NICE guidelines

The NICE guidelines are the UK's National Health Service (NHS) diagnostic and treatment guidelines for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), but are written only for use in England and Wales. In 2018, NICE began appointing a committee of professionals and lay members to NICE guidelines review committee to rewrite the guidelines. The new ME/CFS guidelines were published in October 2021, and include changes to the diagnostic criteria and recommended treatments.

NICE, the National Institute for Health and Care Excellence, is a UK government body that approves and recommends treatments for use within the NHS with the mission to improve health and social care through evidence-based guidance.

NICE Guidelines Review for CFS/ME (2017-2021)
NICE initially announced that the 2007 guidelines would not be updated as a result of the 2017 review, but then changed this decision in September 20, 2017; the new ME/CFS guideline were due in April 2020 but were finally published in October 2021. The new guidelines refer to ME/CFS rather than CFS/ME.

Reasons for the update

 * Out of 38 stakeholders, 32 wanted to update the guidelines - the Royal College of General Practitioners plus 31 patient-representative bodies.
 * The reanalysis of the data from the UK's 2011 £5 million PACE trial was hugely influential, with the full release of patient data in 2016 clearly showing no clinically significant improvements from graded exercise therapy (GET) or cognitive behavioral therapy (CBT, a psychological and behavioral treatment) which were the two key treatments in the 2007 NICE guidelines
 * New scientific evidence was published, including the U.S. Institute of Medicine report (2015), and the International Consensus Criteria (2011) 
 * Post-exertional malaise was increasingly shown to be the hallmark symptom, not fatigue
 * A petition by the ME Association showed extremely widespread support for change by patients, carers, and the general public
 * Patient surveys reported consistently that the GET and CBT treatments were ineffective, and had caused wipespread unexpected harm to the physical and mental health of a significant proportion of patients
 * Since the publication of the previous guidelines, the Netherlands and United States had both abandoned the UK's prominent treatment approaches, and moved from using a underlying biopsychosocial model to a biomedical model of ME/CFS
 * A number of doctors diagnosed with ME/CFS including Robin Brown and Nina Muirhead became increasingly critical of the NICE guidelines and the NHS treatment offered to patients, and became involved in advocacy and developing NHS-focused

Authors
List of the NICE ME/CFS Guideline Development Group (GDG) review panel members:
 * Peter Barry - Chair, pediatrician
 * Ilora Finlay - Vice chair, Baroness Finlay of Llandaff
 * Theo Anbu - secondary care pediatrician - clinical lead for Alder Hey pediatric CFS/ME clinic, Liverpool
 * Joanne Bond-Kendall - physiotherapist
 * Mike Beadsworth - physician with a special interest in CFS/ME, on the BACME executive
 * Susan Watson - occupational therapist, Leeds and West Yorkshire CFS/ME clinic
 * Jo Daniels - psychologist for CFS/ME clinic
 * Luis Nacul, Chris Burton - GPs
 * Tony Crouch - social worker
 * Alan Stanton - community pediatrician
 * Gabrielle Murphy - physician with a special interest in ME/CFS, also BACME Chair, see PACE trial
 * Charles Shepherd - doctor, co-opted member (no voting rights), ME Association medical advisor
 * William Weir - doctor
 * Caroline Kingdon - nurse with special interest in ME/CFS
 * Dietician - role not filled


 * Children's community nurse - role not filled (removed from final list)
 * Lay members - Saran Bonsar, Sally Burch, Nicola Kidby, Adam Lowe, and Dorinda Jack
 * Expert witnesses - Greg Crowhurst and Dr. Jonathan Edwards - invited to give evidence on particular topics

Stakeholders
A large number of organizations registered as stakeholders, and stakeholder meetings began in 2018.

Suspected ME/CFS

 * the person has had all of the persistent symptoms in the box below for a minimum of 6 weeks in adults (4 weeks in children and young people) and
 * the person's ability to engage in occupational, educational, social or personal activities is significantly reduced from pre‑illness levels and
 * symptoms are not explained by another condition.

