What is the management plan for chronic fatigue syndrome?

Management of Chronic Fatigue Syndrome

Cognitive-behavioral therapy (CBT) and graded physical activity should be offered as first-line interventions for chronic fatigue syndrome (CFS), as they have demonstrated moderate improvements in fatigue, distress, cognitive symptoms, and quality of life. 1

Diagnosis and Initial Assessment

• CFS is characterized by persistent fatigue lasting more than 6 months, accompanied by symptoms including headache, arthralgias, myalgias, concentration problems, and gastrointestinal disorders that significantly interfere with daily functioning 1
• Diagnosis is made clinically after excluding other potential causes of chronic fatigue 2
• Building a therapeutic patient-provider alliance is crucial while conducting a thorough evaluation 1

Evidence-Based Interventions

Non-Pharmacological Approaches (First-Line)

• Cognitive-behavioral therapy (CBT) has shown moderate effectiveness for improving fatigue, mental functioning, and distress 1
• Graded physical exercise should be gradually introduced, as it demonstrates statistical benefits in improving quality of life and reducing pain 1
• Mindfulness-based therapies show moderate effect sizes for enhancing quality of life compared to waitlist or support groups 1
• Yoga or tai chi can be beneficial, with studies showing significant improvements in physical functioning, pain, fatigue, sleep quality, and mood 1
• Emotion-focused therapy has shown benefits for patients with CFS 1
• Manual acupuncture can be considered as part of management 1

Pharmacological Options (Second-Line)

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) can be considered for pain management and improved functional status 1
• Pregabalin may be offered for pain management in patients with CFS 1
• Bupropion has shown favorable results in open-label trials for CFS management 3
• Modafinil may be effective for individuals with severe fatigue, though overall trial results were negative 3

Treatment Approach Algorithm

1. Start with non-pharmacological interventions:

   • Implement CBT to address illness perceptions and coping strategies 1, 4
   • Begin graded exercise therapy with very gradual increases in activity 1
   • Establish consistent patterns of activity, rest, and sleep 4

2. Consider complementary approaches:

   • Mindfulness-based stress reduction 3, 1
   • Manual acupuncture if available 1

3. Add pharmacological interventions if needed:

   • SNRIs for pain and functional improvement 1
   • Pregabalin for pain management 1
   • Consider bupropion for fatigue 3
   • For severe fatigue, modafinil may be considered, though with caution 3, 5

Important Cautions and Contraindications

• Avoid opioid medications for CFS-related pain 1
• Avoid corticosteroids, antivirals, or antibiotics as they have shown no benefit 1
• Avoid stimulants for fatigue symptoms unless severe and other options have failed 1
• Avoid NSAIDs for chronic pain related to CFS 1
• If combining bupropion and modafinil, monitor closely for increased seizure risk, blood pressure changes, and sleep disturbances 5
• Paroxetine has not shown benefit for CFS 3
• Progestational steroids have not demonstrated benefit for CFS 3

Monitoring and Follow-up

• Regularly assess fatigue levels, functional status, and treatment response 1
• Monitor for development of comorbid conditions, particularly depression and anxiety 4, 6
• When using pharmacological interventions, monitor for specific side effects (e.g., blood pressure with SNRIs, seizure risk with bupropion) 5
• Adjust interventions based on patient response and tolerance 1

Pitfalls to Avoid

• Focusing exclusively on either physical or psychological aspects of CFS; the condition requires addressing both biological and psychosocial factors 1
• Dismissing symptoms as "just psychological" or failing to validate the patient's experience 4
• Overmedication without adequate non-pharmacological support 1
• Pushing physical activity too aggressively, which can worsen symptoms 1
• Neglecting to address sleep disturbances, which can perpetuate fatigue 4

The management of CFS requires a systematic approach that addresses both the symptoms and the factors that may perpetuate the illness. While no cure exists, evidence supports that CBT and graded exercise can significantly improve quality of life and reduce symptom burden for many patients with CFS.