 hours. Hydrocortisone takes around 1 to 2 hours. Ref: 1

So when taking any of these corticosteroids in advance to prevent PEM from a physical or mental exertion you are about to perform, give these drugs enough time to kick in before starting the exertion, else your PEM shield will not be in place. CAUTION: note that there are also timed release versions of prednisone, which only slowly release the drug into your system over several hours, so it might be best to avoid these.


What is the dose equivalence of different corticosteroids? Difference corticosteroid drugs have different strengths: hydrocortisone 80 mg = prednisone 20 mg = prednisolone 20 mg = methylprednisolone 16 mg = triamcinolone 16 mg = dexamethasone 3 mg = betamethasone 2.4 mg. Source: here.


How long does the corticosteroid PEM shield last? In terms of how long the "PEM shield" lasts, the plasma half-life of prednisone and prednisolone is 3 to 4 hours, and the plasma half-life of hydrocortisone is 2 hours. So once your "PEM shield" is active it will last for say one or two half-lives, ie, your PEM shield may last about 4 to 8 hours for prednisone and prednisolone, and last around 2 to 4 hours for hydrocortisone.

When taking prednisone 20 mg, @hamsterman found its PEM protection lasted for as long as 8 hours; but when he tried exercising 13 hours after his prednisone, then he crashed. So for a single 20 mg dose of prednisone, around 8 hours would seem the limit of its protective effects. Of course you could take a second 20 mg dose at the 8 hour point, and get another 8 hours of protection.


Efficacy of the corticosteroid PEM shield. This is how effective @hamsterman found a one-off dose of prednisolone 20 mg to be at completely eliminating PEM from a major physical workout at the gym:

Note that @hamsterman was using prednisolone and not prednisone as he stated in the quote above. Interestingly enough, after doing this intense cardiovascular exercise once weekly for a year, courtesy of the PEM shielding provided by corticosteroids, @hamsterman was able to completely cure his POTS (see here). But his ME/CFS has not improved through exercise. POTS is known to responds well to exercise, whereas ME/CFS does not.


Corticosteroids may lead to major problems if taken daily for weeks in a row. If corticosteroids are used every day on a long term basis of weeks, this can lead to worsening of ME/CFS, perhaps because the immune suppression from the corticosteroids may allow any underlying infections to proliferate (corticosteroids reduce the antiviral Th1 response, reduce T-cell function, and increase the antibacterial Th2 response).

See the warning in this post, which cautions against using prednisone for any extended period of time, and warns that the PEM protective effects do not work for the whole day, they seem to wear off after about 6 to 8 hours. Prednisone is a strong drug, and has sometimes caused adverse events in ME/CFS patients.

Dr Chia says two ME/CFS patients who took prednisone daily for two weeks remarkably improved; but when they tapered off they got much worse, and ended up in the hospital. He believes it such extended use of corticosteroids allows enterovirus to proliferate.


The mechanism by which corticosteroids provide a potent PEM shield may relate to their effects on energy metabolism and mitochondrial oxidative phosphorylation. Mitochondria possess a glucocorticoid receptor, and that receptor regulates oxidative phosphorylation. Refs: 1 2


Interestingly, the over-the-counter drug theophylline greatly potentiates the anti-inflammatory effects of corticosteroids. Ref: 1 In this study of adding theophylline to the corticosteroid regimen of asthma patients, they used a dose of 250 mg of theophylline daily. Theophylline also has a vasoconstriction effect, and is thus useful for POTS, to reduce blood pooling in the legs on standing. Whether theophylline would help ME/CFS patients get the same anti-PEM effects from lower doses of corticosteroids remains to be seen.

Hi fellow searchers.

Do anyone here experience frequent urination and lower back tingling/heat from taking baking soda before exercise?