All the following symptoms are required for suspected ME/CFS:
 * Debilitating fatigue that is worsened by activity, is not caused by excessive cognitive, physical, emotional or social exertion, and is not significantly relieved by rest.
 * Post-exertional malaise after activity in which the worsening of symptoms:
 * is often delayed in onset by hours or days
 * is disproportionate to the activity
 * has a prolonged recovery time that may last hours, days, weeks or longer.
 * Unrefreshing sleep or sleep disturbance (or both), which may include:
 * feeling exhausted, feeling flu-like and stiff on waking
 * broken or shallow sleep, altered sleep pattern or hypersomnia
 * Cognitive difficulties (sometimes described as 'brain fog'), which may include problems finding words or numbers, difficulty in speaking, slowed responsiveness, short-term memory problems, and difficulty concentrating or multitasking.

Definitions:
 * Activity

Any effort that uses energy, which includes cognitive, emotional and social activity as well as physical activity. Different activities combine and interact to cause a cumulative impact for the person. Fatigue in ME/CFS typically has the following components:
 * Fatigue
 * feeling flu-like, especially in the early days of the illness
 * restlessness or feeling 'wired but tired'
 * low energy or a lack of physical energy to start or finish activities of daily living and the sensation of being 'physically drained'
 * cognitive fatigue that worsens existing difficulties
 * rapid loss of muscle strength or stamina after starting an activity, causing for example, sudden weakness, clumsiness, lack of coordination, and being unable to repeat physical effort consistently.
 * Post-exertional malaise

The worsening of symptoms that can follow minimal cognitive, physical, emotional or social activity, or activity that could previously be tolerated. Symptoms can typically worsen 12 to 48 hours after activity and last for days or even weeks, sometimes leading to a relapse. Post-exertional malaise may also be referred to as post-exertional symptom exacerbation.
 * Unrefreshing sleep

Unrefreshing sleep means sleep that is non-restorative. Even after a full night's sleep, people do not feel refreshed. People with ME/CFS often report waking up exhausted and feeling as if they have not slept at all, no matter how long they were asleep.

Neurological disease
The revised ME/CFS guideline clearly states that ME/CFS is a physical illness:

Near the end in the guideline, the Context section also states it is classified as a Disease of the Nervous System using ICD-10 code G93.3 by the World Health Organization, and by SNOWMED, the GP's computer system.

Management, not a cure
The new guideline states that no treatments should be regarded as a cure, and that treatments are for symptom management.

No graded exercise therapy
The new guideline states that graded exercise therapy or any other approach using fixed increases in physical activity or exercise should not be used.

Three month "pause"
Hours before the new ME/CFS was due to be published, NICE took the extraordinary step of halting publication as a result of several Royal Colleges, including the Royal College of Paediatrics and Child Health and the Royal College of Physicians, circumventing the guideline review process by complaining to NICE and demanding changes to the final, approved guideline.

The delay was heavily criticised by guideline stakeholders including Doctors with M.E. who accused NICE of acting unlawfully, and all the national patient groups, who had not been aware of the private discussions taking place.

In the UK news coverage, NICE was accused of "capitulating to vested interests" and "putting patients at risk" over the delays. During the three month "pause" in publication, NICE invited a limited number of guideline stakeholders to a roundtable meeting, and communicated directly with a number of Royal Colleges and other stakeholders.

Patient court case
After NICE halted publication of the guideline in Aug 2017, a patient began a legal proceedings to challenge NICE over the delay, and find out the reasons for the delay. NICE did not respond to the publication deadline set by the patient's lawyer, but published the guideline soon after.

Forward-ME response
Forward-ME welcomed the new guideline and highlighted the introduction of energy management as a new treatment approach in the NICE guideline, including pacing, and the significant improvements made to child safeguarding, stating that "some parents of children with ME have been subjected to inappropriate child protection orders, and threatened with the removal of their children, in the belief that the parents had caused a ‘fabricated or induced illness’."

Forward-ME started that "the recommendations on ‘Energy Management’ will also help people with LongCovid who experience Post-Exertional Malaise (PEM), many of whom have reported that ‘Graded Exercise Therapy’ worsened their condition, and their symptoms were dismissed as anxiety."

