Dukes, Jason C, Chakan, Matthew, Mills, Aaron et al. · The Medical clinics of North America · 2021 · DOI
Fatigue can come from many different causes, so doctors need to carefully listen to patients' histories and perform physical exams rather than just ordering lots of tests. Fatigue may be caused by an underlying medical condition that can be treated, or it may be a primary condition on its own (now called system exertion intolerance disease). Currently, there are no FDA-approved medications specifically for primary fatigue, so treatment focuses on personalized exercise programs and cognitive behavioral therapy.
This guideline is important for ME/CFS patients because it recognizes system exertion intolerance disease (SEID, the current diagnostic term for ME/CFS) as a distinct primary condition rather than purely a symptom of other diseases. It emphasizes the limitations of standard diagnostic testing and advocates for personalized treatment approaches, which can help patients avoid unnecessary and potentially harmful medical workups and receive more appropriate care.
This guideline does not provide evidence about what causes system exertion intolerance disease, the biological mechanisms underlying it, or the effectiveness of specific exercise or cognitive behavioral therapy protocols. It does not present original research data or comparative effectiveness studies, and does not establish which patients will benefit most from which interventions.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →
The first block is for the primary paper and is the citation you should use in research work. The atlas-snapshot line only applies if you are specifically referring to this atlas’s reading of the paper on the date shown.
Primary citation
Dukes, Jason C, Chakan, Matthew, Mills, Aaron, & Marcaurd, Maurice (2021). Approach to Fatigue: Best Practice.. The Medical clinics of North America. https://doi.org/10.1016/j.mcna.2020.09.007
BibTeX
@article{mecfsatlas-dukes-2021-approach-fatigue,
author = {Dukes, Jason C and Chakan, Matthew and Mills, Aaron and Marcaurd, Maurice},
title = {Approach to Fatigue: Best Practice.},
journal = {The Medical clinics of North America},
year = {2021},
doi = {10.1016/j.mcna.2020.09.007},
note = {PubMed: 33246515},
url = {https://www.mecfsatlas.com/evidence/dukes-2021-approach-fatigue},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-25. https://www.mecfsatlas.com/evidence/dukes-2021-approach-fatigue
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