What are the treatment recommendations for chronic fatigue syndrome?

Treatment Recommendations for Chronic Fatigue Syndrome

Cognitive-behavioral therapy (CBT) and graded exercise therapy (GET) should be offered as first-line interventions for chronic fatigue syndrome, as they have demonstrated the most consistent evidence for improving fatigue symptoms, physical functioning, and quality of life. 1, 2

Initial Assessment

• Chronic fatigue syndrome (CFS) is characterized by persistent fatigue lasting more than 6 months that interferes with daily functioning, accompanied by symptoms such as headache, joint/muscle pain, concentration problems, and gastrointestinal disorders 1, 3
• Establish a therapeutic patient-provider alliance while conducting a thorough evaluation of symptoms and assessing for comorbid conditions 1
• Regular assessment of fatigue severity, impact, and coping strategies should be incorporated into clinical consultations 4

Non-Pharmacological Interventions

Cognitive-Behavioral Therapy

• CBT has demonstrated moderate improvements in fatigue, distress, cognitive symptoms, and mental health functioning 1, 2
• Should be structured and tailored to address thoughts, feelings, and behaviors related to fatigue 4
• Access to psychoeducational interventions should be discussed periodically based on patient needs 4

Physical Activity Interventions

• Graded exercise therapy should be gradually introduced with careful monitoring to avoid exacerbation of symptoms 1, 5
• Exercise programs must be designed for individual physical capabilities and account for the fluctuating nature of symptoms 5
• Moderate-intensity resistance training and aerobic exercise can improve strength, energy, and fitness 4
• Long-term physical activity as a lifestyle change should be encouraged 4

Complementary Approaches

• Mindfulness-based therapies show moderate effect sizes for enhancing quality of life 1
• Manual acupuncture can be considered as part of management 1
• Emotion-focused therapy has shown benefits for patients with CFS 1

Pharmacological Interventions

• Limited evidence supports the effectiveness of pharmacological interventions for CFS 3, 6
• Bupropion may be considered for fatigue management based on favorable results in open-label trials 4, 1
• Modafinil may be effective for individuals with severe fatigue, though overall trial results were negative 4, 1
• 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

Treatment Approaches to Avoid

• Avoid corticosteroids, antivirals, or antibiotics as they have shown no benefit 1
• Avoid stimulants for fatigue symptoms unless severe fatigue is present 1
• Avoid NSAIDs for chronic pain related to CFS 1
• Avoid opioid medications for pain related to CFS 1
• Paroxetine has not shown benefit for CFS 4, 1
• Progestational steroids have not demonstrated benefit 4

Multidisciplinary Approach

• CFS is best managed by a multidisciplinary team led by primary care physicians with referrals to appropriate specialists based on predominant symptoms 1
• Specialists may include rheumatologists, mental health professionals, physical therapists, and integrative medicine specialists 1
• Management should address both biological and psychosocial factors 1, 6

Follow-up and Monitoring

• Regular follow-up is essential to assess treatment response and adjust interventions as needed 1
• Fatigue should be routinely monitored as part of clinical care 4
• Decisions on managing fatigue should be shared between the patient and healthcare providers 4, 1

Common Pitfalls to Avoid

• Focusing exclusively on either physical or psychological aspects of CFS; the condition requires addressing both biological and psychosocial factors 1, 6
• Implementing exercise programs that are too vigorous, which can exacerbate symptoms 5
• Assuming that a single intervention will be sufficient; most patients require multiple approaches tailored to their specific symptoms 1, 6
• Failing to recognize that CFS symptoms fluctuate, requiring periodic reassessment and adjustment of treatment plans 4, 5