1. ‘Tired all the time’ and Chronic Fatigue Syndrome

2. Why? Common 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…

3. ‘oh - is that the thing that makes people lazy?’

4. Content TATT Diagnosis Investigations Chronic fatigue Diagnosis Investigations Management

5. Tired all the time Common Average 30 patients/yr per GP Most common ‘unexplained complaint’ Underlying factors…. Physical in ~9% Psychological in up to 75%

6. History and Examination 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

7. Prediction of outcome in patients presenting with fatigue in primary care (BJGP 2009) Prospective cohort study n=642 Adverse prognostic factors for chronicity Severity of fatigue and associated pain Expectation of chronicity Less social support Patient expectation of chronicity especially predicted negative outcomes Enjoying daily activities associated with positive outcome ?potentially modifiable patient expectations leading to better outcome.

8. Differential Diagnosis TATT Depression Asthma DM Hypo/hyperthyroidism Anaemia Sleep apnoea Infection e.g. CMV/EBV/Hepatitis Neurological e.g. MS Connective Tissue e.g. RA/SLE Peri-menopausal Malignancy Chronic Fatigue

9. Investigations 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

10. VAMPIRE Study (BJGP 2009) VAgue Medical Problems In Research Trial GP presentations with unexplainable fatigue n=325 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

11. Chronic Fatigue Syndrome (ME) Female:Male 4:1 Most common 40-50yrs NICE Clinical Guideline 53 - 2007

12. Definition 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 New or specific onset Persistent and/or recurrent Unexplained by other conditions Substantial reduction in activity level Post-exertional malaise and/or fatigue

13. 2) One or more of…. 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

14. Severity Mild Mobile Self caring Light domestic tasks with difficulty Still working but days off Stopped leisure/social activities

15. Moderate Reduced mobility Restricted in all activities daily living Usually stopped work Need rest periods Poor/ disturbed sleep

16. 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

17. Aetiology Poorly understood - lots of theories Viral Genetic Immunological Neuro-endocrine Psychological Best regarded as a spectrum

18. Investigations FBC UE LFT TFT CRP PV Urinalysis Glucose Coeliac serology Calcium CK Not unless indicated… Ferritin unless young Viral serology B12/ folate

19. General management Coordinated by named professional Shared decision making Individualized management plan Access to community services Occupational Social care Regular structured review Specialist referral if required

20. Drug therapy No firm evidence for any Consider SSRI if mood symptoms Consider low dose TCA if pain/ sleep problems Little evidence for…. Anticholinergics Steroids Antivirals Dexamphetamine MAOIs No evidence for requiring reduced dose

21. Non drug treatment Discourage rest periods > 30minutes Cognitive Behavioural Therapy Reduces symptoms Increases functioning Increases QOL Graded Exercise Therapy Evidence for increased functioning NOT just ‘exercise more’

23. Others - little evidence but may help Sleep Management Relaxation Pacing Activity Management Exclusion diets

24. Setbacks in recovery Expect them Triggers Poor sleep/ increase in activity/ stress Infections/ other illness Should have a clear plan including rests and when to cut activities

25. Prognosis Most improve over time Only 5-10% achieve complete recovery to former levels despite remission Some relapse Should have planned setback strategies Small number remain severely affected

26. Summary Delay Ix for 4 weeks Simple bloods only Chronic fatigue is a spectrum but still poorly understood. Best evidence is for Graded Exercise/CBT

27. Any questions?