Where drugs may have a role are in managing pain, gastrointestinal symptoms, autonomic symptoms (such as postural hypotension), sleep disturbance, mental health issues, and allergic symptoms.26

Non-pharmacological methods for managing pain are more likely to help than standard analgesics. However, as pain is considered likely to arise from a central sensitisation of the central nervous system, “the best evidence for efficacy and tolerance is for low dose tricyclic medication.”

Other drug categories for addressing pain in ME/CFS are:

·       anticonvulsants;

·       non-steroidal anti-inflammatory drugs (NSAIDs) for pain and stiffness accompanying musculoskeletal conditions such as osteoarthritis;

·       opiates – codeine and tramadol may have limited efficacy in central sensitisation pain, but tolerance develops;

·       possibly selective serotonin reuptake inhibitors (SSRIs), at higher doses.

GI problems are common in ME/CSF, with symptoms possibly arising from autonomic dysfunction and functional sensitivity, but can often be self-managed, or have standard drug approaches.

For sleep disturbance, the guideline discusses the potential value of amitriptyline, but also considers zopiclone, zolpidem, and melatonin in certain circumstances.