Chronic Fatigue Syndrome Treatment Options, Page 1

Treatment options for sufferers of Chronic Fatigue Syndrome, or Myalgic Encephalomyelitis, include pharmacological therapies as well as cognitive behavioural therapy.

A variety of therapeutic approaches have been described as benefiting patients with chronic fatigue syndrome (CFS). Since no cause for CFS has been identified and the pathophysiology remains unknown, treatment programs are directed at relief of symptoms, with the goal of the patient regaining some level of pre-existing function and well-being. Although desirable, a rapid return to pre-illness health may not be realistic, and patients who expect this prompt recovery and do not experience it may exacerbate their symptoms because of overexertion, become frustrated, and may become more refractory to rehabilitation.

Decisions regarding treatment for CFS or any chronically fatiguing illness should be made only in consultation with a health care provider. The health care provider, together with the patient, will develop an individually tailored program that provides the greatest benefit. This treatment program will be based on assessment of the patient’s overall medical condition and current symptoms, and will be modified over time on the basis of regular follow-up and assessment of the patient’s changing condition. Currently, most health care providers with experience in treating persons with CFS use some combination of the therapies discussed below. Persons who have questions about a particular treatment should contact a qualified health care provider, local medical society, or university medical school for additional information.

Some proposed treatments are unproven and may be harmful. Therapy should not aggravate existing symptoms or create new ones. It should not mask another illness that needs identification and specific treatment. Finally, therapy should not impose an excessive financial burden on the patient.

As a service to CFS patients and other interested persons, this section provides some basic information about different therapies that have been used for the treatment of patients with CFS. These descriptions are intended only for general informational purposes. The Agency for Healthcare Research and Quality has recently completed an Evidence Report Defining and Managing Chronic Fatigue Syndrome that can be downloaded from their website.

Non-Pharmacologic Therapy

Physical Activity: An appropriate amount of physical activity is required by everyone for physical and emotional well-being. Patients with CFS are no exception. A key consideration for patients with CFS is to know how much to do and when to stop the activity. Regardless of the level of activity a patient with CFS may attempt, the most important guideline is to avoid increasing the level of fatigue.

In general, health care providers advise patients with CFS to pace themselves carefully and encourage them to avoid unusual physical or emotional stress. The paced activity can be counter-productive if it increases fatigue or pain. A regular, manageable daily routine helps avoid the “push-crash” phenomenon characterized by overexertion during periods of better health, followed by a relapse of symptoms perhaps initiated by the excessive activity. Although patients should be as active as possible, clinicians may need to explain the disorder to employers and family members, advising them to make allowances as possible. Modest regular exercise to avoid de-conditioning is important. The program of exercise and/or the exercise itself should be supervised by a knowledgeable health care provider or physical therapist. Such supervision is particularly important for severely compromised patients.

Non-pharmacologic therapies that have a passive physical component sometimes used by CFS patients include massage therapy, acupuncture, chiropractic, cranial-sacral, massage, self-hypnosis, and therapeutic touch. These modalities may contribute to feeling better, but they are most effective when combined with patient-generated activity, including aquatic therapy, light exercise (adapted to personal capabilities), and stretching. Some patients may tolerate activities such as yoga and tai chi that require more energy.

Education

Learning about what CFS is and what it is not is a critical component of therapy. This approach includes learning how to adjust activities and behaviors that may aggravate the illness. A formal method to impart this information is known as cognitive behavioral therapy. Cognitive behavioral therapy has been shown to facilitate patient coping and to allow increased activities without triggering increased symptoms. Any chronic illness, including CFS, can affect the patient’s family. Family education may foster good communication and reduce the adverse effect of CFS on the family.

Pharmacologic Therapy

Pharmacologic therapy is directed toward the relief of specific symptoms experienced by the individual patient. Patients with CFS appear particularly sensitive to many medications, especially those that affect the central nervous system. Thus, the usual treatment strategy is to begin with very low doses and to gradually increase dosage as necessary and as tolerated. It is important to remember that use of any drug for symptom relief should be attempted only if an underlying cause for the symptom in question has not been found. The best example is use of a sleep-enhancing medication for non-restorative sleep. Although the patient may state that they sleep better, the sleep disorder remains obscured and thus treatment of the sleep disorder not given. It is also important to remember that all medications can cause untoward side effects, which may lead to new symptoms.

