Naturopathic and holistic physicians use many individual nutrients and botanicals in the treatment of our patients with chronic fatigue syndrome and fibromyalgia (CFS/FM). They include magnesium, CoQ10, malic acid, vitamin D, resveratrol, carnitine, and herbs like Rhodiola, Licorice, Ginseng. All of these have their place, but in working with these challenging patients, I have found D-ribose to be the single most important nutrient for alleviating symptoms and helping my patients back on a path towards health.

This makes sense if we take a closer look at the physiology and biochemistry of these syndromes.

Mitochondrial dysfunction and consequent impairment of cellular metabolism are very important in women’s health practice: they underlie numerous problematic changes that result in hypothalamic suppression as well as dysfunctions in the brain, heart, skeletal muscles, liver and endocrine system (Symptoms of mitochondrial cytopathies. United Mitochondrial Disease Foundation. Available at: http://www.umdf.org/site/c.dnJEKLNqFoG/b.3042207/).

The hypothalamus controls sleep, pituitary and autonomic functions, so when hypothalamic function is suppressed, it can result in insomnia, irritable bowel syndrome, deficiencies of growth hormone and dysregulation of the hypothalamic-pituitary-adrenal and thyroid axis (Mignot E, et al. Nat Neurosci. 2002; 5(Suppl): 1071–1075. Palkovits M. Front Neuroendocrinol. 1999; 20(4): 270–295. Demitrack M, et al. J Clin Endocrinol Metab.1991; 73(6): 1223–1234).

Chronic fatigue syndrome (CFS) and fibromyalgia (FMS) in particular, are common in women, and they’re strongly associated with decreased mitochondrial function and declining tissue levels of adenosine triphosphate (ATP). People with CFS/FMS are found to have: 20% less energy in their muscles, defective or inefficient mitochondria, and thickened capillary walls. As the list of references at the end of this article indicates, we’ve known some of these facts for decades. But we’re just starting to understand how it plays out clinically.

As cellular energy is depleted, fatigue and muscle pain become more and more severe and the muscles require additional energy in their recovery efforts. Energy is used faster than fuel is made available to renew it, and the fatigue, soreness, pain and stiffness progress. In essence, CFS/FM represent a state in which the mechanisms for energy recovery are overwhelmed.

D-Ribose is a naturally occurring five-carbon sugar found in all living cells. The body naturally converts glucose into ribose, which then drives cellular metabolic pathways. D-ribose is a component of ATP, RNA, NADH, and coenzyme-A, all of which are essential for mitochondrial energy homeostasis.

In the body, we form ribose through the pentose phosphate pathway (PPP) or through the hexose monophosphate shunt. In heart and muscle tissue, the PPP is fairly slow, because these tissues lack the enzymes needed to shunt the glucose in the pathway of ribose synthesis. Myocardium and skeletal muscle prefer to use glucose to fuel ATP. The enzymes glucose-6-phosphate dehydrogenase and 6-phosphogluconate dehydrogenase preserve that glucose metabolism, at a cost to ribose synthesis. When ribose is needed to rebuild the ATP pools, the process is a relatively slow one.

When the body’s stores of ribose have been depleted, tissues such as heart and muscle are unable to produce it quickly enough to replenish what has been lost. It is this delay that slows cellular and tissue energy recovery.

Most body tissues cannot make enough ribose to restore energy levels to normal once they have been severely depleted. When cells suffer metabolic stress or mitochondrial dysfunction, ATP is catabolized and metabolic recovery is further compromised.

This, in essence is what occurs in individuals with CFS. Under these conditions, adenosine diphosphate (ADP) accumulates and the cells try to balance the ratios of ATP with ADP to maintain energy. These reactions lead to catabolic end products that are washed out of the cell with a subsequent loss of purines and adenine nucleotides.

