A 35-Year-Old Woman With Fatigue and Joint Pain

Zain Ul Abideen Asad, MD, MBBS


May 09, 2017

Treatment options include cognitive-behavioral therapy, graded exercise therapy, corticosteroids, antidepressants, dietary supplements, oral nicotinamide adenine dinucleotide (NADH), and immunotherapy. All of these focus on symptom control because no cure has been identified. Usually, multiple modalities are tried, with limited success.

Cognitive-behavioral therapy and graded exercise therapy are the only interventions found to be beneficial.[7,8] Cognitive-behavioral therapy involves the patient developing a greater understanding of the necessary lifestyle changes, motivation, identification of and change in fatigue-related cognitive problems, and careful planning of daily activities, in an attempt to enable the patient to acquire gradual control over symptoms.

Similarly, graded exercise therapy involves a balance between activity and rest. It aims at starting physical activity slowly and gradually increasing it while being careful to avoid extremes. The duration is usually a trial-and-error approach; the goal is to stop before extreme fatigue. Although both cognitive-behavioral therapy and graded exercise therapy have been studied in randomized controlled trials and systematic reviews reinforce their benefit, many doubts surround these interventions. Prolonged rest is not indicated; it has shown no benefits and may worsen fatigue and other symptoms.

Drug therapy is usually targeted to address pain and sleep disturbances. Three randomized controlled trials found that the benefits of corticosteroids were short-lived.[9,10,11] Randomized controlled trials failed to show evidence for benefit of antidepressants in chronic fatigue syndrome. Fluoxetine, 20 mg daily, did not improve depression or insomnia in chronic fatigue syndrome.[12] Limited benefit and significant side effects were observed in major randomized control trials that explored the use of immunotherapy (immunoglobulin G).[13,14,15]

Of note, interferon-2a was found to improve quality of life for a subgroup of patients with chronic fatigue syndrome who had baseline decreased natural killer cell function.[16] Oral NADH showed limited benefit in a single randomized controlled trial with a small sample; the rationale was that it facilitates generation of adenosine triphosphate, which might be depleted in patients with chronic fatigue syndrome.[17] Narcotics are not indicated for chronic fatigue syndrome associated pain; other choices should be limited to acetaminophen, aspirin, or nonsteroidal anti-inflammatory drugs.

This patient was followed up at 3-month intervals for 1 year. Her symptoms were under good control with cognitive-behavioral therapy, and she managed to adapt to a new lifestyle and recognize her activity limitations.


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