Release Date : March 24 2023
Chronic Multisymptom Illness: VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness (2021)
About the Guideline
- In October 2014, the Veterans Affairs (VA) and Department of Defense (DoD) published a clinical practice guideline (CPG) for the management of chronic multisymptom illness (CMI). It was based on evidence reviewed through October 2013. An update of the 2014 CMI CPG was initiated in 2019 using published clinical evidence and related information available through April 7, 2020. The third update was published in 2021.
- CMI is characterized by multiple, persistent symptoms present or frequently recurring for more than six months, across more than one body system, and severe enough to interfere with daily functioning. Symptoms include fatigue, headache, arthralgias, myalgias, concentration and attention problems, and gastrointestinal disorders.
- The guideline is a set of recommendations for the individualized treatment of adult patients with CMI in the VA and DoD.
- The guideline is not intended to serve as a standard of care.
- The guideline work group consisted of four clinical champions as well as experts representing internal medicine, psychiatry, nutrition, gastroenterology, pharmacology, rheumatology, neurology, behavioral health, social work, psychology, nursing, and physical therapy.
Key Clinical Considerations
Become familiar with the recommendations and best-practice statements provided in this guideline.
Treatment of CMI
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- Long-term use of opioid medications is not recommended for the management of chronic pain in patients with CMI.
- MiFEPRIStone is not recommended for patients with CMI.
- For patients with CMI and symptoms consistent with fibromyalgia syndrome (FMS), irritable bowel syndrome (IBS), or myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS):
- Cognitive behavioral therapy is suggested.
- Mindfulness-based therapies are suggested.
- There is no recommendation for or against biofeedback modalities.
- There is no recommendation for or against manual musculoskeletal therapies.
CMI and Symptoms Consistent with FMS or IBS
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- For patients with CMI and symptoms consistent with FMS or IBS:
- Emotion-focused therapy is suggested.
- There is no recommendation for or against offering relaxation therapy.
- There is no recommendation for or against the use of guided imagery and hypnosis modalities.
Treatment of CMI and Symptoms Consistent with FMS
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- For the treatment of pain and to achieve improved functional status in patients with CMI and symptoms consistent with fibromyalgia:
- There is no recommendation for or against offering a trial of mirtazapine, selective serotonin reuptake inhibitors, or amitriptyline for pain management.
- A trial of serotonin-norepinephrine reuptake inhibitors for the treatment of pain and improved functional status is suggested.
- Pregabalin is suggested for the treatment of pain.
- Nonsteroidal anti-inflammatory drugs are suggested for the treatment of chronic pain.
- Yoga or tai chi is suggested.
- Manual acupuncture is suggested.
- There is no recommendation for or against the use of deep tissue massage modalities.
- Physical exercise is suggested.
Treatment of CMI and Symptoms Consistent with IBS
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- For patients with CMI and symptoms consistent with IBS:
- There is no recommendation for or against offering tricyclic antidepressants for the management of gastrointestinal symptoms.
- There is no recommendation for or against the use of antispasmodics for gastrointestinal symptoms.
- Linaclotide and plecanatide are suggested for patients with constipation who do not respond to a trial of osmotic laxatives.
- There is no recommendation for or against offering lubiprostone for patients with constipation who do not respond to a trial of osmotic laxatives.
- There is no recommendation for or against offering eluxadoline for patients with diarrhea.
- A 14-day course of rifAXIMin for gastrointestinal symptoms without constipation is suggested.
- There is no recommendation for or against offering soluble fiber supplements for gastrointestinal symptoms.
- There is no recommendation for or against offering alosetron for gastrointestinal symptoms.
- There is no recommendation for or against offering selective serotonin reuptake inhibitors for the management of gastrointestinal symptoms.
- There is no recommendation for or against offering psychodynamic therapies.
Treatment of CMI and Symptoms Consistent with ME/CFS
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- For patients with CMI and symptoms consistent with ME/CFS:
- There is no recommendation for or against offering duloxetine.
- Stimulants are not recommended for treatment of fatigue.
Reference
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