BMJ Best Practice Guide, updated Nov 2017: Chronic fatigue syndrome

Written by Dr James N Baraniuk
Reviewed by Dr Rosemary Vallings, Dr Abijhit Chaudhuri

Chronic fatigue syndrome (CFS) is characterised by a sudden or gradual onset of persistent disabling fatigue, post-exertional malaise (PEM, exertional exhaustion), unrefreshing sleep, cognitive and autonomic dysfunction, myalgia, arthralgia, headache, and sore throat and lymph nodes, with symptoms lasting at least 6 months.

Exertional exhaustion is the critical aspect that distinguishes myalgic encephalomyelitis/CFS from other nociceptive, interoceptive, and fatiguing illnesses.

The lack of energy may be caused by autoimmune and metabolomic dysfunction that reduces mitochondrial ATP production.

The primary goals of management are to provide a supportive healthcare environment with a team of occupational, physio, and other appropriate therapists who will manage symptoms and improve functional capacity.

The chronic but fluctuating disabilities require substantial lifestyle changes to plan each day’s activities carefully, conserve energy resources for the most important tasks, schedule rest periods to avoid individuals overtaxing themselves, and to improve the quality of sleep.

Medications are not curative. Pharmacotherapy is indicated to treat pain, migraine, sleep disturbance, and comorbid conditions such as irritable bowel syndrome, anxiety, or depression.

More information (mostly behind a paywall) on:


Theory: Epidemiology; Aetiology; Case history

Diagnosis: Approach; History and exam; Investigations; Differentials; Criteria

Management:  Approach; Treatment algorithm; Emerging; Patient discussions

Follow up: Monitoring; Complications; Prognosis

Resources: Guidelines; References; Patient leaflets; Evidence



Virology blog post, by Steven Lubet and David Tuller, 13 Nov 2017: Trial By Error : The Surprising New BMJ Best Practice Guide

Something has changed.

That’s the only explanation for the recent publication of a “Best Practice” guide for “chronic fatigue syndrome” (behind a paywall, unfortunately) from the BMJ Publishing Group. This thing is good. It’s very good, in fact. One bottom line at this stage for any treatment guide is the following: Would it lead a clinician to prescribe cognitive behavior therapy or graded exercise therapy for patients with ME, as opposed to those suffering from a vague fatiguing illness? The answer here is an unequivocal no.

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