Prescription Medications

Nonsteroidal antiinflammatory drugs:
These drugs can be used to relieve pain in CFS patients. Some are available as over-the-counter medications. Examples include naproxen (Aleve, Anaprox, Naprosen), ibuprofen (Advil, Bayer Select, Motrin, Nuprin), and piroxicam (Feldene). Prescription drugs include tramadol hydrochloride (Ultram), celecoxib (Celebrex), and refecoxib (Vioxx). These medications are generally safe when used as directed, but can cause a variety of adverse effects, including kidney damage, gastrointestinal bleeding, abdominal pain, nausea, and vomiting. Some patients may become dependent on certain of these agents.
Low-dose tricyclic antidepressants:
Tricyclic agents may be prescribed for CFS patients to improve sleep and to relieve mild, generalized pain. Examples include doxepin (Adapin, Sinequan), amitriptyline (Elavil, Etrafon, Limbitrol, Triavil), desipramine (Norpramin), and nortriptyline (Pamelor). Effective dosages are often much lower than those used to treat depression. Some adverse reactions include dry mouth, drowsiness, weight gain, and elevated heart rate.
Other antidepressants:
Newer antidepressants have been used to treat depression in CFS patients, although non-depressed CFS patients receiving treatment with serotonin reuptake inhibitors have been found by some health care providers to benefit from this treatment as well or better than depressed patients. Examples of antidepressants used to treat patients with CFS include serotonin reuptake inhibitors, such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil); venlafaxine (Effexor); trazodone (Desyrel); and bupropion (Wellbutrin). A number of adverse reactions, varying with the specific drug, may be experienced, but include agitation, sleep disturbances, and increased fatigue.
Anxiolytic agents:
Anxiolytic agents may be used to treat symptoms of anxiety in CFS patients. Examples include alprazolam (Xanax) and lorazepam (Ativan). Clonazepam (Klonopin) is another member of this family of drugs that is used to control exaggerated nervous systems problems such as vertigo, burning or exaggerated tenderness in the skin, and “nervous” limb movements, may also be useful. However, they should not be used in the general treatment of CFS. Common adverse reactions include sedation, amnesia, and symptoms accompanying acute withdrawal (insomnia, abdominal and muscle cramps, vomiting, sweating, tremors, and convulsions).
Stimulants:
Fatigue by itself is not a good indication for symptomatic therapy. However, if the fatigue represents lethargy or daytime sleepiness, treatment may be indicated. Trials of a wakefulness agent, modofanil (Provigil), have been completed, but the results have not yet been published. In a small group of patients with excessive sleepiness, the drug decreased symptoms compared with placebo. This drug is currently indicated only with the diagnoses of narcolepsy and excess daytime sleepiness when identified by the proper sleep studies.
Antimicrobials:
An infectious cause for CFS has not been identified, and antibiotics, antivirals, and antifungal agents should not be prescribed for treatment of CFS, unless the patient has been diagnosed with a concurrent infection. A controlled trial of the antiviral drug acyclovir found no benefit for the treatment of patients with CFS. Indiscriminant use of antimicrobials can have a myriad of adverse effects, including increasing the risk for resistant organisms.
Anti-allergy therapy:
Some CFS patients have histories of allergy, and these symptoms may flare periodically. Non-sedating antihistamines may be helpful for CFS patients with allergies. Examples include desloratadine (Clarinex), fexofenadine (Allegra), and ceterizine (Zyrtec). However, anti-allergy therapy has no efficacy in the treatment of CFS itself. Some of the more common adverse reactions associated with use of these medications include drowsiness, fatigue, and headache. Sedating antihistamines such as benadryl can also be of benefit to patients at bedtime. The tricyclic antidepressants mentioned above also have potent antihistamine effects.
Antihypotensive/antitachycardia therapy:
CFS does not respond to treatment with antihypotensive or antitachycardic drugs and general use of such medications may be harmful. However, such medications may be useful in specific circumstances. For example, fludrocortisone (Florinef) has been prescribed for CFS patients who have had a positive tilt table test. However controlled studies have not found Florinef alone effective in the general treatment of CFS patients. Beta blockers such as atenolol (Tenormin) have also been prescribed for patients with orthostatic hypotension. Midodrine (Proamatine), an agent that directly increases blood pressure, may be useful in selected patients identified by an abnormal tilt test. Increased salt and water intake is also recommended for these patients but should be done only under supervision of a health care provider. Adverse reactions include elevated blood pressure and fluid retention.

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