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Chronic Fatigue Syndrome (CFS)                 RX  

Incidence of CFS:

Findings indicated that CFS occurs in about 0.42% (95% confidence interval, 0.29%-0.56%) of this random community-based sample. The highest levels of CFS  were consistently found among women, minority groups, and persons with lower levels of education and occupational status.  Chronic fatigue syndrome is a common chronic health condition, especially for women, occurring across ethnic groups. Earlier findings suggesting that CFS is a syndrome primarily affecting white, middle-class patients were not supported by our findings.
(Arch Intern Med. Oct.11, 1999;159:2129-2137 - Leonard A. Jason)

Classify as CFS if both of the following criteria are met:
See CDC Definition of CDC        

Clinically evaluated, unexplained chronic fatigue cases can be classified as chronic fatigue syndrome if the patient meets both the following criteria:

1. Clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (i.e., not lifelong), is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reduction in previous levels of occupational, educational, social, or personal activities ; and
2. Four or more of the following symptoms are concurrently present for 6 months or longer:
   • Substantial impairment in short-term memory or concentration that impairs everyday activities
   • Sore throat
   • Tender cervical or axillary lymph nodes
   • Muscle pain
   • Multijoint pain without swelling or rednes
   • New headaches of a new type, pattern, or severity
   • Unrefreshing sleep
   • Post exertional malaise lasting more than 24 hours

A note on the use of laboratory tests in the diagnosis of CFS:

A minimum battery of laboratory screening tests should be performed. Routinely performing other screening tests for all patients has no known value. However, further tests may be indicated on an individual basis to confirm or exclude another diagnosis, such as multiple sclerosis. In these cases, additional tests should be done according to accepted clinical standards.

In clinical practice, no tests can be recommended for the specific purpose of diagnosing chronic fatigue syndrome. Tests should be directed toward confirming or excluding other possible clinical conditions.

Examples of specific tests that do not confirm or exclude the diagnosis of chronic fatigue syndrome include serologic tests for Epstein-Barr virus, enteroviruses, retroviruses, human herpesvirus 6, and Candida albicans; tests of immunologic function, including cell population and function studies; and imaging studies, including magnetic resonance imaging scans and radionuclide scans (such as single-photon emission computed tomography and positron emission tomography).

Treatment of CFS:                                   See    CDC    CFS Rx Guidelines

1. Nonpharmocologic Therapy
   • Physical Activity
   • Psychotherapy and Supportive Counseling
2. Pharmocologic Therapy
   • Prescription Medication
   • Experimental Drugs and Treatment
   • Dietary Supplements and Herbal Preparations

Medication Rx:

• Low-dose Tricyclic Agents: Tricyclic agents are sometimes 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). Some adverse reactions include dry mouth, drowsiness, weight gain, and elevated heart rate.
• Antidepressants: 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 physicians to benefit from this treatment as well or better than depressed patients. Examples of antidepressants used to treat CFS include serotonin reuptake inhibitors such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil); venlafaxine (Effexor); trazodone (Desyrel); and bupropion (Wellbutrin). A number of mild adverse reactions, varying with the specific drug, may be experienced.
• Anxiolytic agents: Anxiolytic agents are used to treat panic disorder in CFS patients. Examples include alprazolam (Xanax), clonazepam ( Klonopin), and lorazepam (Ativan). Common adverse reactions include sedation, amnesia, and withdrawal symptoms (insomnia, abdominal and muscle cramps, vomiting, sweating, tremors, and convulsions).
• Nonsteroidal Anti-inflammatory Drugs: These drugs may be used to relieve pain and fever 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). 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.
• Antimicrobials: An infectious cause for CFS has not been identified, and antimicrobial agents are not commonly prescribed for CFS, unless of course the patient has been diagnosed with a concurrent infection..
• A controlled trial of the antiviral drug acyclovir found no benefit in patients with CFS.
• Antiallergy Therapy: Some CFS patients have histories of allergy, and these symptoms may flare periodically. Non-sedating antihistamines may be helpful for CFS patients. Examples include astemizole (Hismanal) and loratadine (Claritin). Some of the more common adverse reactions associated with their use include drowsiness, fatigue, and headache. Sedating antihistimines can also be of benefit to patients at bedtime.
• Antihypotensive Therapy: Fludrocortisone (Florinef) has sometimes been prescribed for CFS patients who have had a positive tilt table test. Florinef is currently being tested in controlled studies for its efficacy in the treatment of CFS patients. Beta blockers such as atenolol (Tenormin) have also been prescribed for patients with a positive tilt table test. Increased salt and water intake is also recommended for these patients. Adverse reactions include elevated blood pressure and fluid retention.
• Low dose Hydrocortisone Rx  (Letters)
  (JAMA 1998;280:1061 - McKenzie R)
  (JAMA, May 26, 1999, 281:1887)

REF:
http://www.cfidsfoundation.org  -  National Chronic Fatigue Syndrome & Fibromyalgia Association
http://www.cdc.gov/ncidod/diseases/cfs/cfshome.htm  -  Centers for Disease Control & Prevention CFS 888-232-3228
Conn's Current Therapy 1998
Ann Intern Med 1994;121:953 The Chronic Fatigue Syndrome - Fukuda K, etc.

CFS Foundation

CFS (CDC)  

Chronic Fatigue Syndrome (JAMA May 23/30, 2001;285:2557  Benjamin H Natelson)

Postgradmed.com April 2002 - Chronic Fatigue Syndrome - Patient Note   

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