"This recommendation is a clear break from the past. Previously, people with ME were offered ‘Graded Exercise Therapy’ (GET), based on a hypothesis that they were deconditioned. NICE found the evidence for this to be poor quality, and many people with ME reported that GET caused serious harm. The new guideline on ME/CFS was due to be published in August, but NICE ‘paused’ the release following intervention from some clinicians. After a round-table with representatives from the ‘Royal Colleges’ and ME charities, NICE is now confident that the guideline can be fully implemented."

Invest in ME Research response
Invest in ME Research stated that they welcomed the changes in the new guideline, but felt that undoing the harmful therapies used during the last 14 years was not enough, and the result was a fudge resulting in a guideline that could, and should, have been written in 2007.

ME Research UK response
ME Research UK broadly welcomed the new guideline as "a significant step in both the acceptance of ME as a physical illness and the recognition of appropriate treatment needs of those affected by the condition" and highlighted the need for further research funding, especially to better establish clear diagnostic criteria.

BACME response
The British Association for CFS/ME, the largest group of doctors and health practioners working in UK ME/CFS specialist clinics, welcomed the changes in the guidelines, stating that many of its members had wanted to offer treatments others than graded exercise therapy and cognitive behavioral therapy but had been prevented from doing so due to funding being tied to guideline recommendations.

Royal Colleges response
The Royal Colleges issued a joint statement stating that the guideline contained some positive changes, but that it understated "the importance of activity and exercise in the management of ME/CFS and the connection between people’s mental and physical health", in particular mentioning their view of the importance of cognitive behavioral therapy and psychological therapies.

Medical leaders sign joint statement in response to NICE guidance on ME/CFS Details 29 October 2021

We are pleased that NICE have now published their guidance for the management of ME/CFS which is a chronic, poorly understood condition and can be highly disabling and distressing. It is important that all patients with this condition are given access to the best possible services and treatments available.

The published guideline contains some positive changes, but these do not go as far as we would have liked and understate the importance of activity and exercise in the management of ME/CFS and the connection between people’s mental and physical health. We also do not think the changes represent the positive discussions that have been had with patient groups.

As in many chronic conditions, people’s mental and physical health are intrinsically linked. This guidance risks undermining the importance of these links by dismissing the potential of treatments such as Cognitive Behavioural Therapy (CBT) as of less value in alleviating symptoms than pharmacological interventions.

There is considerable disquiet in the medical profession and some patient groups about the way the data and evidence have been assessed but the important thing now is that services are commissioned in a safe and effective way that does not disadvantage any patients being treated now or in the future.

When commissioning services we would reiterate that:

Graded Exercise Therapy) as defined in the guidance is not reflective of the personalised paced exercise programmes that are currently used in the NHS and termed GET. These have provided benefit to many patients and should not be discontinued. However, we recognise that the phrase GET is unhelpful and this terminology should be dropped to allow clinicians to work with their patients in a more productive way.

CBT remains a valuable treatment for alleviating symptoms in ME/CFS and services should ensure patients have access to this and other psychological therapies.

Specialist rehabilitation medicine services and exercise medicine services regularly look after patients with ME/CFS (and also provide complex care and long-term support for very severe ME/CFS) but are not specifically recommended in the guidance. There are very few dedicated ME/CFS specialist services either in the community or hospital setting and thus if commissioners do not use specialist rehabilitation medicine services and exercise medicine services, these patients will lose out.

Commissioners must also take action to ensure training and support is available for the full range of specialist ME/CFS roles needed and are easily accessible for GPs and other clinicians across the NHS, so that this guidance can effectively be put into practice.

Many patients with ME/CFS have other conditions including chronic pain and fibromyalgia which are improved with exercise as recommended in other NICE guidance. It is important that a holistic approach is taken to ensure that other conditions do not deteriorate.

Royal College of Physicians Royal College of Physicians of Edinburgh Royal College of General Practitioners Royal College of Psychiatrists Academy of Medical Royal Colleges Faculty of Sport and Exercise Medicine Faculty of Occupational Medicine

Doctors with M.E. response
Individuals doctors gave different responses.

