What is the management plan for chronic fatigue syndrome?

Management of Chronic Fatigue Syndrome

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis by documenting severe fatigue lasting >6 months plus at least 4 of these symptoms: postexertional malaise, unrefreshing sleep, impaired memory/concentration, muscle pain, polyarthralgia, sore throat, tender lymph nodes, or new headaches. 1, 2

• Screen fatigue severity using a 0-10 numeric rating scale at every encounter; scores ≥4 require comprehensive evaluation including assessment of physical, cognitive, and emotional domains 2
• Exclude alternative causes first: anemia (check CBC, iron studies), hypothyroidism (TSH), depression/anxiety (clinical assessment), and sleep disorders 2
• This is a diagnosis of exclusion—no laboratory tests confirm CFS 1

First-Line Treatment: Cognitive-Behavioral Therapy

Offer structured cognitive-behavioral therapy (CBT) as the primary intervention, as it demonstrates moderate improvements in fatigue, distress, cognitive symptoms, and mental health functioning. 1, 2

• CBT must be delivered by trained providers and structured to address thoughts, feelings, and behaviors related to fatigue 1, 2
• Focus on promoting consistent patterns of activity, rest, and sleep, followed by gradual return to normal activity 1
• Address catastrophic misinterpretations of symptoms and problem-solve current life difficulties 1

Second-Line Treatment: Graded Physical Activity

Prescribe tailored physical activity starting at low intensity and gradually increasing based on tolerance, with moderate aerobic exercise (walking, swimming, cycling) 3-5 times weekly. 1, 2

• Begin with low-intensity exercise and increase gradually to prevent postexertional malaise 2
• Incorporate both aerobic and resistance training to improve muscle strength and reduce fatigue 1, 3
• Consider tai chi, qigong, or yoga as gentler alternatives showing significant improvements in physical functioning, quality of life, pain, fatigue, and sleep quality 1, 2
• Teach activity pacing and energy conservation strategies to prevent overexertion 3

Complementary Non-Pharmacological Options

Consider mindfulness-based programs and manual acupuncture as adjunctive therapies. 1, 2

• Mindfulness-based therapies show moderate effect sizes for enhancing quality of life 1, 2
• Manual acupuncture: 20-30 minute sessions three times weekly for 2-3 weeks, then twice weekly for 2 weeks, then weekly for 6 weeks (note: adverse events reported in some studies) 2
• Emotion-focused therapy has shown benefits and should be considered 1

Pharmacological Management

For pain management, consider SNRIs or pregabalin; for fatigue, bupropion may be tried on a pragmatic basis. 1, 2

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) can improve pain and functional status 1, 2
• Pregabalin may be offered specifically for pain management 1
• Bupropion showed favorable results in open-label trials for fatigue, though evidence is limited 1, 2

Critical Medications to AVOID

Do NOT prescribe: opioids, NSAIDs, stimulants, corticosteroids, antivirals, antibiotics, mifepristone, paroxetine, or progestational steroids—none have demonstrated benefit and some carry significant risks. 1, 2

• American College of Physicians explicitly recommends avoiding opioids and NSAIDs for CFS-related pain 1, 2
• American Academy of Neurology recommends avoiding stimulants for fatigue symptoms 1, 2
• American College of Rheumatology recommends avoiding corticosteroids, antivirals, and antibiotics 1, 2
• Paroxetine and progestational steroids have not shown benefit 1, 2

Ongoing Monitoring and Follow-Up

Reassess fatigue levels at every visit using the same 0-10 numeric scale and adjust interventions based on response. 2, 3

• Incorporate regular assessment of fatigue severity, impact, and coping strategies into clinical consultations 1, 2
• Discuss access to psychoeducational interventions periodically based on patient needs 1, 2
• Encourage long-term physical activity as a lifestyle change 1, 2
• Refer to specialists for unresolved fatigue despite comprehensive management 2

Multidisciplinary Team Approach

Primary care physicians should lead management with referrals to rheumatology (for musculoskeletal symptoms), mental health professionals (for CBT and mindfulness), physical therapists (for exercise programs), and integrative medicine specialists (for complementary approaches). 1

• No single specialist is exclusively responsible for CFS management 1
• Mental health professionals are crucial for implementing evidence-based interventions like mindfulness-based treatments 1
• Physical therapists address physical deconditioning and activity limitations 1

Common Pitfalls to Avoid

• Failing to establish a therapeutic patient-provider alliance early in treatment 1
• Focusing exclusively on either physical or psychological aspects rather than addressing both 1
• Prescribing medications without proven efficacy (see avoidance list above) 1, 2
• Neglecting to monitor fatigue that persists despite well-controlled interventions 3
• Inadequate follow-up and failure to adjust management strategies based on response 2