Fibromyalgia is a crippling chronic condition estimated to affect around ten million Americans. Despite increasing acknowledgment of fibromyalgia as a serious illness, and despite multiple attempts to treat its symptoms (generally widespread muscle and joint pain, chronic fatigue, fibro “brain fog,” and more, depending on the individual), we still don’t have a clear biochemical or neurological account of what fibromyalgia really is, why it causes the symptoms it does, and, perhaps most importantly, how to effectively treat the condition itself rather than just its symptoms.
There is room for hope, however. Growing research shows a strong correlation between fibromyalgia symptoms and multiple severe vitamin deficiencies. Though this correlation alone isn’t enough on its own to understand fibromyalgia’s mechanism of action, researchers are hopeful that vitamin deficiencies and their causes might be a better starting point from which to work toward discovering the underlying processes of fibromyalgia than a cluster of symptoms alone.
In the meantime, though, there is also increasing evidence that correcting for these vitamin deficiencies can significantly improve fibromyalgia pain and other symptoms. While there are multiple supplements increasingly used to regulate fibro patients’ vitamin levels, I’ll discuss only one of them in this article: the supplement malic acid (or malate).
1. What is malic acid?
Malic acid is an organic substance typically found in fruits, responsible for their sweet-tart taste (in fact, it’s often used as an additive in sour candies). It’s also synthesized by your body in a series of chemical reactions known as the Krebs cycle (or citric acid cycle).
What is the Krebs cycle?
Well, it’s quite complicated biochemically, so the clearest way to understand it is through metaphor: to start, imagine that your body is run by an engine. In order for your body to run properly (or at all!) you must put coal (that is, food) into the engine (or, your cells’ mitochondria), where the raw coal is synthesized into fuel that makes the engine run (in your body, that final fuel substance is called ATP). There isn’t just a single reaction transforming raw coal (or food) into fuel (or ATP), however. Instead, there are multiple steps, where each step takes the substance produced by the previous step and uses it in another reaction to create a new substance. To add another metaphor into the mix, you can also think of the Krebs cycle as a sort of cyclical assembly line, where, at each stop, the product being put together is turned into something new.
Why am I talking about this, again? Well, malic acid is one of the last byproducts of the Krebs cycle—its production is one of the last stops on the assembly line—on the way to synthesizing ATP. And ATP is extremely important for fibromyalgia patients, as I’ll discuss next.
Remember how fibromyalgia symptoms are linked to multiple vitamin deficiencies? Well, one of those deficiencies (though not a vitamin exactly) is ATP. In fact, upon taking biopsies and studying the muscle tissue of fibro patients, researchers consistently find muscle tissue breakdown, decreased levels of oxygen in the muscles (called muscle hypoxia), mitochondrial damage, and very low levels of ATP.
Depending on the extent to which the mitochondria are damaged, Krebs cycles in fibro patients’ muscles function very poorly if at all. If the Krebs cycle isn’t working, then little (if any) ATP can be produced; if the muscle doesn’t have enough ATP—if it doesn’t have enough fuel—it can’t function properly and begins to break down. And if your muscle tissue is significantly broken down, this can go a long way toward explaining the widespread muscle pain experienced by fibro patients. A lack of fuel throughout your body can also cause chronic fatigue—another symptom common to fibromyalgia.
By taking malic acid, though, you can help your damaged mitochondria produce more ATP. Again, since malic acid is one of the last byproducts produced by the Krebs cycle and is necessary for ATP production, taking the supplement can jumpstart the production of ATP, helping to fuel and repair the damage to your muscles (and causing a significant decrease in pain).
As mentioned previously, malic acid does occur naturally in fruits, especially tart fruits such as apples (and you can find smaller amounts in some vegetables as well). In non-fibro patients, the body synthesizes enough malic acid on its own—however, that isn’t very helpful information for treating fibromyalgia! In addition, there isn’t enough naturally occurring malic acid in foods for you to ingest a therapeutic dose, even if you eat multiple apples every day! For this reason (and because it’s easier to regulate doses), doctors prescribing malic acid usually prescribe it in pill form.
The Fibromyalgia Treatment Group and their supplement product Fibromyalgia Support Formula is the market's leading supplement for fibro pain and contains one of the most concentrated doses of malic acid as well as alpha lipoic acid. You can read more about it here.
Unlike many supplements, there aren’t many known interactions with other drugs or serious side effects at therapeutic doses of malic acid (some patients taking the highest doses mentioned reported loose stools). Still, as with any new medication, whether it’s prescription, an OTC drug, or a supplement, it’s always best to talk to your doctor before beginning a new regimen.
Finally, please note: while malic acid can help restore your body’s levels of ATP, it can’t reverse mitochondrial damage, which is usually caused by free radicals. Taking additional antioxidants—especially alpha lipoic acid—can help to reverse this free radical damage and heal your mitochondria so that they are better able to produce essential fuel for your body themselves.
1. It’s usually recommended to take malic acid and magnesium together. Magnesium is also severely deficient in fibro patients: its deficiency is associated with decreased serotonin and increased levels of a neurotransmitter called “substance P” which can cause hypersensitivity to pain. However, there’s evidence that taking magnesium in combination with malic acid improves the function of the malic acid and production of ATP—though the reason for that isn’t exactly clear.