What are the current treatment options for chronic fatigue syndrome?

Current Treatment Options for Chronic Fatigue Syndrome

Cognitive behavioral therapy (CBT) and mindfulness-based therapies are the first-line treatments for chronic fatigue syndrome (CFS), showing the strongest evidence for improving functional status, quality of life, and symptom management. 1

Non-Pharmacological Interventions

First-Line Treatments

• Cognitive Behavioral Therapy (CBT)

  • Strong evidence for improving health function, quality of life, and physical function 2, 1
  • Multiple studies in patients with Gulf War illness, fibromyalgia, irritable bowel syndrome, and ME/CFS consistently show significant improvement 2
  • Web-based versions may increase accessibility for patients with limited mobility 1

• Mindfulness-Based Therapies

  • Demonstrated small to moderate improvements in quality of life outcomes 1
  • Effective during and after treatment 1

Second-Line Non-Pharmacological Options

• Movement-Based Therapies

  • Yoga or tai chi for patients with fibromyalgia-like symptoms 2, 1
  • Physical exercise for patients with fibromyalgia-like symptoms 2
  • Manual acupuncture as part of management for fibromyalgia-like symptoms 2, 1
  • Note: Traditional graded exercise therapy is no longer recommended and may worsen symptoms 1

• Other Behavioral Approaches

  • CBT specifically for insomnia for sleep disturbances 1
  • Emotion-focused therapy for patients with symptoms consistent with fibromyalgia or irritable bowel syndrome 2
  • Psychoeducational interventions 1

Pharmacological Interventions

For Pain Management

• Serotonin-norepinephrine reuptake inhibitors (SNRIs)

  • Suggested for treatment of pain and improved functional status in patients with CFS and fibromyalgia-like symptoms 2, 1

• Pregabalin

  • Suggested for treatment of pain in patients with CFS and fibromyalgia-like symptoms 2, 1

For Gastrointestinal Symptoms

• For IBS with constipation:

  • Linaclotide and plecanatide for patients who don't respond to osmotic laxatives 2

• For IBS without constipation:

  • 14-day course of rifaximin 2

Treatments to Avoid

• Not Recommended:
  • Long-term use of opioid medications 2, 1
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic pain related to CFS 2, 1
  • Stimulants for treatment of fatigue 2, 1
  • Mifepristone 2

Treatment Algorithm

1. Initial Approach:

   • Begin with CBT and/or mindfulness-based therapies as first-line treatment 2, 1
   • Implement regular self-monitoring of fatigue levels to document changes

2. For persistent symptoms after first-line treatment:

   • For pain predominance: Add SNRIs or pregabalin 2, 1
   • For sleep issues: Add CBT specifically for insomnia 1
   • For patients with fibromyalgia-like symptoms: Consider adding yoga, tai chi, manual acupuncture, or appropriate physical exercise 2, 1

3. For gastrointestinal symptoms:

   • For IBS with constipation: Consider linaclotide or plecanatide if osmotic laxatives fail 2
   • For IBS without constipation: Consider a 14-day course of rifaximin 2

Common Pitfalls and Caveats

• Avoid traditional graded exercise therapy as it may worsen symptoms in some patients 1, 3
• Don't rely solely on pharmacological treatments as evidence strongly supports psychosocial interventions over medication-based approaches 1
• Avoid stimulants, corticosteroids, antivirals, and antibiotics as they lack evidence of benefit 1
• Be cautious with diagnosis - CFS is a diagnosis of exclusion that requires ruling out other conditions 4
• Consider specialist referral for patients with suspected ME/CFS for diagnosis and initial treatment planning 1
• Regular reassessment is essential to monitor fatigue levels, treatment response, and development of new symptoms or comorbidities 1

The evidence clearly demonstrates that non-pharmacological approaches, particularly CBT and mindfulness-based therapies, should form the foundation of treatment for chronic fatigue syndrome, with targeted pharmacological interventions added for specific symptoms when necessary.