Treatment of Chronic Fatigue Syndrome

A variety of vitamin supplements, medications, and other substances have been described as having potential therapeutic benefits for chronic fatigue syndrome (CFS) patients. Many of the treatments recommended for CFS patients are intended to provide relief for symptoms of this condition. However, some proposed treatments are unproven and potentially dangerous. 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 CFS patients. These descriptions are intended to be used only for general informational purposes.

Decisions regarding the use of these or other treatments should be made only in consultation with a physician. If you have doubts about a particular treatment, contact your local medical society, university medical school, or another physician for additional information.

Non-Pharmacologic Therapy

Since no cause for CFS has been identified, the therapies for this disorder are directed at relief of symptoms. The physician, together with the patient, will develop an individually tailored program that provides the greatest perceived benefit, based on some combination of the therapies discussed in this section.

Physical Activity

In general, physicians advise patients with CFS to pace themselves carefully and encourage them to avoid unusual physical or emotional stress. 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 and should be supervised by a physician or physical therapist.

Physical Activities and Therapy: Non-pharmacologic therapies sometimes used by CFS patients include acupuncture, aquatic therapy, chiropractic, cranial-sacral, light exercise, massage, self-hypnosis, stretching, tai chi, therapeutic touch, and yoga.

Psychotherapy and Supportive Counseling

Certain psychotherapies, such as cognitive behavior therapy, have shown promise for facilitating patient coping and for alleviating some of the distress associated with CFS. In addition, any chronic illness can affect the patient caregivers and family. In such instances, family therapy may foster good communication and reduce the adverse impact 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 drugs, especially those that affect the central nervous system. Thus, the usual treatment strategy is to begin with very low doses and to escalate the dosage gradually as necessary.

Prescription Medications

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 Antiinflammatory 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 for the treatment of 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.

Experimental Drugs and Treatments

Ampligen is a synthetic nucleic acid product that stimulates the production of interferons, a family of immune response modifiers that are also known to have anti-viral activity. One report of a double-blinded, placebo-controlled study of CFS patients documented modest improvements in cognition and performance among Ampligen recipients compared with the placebo group. These preliminary results will need to be confirmed by further study. Ampligen is not approved by the Food and Drug Administration (FDA) for widespread use, and the administration of this drug in CFS patients should be considered experimental. Although the recipients of Ampligen in this study tolerated the drug well, the adverse reactions of this material are still incompletely characterized, and some participants did experience reactions that might be attributable to Ampligen.

Dehydroepiandrosterone (DHEA) was reported in preliminary studies to improve symptoms in some patients; however, this finding has not been confirmed and the use of DHEA in patients should be regarded as experimental.

Gamma globulin (Gammar) is pooled human immune globulin. It contains antibody molecules directed against a broad range of common infectious agents and is ordinarily used as a means for passively immunizing persons whose immune system has been compromised, or who have been exposed to an agent that might cause more serious disease in the absense of immune globulin. Its use with CFS patients is experimental and based on the unsubstantiated hypothesis that CFS is characterized by an underlying immune disorder. Serious adverse reactions are uncommon, although in rare instances gamma globulin may initiate anaphylactic shock.

High colonic enemas have no demonstrated value in the treatment of CFS. The procedure can promote intestinal disease.

Kutapressin is a crude extract from pig's liver. Its use should be regarded as experimental in any clinical circumstance, and there is no scientific evidence that it has any value in the treatment of CFS patients. Kutapressin can elicit allergic reactions.

Dietary Supplements and Herbal Preparations

General Comments: A variety of dietary supplements and herbal preparations are claimed to have potential benefits for CFS patients. With few exceptions, the effectiveness of these remedies for treating CFS patients has not been evaluated in controlled trials. Contrary to common belief, the "natural" origin of a product does not ensure safety. Dietary supplements and herbal preparations can have potential side reactions and some can interfere or interact with prescription medications. CFS patients should seek the advice of their physician before using any unprescribed remedy.

Vitamins, Coenzymes, Minerals: Preparations that have been claimed to have benefit for CFS patients include adenosine monophosphate, coenzyme Q-10, germanium, glutathione, iron, magnesium sulfate, melatonin, NADH, selenium, l-tryptophan, vitamins B12, C, and A, and zinc. An early CFS study found reduced red blood cell magnesium sulfate in CFS patients, but two subsequent studies have found no difference between patients and healthy controls. The therapeutic value of all these preparations has not been validated.

Herbal Preparations: Plants are known sources of pharmacological materials. However, unrefined plant preparations contain variable levels of the active compound as well as many irrelevant, potentially harmful substances. Preparations that have been claimed to have benefit to CFS patients include astralagus, borage seed oil, bromelain, comfrey, echinacea, garlic, Ginkgo biloba, ginseng, primrose oil, quercetin, St. John's wort, and Shiitake mushroom extract. Only primrose oil was evaluated in a controlled study, and the beneficial effects noted in CFS patients have not been independently confirmed. Some herbal preparations, notably comfrey and high-dose ginseng, have recognized harmful effects.

Source: Centers for Disease Control and Prevention, September 2000