NICE Guideline revision process (2018-2021)
The public pressure from ME patients, including a petition by the ME Association, led to the decision to fully revise the guideline and which would not be concluded until around October 2020.

NICE held a Stakeholders Engagement Workshop on 16 January 2018 and a summary of the day has been produced by the ME Association.

Invest in ME Research wrote to Professor Mark Baker, Centre for Guidelines Director, on January 15th 2018 asking NICE to urgently remove or add an addendum or correction for the recommendation of CBT and GET now to avoid harm to patients. Prof. Baker responded that they could not remove such recommendations for CBT and GET and had to wait for the full review of the guidelines which would be due in 2020. Invest in ME wrote back on 16 January repeating that they should at least add an addendum about CBT/GET. Patient advocates have commented that the right to refuse CBT/GET treatment as stated by Prof Baker is an offer you can't refuse.

An unprecedented proactive open letter to Sir Andrew Dillon was sent on January 12th 2018 by ME sufferers regarding the composition of the new guideline committee due to the history of the CFS/ME NICE guideline and committee and an Appeal to NICE concerning the Guideline Committee for ME/CFS petition was also launched to support this. ME sufferers led by Graham McPhee from MEAnalysis produced a video to accompany the letter and petition.

An unprecedented third petition was launched to NICE Stop harming ME/CFS patients - take CBT/GET out of NICE guidelines NOW which asked that NICE immediately remove CBT/GET from the guidelines in the face of evidence of harm amounts to medical abuse and violation of human rights.

In a BBC Newsround article it was again stated by patient groups that the guideline for CBT/GET should be withdrawn immediately but this was refuted by a statement by the "country's leading ME researchers" that they should not. It was later clarified that many of the proponents were involved in the PACE trial. The article stated that in 2018 "NICE admits there is "controversy" around existing treatments".

A scoping workshop was undertaken on May 25th, 2018. It was announced that the new Chair of the GDG would be Dr Peter Barry and the Vice Chair Ilora Finlay. A draft scope consultation was also produced. The name of the illness was changed from CFS/ME to ME/CFS and the new guideline was called Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. Some stakeholders were not notified until the night before of the workshop. Others raised some concerns with the stakeholder workshop.

Positive Health magazine reported on What Can We Expect from the Current Review of NICE Guideline CG53 and concluded that the biopsychosocial (psychiatric) model proponents would still try to influence the guidelines to retain the status quo.

NICE guidelines NG206 published 2021
After a series of delays through the NICE guidelines review, including a three month "pause" in publication, the final Myalgic encephalomyelitis (or encephalopathy)/Chronic fatigue syndrome: diagnosis and management guidelines, known as NG206, were published on October 2021.

NICE Guidelines for CFS/ME - CG53 (2007)
The NICE guideline for CFS/ME (CG53) for the diagnosis and management of chronic fatigue syndrome/myalgic encephalomyelitis (or encephalopathy) were published in August 2007. They are used by the NHS and other medical professionals in the UK for diagnosing and treating CFS/ME.

Authors
The CFS/ME guideline development group consisted of the following members: Richard Baker, Jessica Bavinton, Esther Crawley, Tony Downes, Richard Eddleston, Ute Elliot, Richard Grünewald, William Hamilton, Judith Harding, Frederick Nye, Amanda O'Donovan, Alastair Santhouse, Julia Smedley]], David Vickers, Gillian Walsh, Carol Wilson, Philip Wood, Gary Britton, Stefanie Kuntze, Elizabeth Shaw, Nancy Turnbull, and Tanya Harrison.

NICE Definition (2007-Oct 2021)
Healthcare professionals should consider the possibility of CFS/ME if a person has:


 * fatigue with all of the following features:
 * new or had a specific onset (that is, it is not lifelong)
 * persistent and/or recurrent
 * unexplained by other conditions
 * has resulted in a substantial reduction in activity level
 * characterised by post-exertional malaise and/or fatigue (typically delayed, for example by at least 24 hours, with slow recovery over several days)

and


 * one or more of the following symptoms:
 * difficulty with sleeping, such as insomnia, hypersomnia, unrefreshing sleep, a disturbed sleep–wake cycle
 * muscle and/or joint pain that is multi-site and without evidence of inflammation
 * headaches
 * painful lymph nodes without pathological enlargement
 * sore throat
 * cognitive dysfunction, such as difficulty thinking, inability to concentrate, impairment of short-term memory, and difficulties with word-finding, planning/organising thoughts and information processing
 * physical or mental exertion makes symptoms worse
 * general malaise or "flu-like" symptoms
 * dizziness and/or nausea
 * palpitations in the absence of identified cardiac pathology

Healthcare professionals should be aware that the symptoms of CFS/ME fluctuate in severity and may change in nature over time.

