Transcript Hot Topic - Chronic Fatigue Syndrome

‘Tired all the time’ and
Chronic Fatigue Syndrome
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Louise Marshall
Why?
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Common
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Trials show poor patient satisfaction
Poorly understood
CFS recent media coverage
CFS is recognized by NICE as real and defined by
WHO as a neurological illness (G93.3) but many
differing attitudes of doctors, public and patients…
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‘oh - is that the thing that makes people lazy?’
Content
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TATT
• Diagnosis
• Investigations
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Chronic fatigue
• Diagnosis
• Investigations
• Management
Tired all the time
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Common
• Average 30 patients/yr per GP
• Most common ‘unexplained complaint’
Underlying factors….
• Physical in ~9%
• Psychological in up to 75%
History and Examination
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Onset and duration and pattern of fatigue
• Shorter duration suggests post-viral
• On exertion relieved by rest suggests organic
• Worst in morning ? depression
Sleep pattern
• EMW/ unrefreshing sleep ? depression
• Snoring/ day-time sleeping ? sleep apnoea
Associated symptoms
• SOB/ weight loss/ anorexia/ pain
Psychiatric symptoms
• Depression/ anxiety/ stress
Alcohol/ drugs/ OTC
Patient’s views/ worries
Mental state exam
Physical examination usually normal
Prediction of outcome in patients presenting
with fatigue in primary care
(BJGP 2009)
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Prospective cohort study n=642
• Adverse prognostic factors for chronicity
• Severity of fatigue and associated pain
• Expectation of chronicity
• Less social support
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Patient expectation of chronicity especially predicted negative
outcomes
• Enjoying daily activities associated with positive outcome
• ?potentially modifiable patient expectations leading to better
outcome.
Differential Diagnosis TATT
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Depression
Asthma
DM
Hypo/hyperthyroidism
Anaemia
Sleep apnoea
Infection e.g.
CMV/EBV/Hepatitis
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Neurological e.g. MS
Connective Tissue e.g.
RA/SLE
Peri-menopausal
Malignancy
Chronic Fatigue
Investigations
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Led by history/ examination
• Oxford Handbook suggest if ‘sustained’ fatigue with no obvious
cause check…
• Urinalysis
• FBC/ PV/ CRP/ U&E/ LFT/ Calcium/ TFT/ Glu/ CK/
Coeliac
• Ferritin in young people
• +/- serological viral tests EBV/CMV
VAMPIRE Study (BJGP 2009)
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VAgue Medical Problems In Research Trial
• GP presentations with unexplainable fatigue n=325
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Wait at least 4 weeks
• 78% did not represent for bloods
• 8% patients tested had abnormalities
• Limited blood set picked up most conditions
• FBC/PV/Glu/TSH
• DM most common then anaemia/ EBV
Chronic Fatigue Syndrome (ME)
• Female:Male 4:1
• Most common 40-50yrs
• NICE Clinical Guideline 53 - 2007
Definition
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Symptoms present for at least 4 months (3 in kids)
May fluctuate in severity and change in nature
over time
Other diagnoses excluded
Reconsider if none of 4 key symptoms
1) FATIGUE
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New or specific onset
Persistent and/or recurrent
Unexplained by other conditions
Substantial reduction in activity level
Post-exertional malaise and/or fatigue
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2) One or more of….
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Sleep disturbance
Muscle or joint pain
Cognitive dysfunction
Headaches
Painful lymph nodes without enlargement
Sore throat
Physical or mental exertion makes symptoms
worse
• ‘flu-like’ symptoms
• Dizziness and/or nausea
• Palpitations in the absence of cardiac pathology
Severity
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Mild
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Mobile
Self caring
Light domestic tasks with difficulty
Still working but days off
Stopped leisure/social activities
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Moderate
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Reduced mobility
Restricted in all activities daily living
Usually stopped work
Need rest periods
Poor/ disturbed sleep
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Severe
• Unable to do any activity for themselves or
carry out minimal activities e.g face washing
• Severe cognitive difficulties
• Wheelchair bound
• Often housebound
• Sensitive to light and noise
Aetiology
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Poorly understood - lots of theories
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Viral
Genetic
Immunological
Neuro-endocrine
Psychological
Best regarded as a spectrum
Investigations
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FBC
UE
LFT
TFT
CRP
PV
Urinalysis
Glucose
Coeliac serology
Calcium
CK
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Not unless indicated…
• Ferritin unless young
• Viral serology
• B12/ folate
General management
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Coordinated by named professional
• Shared decision making
• Individualized management plan
• Access to community services
• Occupational
• Social care
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Regular structured review
• Specialist referral if required
Drug therapy
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No firm evidence for any
• Consider SSRI if mood symptoms
• Consider low dose TCA if pain/ sleep problems
• Little evidence for….
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Anticholinergics
Steroids
Antivirals
Dexamphetamine
MAOIs
No evidence for requiring reduced dose
Non drug treatment
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Discourage rest periods > 30minutes
• Cognitive Behavioural Therapy
• Reduces symptoms
• Increases functioning
• Increases QOL
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Graded Exercise Therapy
• Evidence for increased functioning
• NOT just ‘exercise more’
QuickTime™ and a
decompressor
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Others - little evidence but may help
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Sleep Management
• Relaxation
• Pacing
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Activity Management
• Exclusion diets
Setbacks in recovery
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Expect them
Triggers
• Poor sleep/ increase in activity/ stress
• Infections/ other illness
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Should have a clear plan including rests and
when to cut activities
Prognosis
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Most improve over time
Only 5-10% achieve complete recovery to
former levels despite remission
Some relapse
• Should have planned setback strategies
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Small number remain severely affected
Summary
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Delay Ix for 4 weeks
Simple bloods only
Chronic fatigue is a spectrum but still
poorly understood.
Best evidence is for Graded Exercise/CBT
Any questions?