What are the management options for chronic fatigue syndrome?

Management Options for Chronic Fatigue Syndrome

Cognitive-behavioral therapy (CBT) and mindfulness-based therapy should be offered as first-line treatments for chronic fatigue syndrome (CFS), with individualized treatment plans based on symptom presentation. 1, 2

Initial Assessment and Treatment Approach

First-line Interventions:

• Cognitive-behavioral therapy (CBT): Strong evidence supports CBT for improving health function, quality of life, and physical functioning in CFS patients 1, 2
• Mindfulness-based therapy: Demonstrates small to moderate improvements in quality of life and functional impairment 1, 2

Avoid These Treatments:

• Opioid medications for CFS-related pain 1
• Corticosteroids, antivirals, or antibiotics for ME/CFS symptoms 1, 2
• Stimulants for fatigue symptoms 1, 3
• Mifepristone 1
• Graded exercise therapy has been withdrawn as a recommended treatment as it may worsen symptoms in some patients 2

Treatment Algorithm Based on Symptom Presentation

For CFS with Fibromyalgia-like Symptoms:

1. Consider emotion-focused therapy 1
2. Consider movement-based therapies:
   • Yoga
   • Tai chi
   • Manual acupuncture
   • Appropriate physical exercise 1, 2
3. Consider medication trials:
   • Serotonin-norepinephrine reuptake inhibitors (SNRIs)
   • Pregabalin 1
4. Avoid NSAIDs for chronic pain related to CFS 1

For CFS with Irritable Bowel Syndrome-like Symptoms:

1. Consider emotion-focused therapy 1
2. Consider psychodynamic therapies 1
3. Consider medication trials:
   • Tricyclic antidepressants (TCAs)
   • Antispasmodics
   • For patients without significant constipation: rifaximin
   • For constipation-predominant IBS unresponsive to osmotic laxatives: linaclotide, plecanatide (for women only: lubiprostone)
   • For significant diarrhea unresponsive to anti-diarrheals or low-FODMAP diet: eluxadoline 1
4. Avoid alosetron and SSRIs for IBS symptoms 1

Special Considerations

Digital Interventions

• Web-based versions of effective in-person programs have shown benefit and may be more accessible for patients with limited mobility 1, 2

Complementary Approaches

• Evidence supports manual acupuncture for patients with CFS and fibromyalgia-like symptoms 1, 4
• Limited evidence for dietary supplements and complementary medicine products 3

Pharmacological Considerations

• Pharmacotherapy should not be considered first-line treatment 3
• Some immunological therapies (immunoglobulin, hydrocortisone) have shown limited effects, but evidence is inconclusive 5
• Three pharmacological interventions (Staphypan Berna, Poly(I):poly(C12U), and CoQ10 + NADH) have shown statistical significance in trials, but lack coherence and reproducibility 4

Follow-up Care

• Regular monitoring is necessary for ongoing care 2
• Continue to adjust the individualized treatment plan based on symptom response 1
• Address symptoms that may trigger, coincide with, or contribute to fatigue persistence 1

Common Pitfalls to Avoid

• Misdiagnosis: CFS symptoms overlap with many other conditions; ensure thorough evaluation before diagnosis
• Overtreatment: Excessive medication can worsen symptoms and create new problems
• Undertreatment: Failing to address all symptom clusters can lead to poor outcomes
• Dismissing symptoms: Taking patient reports seriously is essential for effective management
• Relying solely on pharmacotherapy: Non-pharmacological approaches often provide better outcomes 3

By following this evidence-based approach to CFS management, clinicians can help patients achieve meaningful improvements in symptoms and quality of life.