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VA/Dod CLINICAL PRACTICE GUIDELINE for the MANAGEMENT of CHRONIC MULTISYMPTOM ILLNESS

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VA/Dod CLINICAL PRACTICE GUIDELINE for the MANAGEMENT of CHRONIC MULTISYMPTOM ILLNESS VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF CHRONIC MULTISYMPTOM ILLNESS Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent Department of Veterans Affairs or TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil by contacting your regional TRICARE Managed Care Support Contractor. Version 3.0 – 2021 VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness Prepared by: The Management of Chronic Multisymptom Illness Work Group With support from: The Office of Quality and Patient Safety, VA, Washington, DC & Office of Evidence Based Practice, Defense Health Agency Version 3.0 – 2021 Based on evidence reviewed through April 7, 2020 May 2021 Page 2 of 117 VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness Table of Contents I. Introduction ..................................................................................................................................... 5 II. Background...................................................................................................................................... 5 III. Scope of this Guideline .................................................................................................................... 7 A. Guideline Audience .............................................................................................................................. 8 B. Guideline Population ........................................................................................................................... 8 IV. Highlighted Features of this Guideline .............................................................................................. 8 A. Highlights in this Guideline Update ..................................................................................................... 8 B. Components of the Guideline ............................................................................................................. 8 V. Guideline Development Team .......................................................................................................... 9 VI. Summary of Guideline Development Methodology........................................................................ 11 A. Evidence Quality and Recommendation Strength ........................................................................... 11 B. Categorization of 2014 Clinical Practice Guideline Recommendations ........................................... 12 C. Management of Potential or Actual Conflicts of Interest ................................................................ 13 D. Patient Perspective ............................................................................................................................ 14 E. External Peer Review ......................................................................................................................... 14 F. Implementation ................................................................................................................................. 14 VII. Approach to Care in Department of Veterans Affairs and Department of Defense ......................... 15 A. Patient-centered Care ....................................................................................................................... 15 B. Shared Decision Making .................................................................................................................... 15 C. Patients with Co-occurring Conditions ............................................................................................. 15 VIII. Algorithm ...................................................................................................................................... 16 Algorithm: Management of CMI ............................................................................................................... 17 IX. Recommendations ......................................................................................................................... 19 A. Treatment of CMI .............................................................................................................................. 23 a. Pharmacotherapy ...................................................................................................................... 23 b. Behavioral Health ...................................................................................................................... 25 c. Complementary and Integrative Health ................................................................................... 29 B. Treatment of CMI and Symptoms Consistent with Fibromyalgia or Irritable Bowel Syndrome .... 30 a. Behavioral Health ...................................................................................................................... 30 b. Complementary and Integrative Health ................................................................................... 31 C. Treatment of CMI and Symptoms Consistent with Fibromyalgia .................................................... 34 a. Pharmacotherapy ...................................................................................................................... 34 b. Complementary and Integrative Health ................................................................................... 38 c. Physical Exercise ........................................................................................................................ 43 May 2021 Page 3 of 117 VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness D. Treatment of CMI and Symptoms Consistent with Irritable Bowel Syndrome ............................... 45 a. Pharmacotherapy ...................................................................................................................... 45 b. Behavioral Health ...................................................................................................................... 53 E. Treatment of CMI and Symptoms Consistent with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome ........................................................................................................................................... 54 a. Pharmacotherapy ...................................................................................................................... 54 X. Research Priorities ......................................................................................................................... 55 A. Fundamental Research Gaps ............................................................................................................. 56 B. Additional Research Gaps .................................................................................................................. 57 C. Recommendation-Specific Research Gaps ....................................................................................... 59 Appendix A: Guideline Development Methodology ........................................................................... 62 A. Developing Key Questions to Guide the Systematic Evidence Review............................................ 62 B. Conducting the Systematic Review ................................................................................................... 66 C. Developing Evidence-based Recommendations .............................................................................. 70 a. Grading Recommendations ....................................................................................................... 70 b. Recommendation Categorization ............................................................................................. 72 D. Drafting and Finalizing the Guideline ................................................................................................ 73 Appendix B: Patient Focus Group Methods and Findings .................................................................... 74 A. Methods ............................................................................................................................................. 74 B. Patient
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