Management of Chronic Fatigue Syndrome

Guideline Recommendations

The VA/DoD Clinical Practice Guideline explicitly states there is insufficient evidence to recommend for or against offering duloxetine for patients with chronic multisymptom illness and symptoms consistent with ME/CFS 1
The guideline makes no recommendation in favor of any pharmacologic agent for the management of CFS/ME/CFS 2
This represents a "neither for nor against" recommendation strength, indicating lack of supporting evidence 3, 4
The American College of Physicians and other guideline societies suggest that the management of CFS/ME/CFS should focus on nonpharmacologic approaches 5, 6

Cognitive-behavioral therapy (CBT) is suggested for CFS/ME/CFS, with consistent evidence showing significant improvement in health function, health-related quality of life, and physical function 5, 6
Mindfulness-based therapies are also suggested for patients with CFS/ME/CFS 5, 6
The guideline emphasizes maximizing nonpharmacologic therapies given the limited success with conventional pharmacologic interventions 3, 4

Stimulants are specifically recommended against for treatment of fatigue in CFS/ME/CFS 1
SNRIs may be appropriate for patients with concurrent fibromyalgia with significant pain as a predominant symptom, or for those with comorbid depression or anxiety, or diabetic neuropathic pain 2, 5, 7

Prescribing SNRIs for CFS without a clear indication may expose patients to side effects such as nausea, constipation, and sexual dysfunction without benefit 7