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Cover of Defining and Managing Chronic Fatigue Syndrome

Defining and Managing Chronic Fatigue Syndrome

Evidence Reports/Technology Assessments, No. 42

, MD, MSc, Program Director and , DrPH, Project Director. Investigators: , PhD and , BS.

Rockville (MD): Agency for Healthcare Research and Quality (US); .
Report No.: 02-E001

Structured Abstract

Objectives:

Objectives of this evidence report are to summarize research evidence regarding the case definitions, prevalence, natural history and therapy of chronic fatigue syndrome (CFS).

Search Strategy:

English and non-English citations were identified through July 2000 from four electronic bibliographic databases (MEDLINE, The Cochrane Library, PsycINFO, EMBASE), CFS Internet sites, the Journal of Chronic Fatigue Syndrome, references of pertinent articles, textbooks, and experts. The electronic search was updated through October 2000 using PubMed; experts identified relevant citations up to January 2001.

Selection Criteria:

Published and unpublished studies that were conducted after 1980 and that involved adults with CFS were reviewed.

Data Collection and Analysis:

Two reviewers (physician, psychometrician, research methodologist, and/or nurse) independently abstracted data from the selected studies. Data were synthesized descriptively, emphasizing the quality and methodologic design of studies. Meta-analyses were not done because of marked heterogeneity of study designs.

Main Results:

There are four well-recognized case definitions of CFS, and the Centers for Disease Control and Prevention (CDC) is spearheading the development of a fifth. Definitions, developed primarily by expert knowledge and consensus, have evolved over time. A few comparative research studies support the concept of a condition, characterized by prolonged fatigue and impaired ability to function, which is captured by the case definitions. The superiority of one case definition over another is not well established. The validity of any definition is difficult to establish because there are no clear biologic markers for CFS, and no effective treatments specific only to CFS have been identified.

Findings from surveys show that the prevalence of CFS in community populations is probably less than 1% and in primary care populations less than 3%. The reliability of these estimates is limited, because surveys used different case definitions and varied assessment and reporting methods, and sometimes had poor response rates.

Precise estimates of recovery, improvement, and/or relapse from CFS are not possible because there are few natural history studies and those that are available have involved selected referral populations or have used varying case definitions and followup methods.

Thirty-eight controlled trials evaluating multiple treatment interventions show the following mixed results:

Immunologic Therapy: Evidence from 11 trials is scant and insufficient to conclude whether immunological therapies, such as immunoglobulin, Ampligen, Acyclovir, interferon, and transfer factor, are effective or ineffective.

Corticosteroids: Evidence from four trials suggests that there are no consistent benefits from mineralocorticoids (fludrocortisone), but that there are some improvements in fatigue and functional status with glucocorticoids (hydrocortisone). However, glucocorticoid therapy may severely suppress adrenal function.

Antidepressants: Evidence from five trials show that there is no consistent pattern of benefit from antidepressant therapy, though some participants in these trials experienced improved vigor and less anxiety.

Behavioral Therapies: Evidence from nine trials generally show that behavioral interventions that emphasize increased activity levels result in improvements in fatigue, overall well-being, quality of life and functional status.

Other: Evidence from trials is scant and insufficient to conclude whether complementary therapies, such as homeopathy, massage therapy and osteopathy are effective or ineffective. Evidence from trials is scant and insufficient to conclude whether multiple other therapies, such as nicotinamide adenine dinucleotide (NADH), galanthamine, growth hormone, essential fatty acids, and liver extract therapies, are effective or ineffective. Findings from one small trial suggest that magnesium therapy may improve energy, overall well-being, pain and distress in patients with CFS and magnesium deficiency.

Conclusions:

Existing case definitions for CFS appear to characterize a group of people with prolonged fatigue and impaired ability to function. The validity and superiority of any particular case definition are not well established. Surveys suggest that the prevalence of CFS in community populations is less than 1%. Precise estimates of rates of recovery, improvement and/or relapse from CFS are not available. Although several therapies have been studied, potential benefits as well as harms of most therapies are not well established. Behavioral interventions that emphasize increasing activity levels may improve quality of life and function in some people with CFS.

Contents

2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.1 Contract No: 290-97-0012. Prepared by: San Antonio Evidence-based Practice Center at The University of Texas Health Science Center at Antonio.

Suggested citation:

Mulrow CD, Ramirez G, Cornell JE, et al. Defining and Managing Chronic Fatigue Syndrome. Evidence Report/Technology Assessment No. 42 (Prepared by San Antonio Evidence-based Practice Center at The University of Texas Health Science Center at San Antonio under Contract No. 290-97-0012). AHRQ Publication No. 02-E001. Rockville (MD): Agency for Healthcare Research and Quality; October 2001.

On December 6, 1999, under Public Law 106-129, the Agency for Health Care Policy and Research (AHCPR) was reauthorized and renamed the Agency for Healthcare Research and Quality (AHRQ). The law authorizes AHRQ to continue its research on the cost, quality, and outcomes of health care and expands its role to improve patient safety and address medical errors.

This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.

AHRQ is the lead Federal agency charged with supporting research designed to improve the quality of health care, reduce its cost, address patient safety and medical errors, and broaden access to essential services. AHRQ sponsors and conducts research that provides evidence-based information on health care outcomes; quality; and cost, use, and access. The information helps health care decisionmakers -- patients and clinicians, health system leaders, and policymakers -- make more informed decisions and improve the quality of health care services.

The authors of this report are responsible for its content. Statements in the report should not be construed as endorsement by the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services of a particular drug, device, test, treatment, or other clinical service.

Partial support for this review was provided by the Veterans Evidence-based Research, Dissemination, and Implementation Center, a Veterans Affairs Health Services Research and Development Center of Excellence (VA HFP 98-002). The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

1

2101 East Jefferson Street, Rockville, MD 20852. www​.ahrq.gov

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