What is the recommended approach for diagnosing and managing a patient with suspected chronic fatigue syndrome (CFS), also known as myalgic encephalomyelitis (ME/CFS)?

Diagnosis and Management of Chronic Fatigue Syndrome (ME/CFS)

Patients with suspected ME/CFS should be referred to a specialist with experience in ME/CFS for diagnosis and initial treatment to improve morbidity, mortality, and quality of life outcomes. 1

Diagnostic Criteria

ME/CFS is defined by a triad of core symptoms:

1. Substantial functional impairment lasting more than 6 months with profound fatigue of new onset (not lifelong) that is not alleviated by rest
2. Post-exertional malaise
3. Unrefreshing sleep

Additionally, patients must have either:

• Orthostatic intolerance OR
• Cognitive impairment ("brain fog") 2

The diagnosis is clinical and requires exclusion of other medical conditions that could explain the symptoms.

Diagnostic Approach

1. Detailed symptom history:

   • Onset (often following viral infection)
   • Duration (>6 months required)
   • Pattern of fatigue and post-exertional malaise
   • Sleep disturbances
   • Cognitive difficulties
   • Associated symptoms (pain, orthostatic intolerance)

2. Assess disability level and impact on:

   • Work/school functioning
   • Social activities
   • Activities of daily living

3. Screen for comorbid conditions:

   • Depression and anxiety
   • POTS (postural orthostatic tachycardia syndrome)
   • Fibromyalgia
   • Irritable bowel syndrome

4. Rule out alternative diagnoses through targeted laboratory testing:

   • Complete blood count
   • Comprehensive metabolic panel
   • Thyroid function tests
   • Inflammatory markers
   • Consider testing for infectious triggers (EBV, CMV, etc.)

Management Recommendations

First-Line Treatments

• Cognitive-behavioral therapy (CBT) - Has the strongest evidence base for improving health function, quality of life, and physical function 2, 1

• Consistent activity pacing - Establish a regular pattern of activity and rest to avoid post-exertional malaise 3

• Sleep hygiene optimization - Address sleep disturbances which can perpetuate symptoms 3

• Mindfulness-based therapies - Shown to provide small to moderate improvements in quality of life 1

Pharmacological Management

• For pain symptoms: Consider SNRIs and pregabalin 1

• For comorbid depression: Consider antidepressants on a pragmatic basis 4

• Avoid:

  • Stimulants for fatigue (specifically recommended against) 2
  • Long-term opioids, corticosteroids, antivirals, or antibiotics 1
  • NSAIDs for chronic pain related to CFS 1

Additional Interventions

• Manual acupuncture - Supported by evidence for patients with CFS and fibromyalgia-like symptoms 1

• Movement-based therapies - Consider gentle approaches like yoga and tai chi 1

• Avoid graded exercise therapy - No longer recommended as it may worsen symptoms 1

Follow-up Care

• Provide clear explanation of the condition, distinguishing between predisposing factors (lifestyle, stress), triggers (viral infections), and perpetuating factors (sleep disorders, inconsistent activity) 4

• Regular specialist monitoring at least annually 1

• Address symptoms that may trigger or contribute to fatigue persistence 1

• Set specific functional targets and develop a personal health plan with timeline for follow-up 1

Common Pitfalls to Avoid

1. Dismissing symptoms as purely psychological - ME/CFS is a complex biological condition with multiple physiological abnormalities

2. Recommending excessive exercise - This can worsen post-exertional malaise

3. Focusing only on fatigue - ME/CFS involves multiple systems and symptoms beyond fatigue

4. Delayed diagnosis - About 80% of patients struggle to get diagnosed due to lack of physician education on ME/CFS 3

5. Overlooking comorbidities - POTS, fibromyalgia, and IBS frequently co-occur with ME/CFS

ME/CFS can be severely disabling, with significant impacts on quality of life and economic costs. Early diagnosis, specialist referral, and appropriate symptom management are essential to improving outcomes.