One therapeutic option is to try to restore these energy substrates in order to recover the function of the cell, including muscle cells. By supplementing with ribose, it is possible to enhance the nucleotide recovery, and preserve or even rebuild cellular energy stores, thereby promoting a quicker more efficient tissue recovery (Pouleur H. Eur Heart J. 1990; 11(Suppl): 30–34; Pasque M, Wechsler A. Ann Surg. 1984; 200: 1–10. Perlmutter N, et al. J Nucl Med. 1991; 32: 193–200).

Current interest in the possibility of treating CFS/FM with D-ribose was sparked by a compelling 2004 case study of a veterinary surgeon with fibromyalgia. After 3 weeks of ribose she was back to full time work, with her profound fatigue and muscle pain having disappeared (Gebhart B, Jorgenson J. Pharmacotherapy. 2004; 24(11): 1646–1648).

Another landmark study involved high-intensity athletes. Normally, post-exercise muscle energy levels were reduced by almost 30%. But athletes taking 10 g of ribose per day for 3 days following intensive exercise restored muscle levels to pre-exercise levels, while those treated with placebo did not (Hellsten Y, et al. Am J Physiol Regul Integr Comp Physiol. 2004; 286(1): R182–R188).

In 2006 Jacob Teitelbaum, MD, and colleagues published an open-label, uncontrolled pilot study evaluating the effect of D-ribose on symptoms in 41 CFS/FM patients. They took D-ribose a dose of 5 grams, thrice daily. for an average of three weeks. Based on patient responses on pre- and post-treatment questionnaires there was a significant improvement in perceived energy, sleep, mental clarity, pain intensity and well being. At the end of the study, approximately 66% of patients experienced significant improvement while using D-ribose; they had a 45% average increase in energy and a 30% overall improvement in well-being (Teitelbaum J, et al. J Altern Complement Med. 2006 Nov; 12(9): 857–862).

Clearly, clinical research into the potential benefits of D-ribose for CFS/FM patients is in its early stages. But in my own practice, I’ve seen the impact it can have. I thank Dr. Teitelbaum and other D-ribose researchers for pointing us in the right direction.

For more on D-ribose in management of heart disease, visit www.holisticprimarycare.net, and read Metabolic Cardiology: Solving the Heart’s Energy Crisis, and Ribose Supplementation Improves Heart Surgery Outcomes.

Further Reading

Lund N, Bengtsson A, Thjorborg P. Muscle tissue oxygen pressure in primary fibromyalgia. Scand J Rheumatol. 1986; 15(2): 165–173.

Strobel E, Krapf M, Suckfull M, et al. Tissue oxygen measurement and 31P magnetic resonance spectroscopy in patients with muscle tension and fibromyalgia. Rheumatol Int. 1997; 16(5): 175–180.

Douche-Aourik F, Berlier W, Feasson L, et al. Detection of enterovirus in human skeletal muscle from patients with inflammatory muscle disease or fibromyalgia and healthy subjects. J Med Virol. 2003; 71(4): 540–547.

Park J, Phothimat P, Oates C, Hernanz-Schulman M, Olson N. Use of P-31 magnetic resonance spectroscopy to detect metabolic abnormalities in muscles of patients with fibromyalgia. Arthritis Rheum. 1998; 41(3): 406–413.

Kushmerick M. Muscle energy metabolism, nuclear magnetic resonance spectroscopy and their potential in the study of fibromyalgia. J Rheumatol Suppl. 1989 Nov; 19: 40–46.

Bengtsson A, Henriksson K, Larsson J. Reduced high-energy phosphate levels in the painful muscles of patients with primary fibromyalgia. Arthritis Rheum. 1986; 29(7): 817–821.

Lund E, Kendall S, Janerot-Sjoberg B, Bengtsson A. Muscle metabolism in fibromyalgia studied by P-31 magnetic resonance spectroscopy during aerobic and anaerobic exercise. Scand J Rheumatol. 2003; 32(3): 138–145.

Eisinger J, Bagneres D, Arroyo P, Plantamura A, Ayavou T. Effects of magnesium, high-energy phosphates, piracetam and thiamin on erythrocyte transketolase. Magnes Res. 1994; 7(1): 59–61.