Signs and symptoms that can be caused by other serious conditions (‘red flags’) should not be attributed to CFS/ME without consideration of alternative diagnoses or comorbidities. In particular, the following features should be investigated:
 * localising/focal neurological signs
 * signs and symptoms of inflammatory arthritis or connective tissue disease
 * signs and symptoms of cardiorespiratory disease
 * significant weight loss
 * sleep apnea
 * clinically significant lymphadenopathy

A diagnosis should be made after other possible diagnoses have been excluded and the symptoms have persisted for:
 * 4 months in an adult
 * 3 months in a child or young person; the diagnosis should be made or confirmed by a paediatrician

The diagnosis of CFS/ME should be reconsidered if none of the following key features are present:
 * post-exertional fatigue or malaise
 * cognitive difficulties
 * sleep disturbance
 * chronic pain

Criticism and controversy
Charities and patient groups condemned the guidelines as "unfit for purpose".

The submissions were from:

Invest in ME Submission

 * IIME Response to draft guidelines November 2006
 * IIME Stakeholder Submission Response to full Guidelines
 * IIME Respone to Final August 2007 NICE Guidelines CG53

ME Association Submission

 * MEA Submission on draft NICE guidelines
 * MEA August 2007 Comments

25 Percent ME Group Submission

 * 25% ME Group Response to NICE

Tymes Trust Submission
Tymes Trust November 2006 Submission

Agreed statement from all ME Charities
An agreed statement was also put out by all ME Charities.

Criticism of the York Review by Professor Hooper
The NICE guidelines were based on the evidence presented by the 2005 York Review, produced by the Centre for Reviews and Dissemination (CRD). Prof. Malcolm Hooper submitted written criticism of the York Review to UK Parliament, stating that this supposedly independent review was strongly influenced by the Wessely school's biopsychosocial model. Hooper & Reid published an analysis of the failings in the York Review.

Professor Hooper also submitted written evidence to the House of Commons Select Committee on NICE and the CFS/ME guidelines.

MEActionUK Submission and Reports
MEActionUK published their Concerns and Submission about the draft NICE guidelines in October 2006. MEActionUK also published comment on the final draft of the August 2007 guidelines. The failure by NICE to fulfil its remit and the biomedical evidence that NICE ignored in its production is also investigated and reported on. MEAction UK have published a number of other reports into the criticism of the NICE guidelines on their website.

NICE Judicial Review Court Case (2009)
In 2009, two ME patients launched a court case against NICE and against the newly-published NICE guidelines, leading to a judicial review which was not successful.

Move to static list (2013)
On September 2013 NICE placed the CFS/ME guidelines CG53 on a static list and confirmed they won't be reviewing them, this then led to protests from patients, researchers and clinicians; and a guideline review was announced in September 2017. There were considerable concerns raised on 2013.

The Countess of Mar and Forward-ME said "We express our extreme concern over this proposal and strongly feel that the guideline must remain on the active list for the following reasons. Medical and scientific advances in relation to ME and CFS are taking place very rapidly." This was a joint letter was signed by a number of ME Charities.

The ME Association opposed the plan to place it on static list and wrote a submission with four reasons including that "Along with most other ME/CFS charities, and people with ME/CFS, we have been unable to endorse the current NICE guideline."

Patients and patient advocacy groups are not in favor of the NICE guidelines and on June 25th 2014 the Forward-ME Group met with Prof Mark Baker, Director of the Centre for Clinical Practice at the National Institute for Health and Clinical Excellence (NICE)]. Professor Baker that the ME/CFS Guideline did not meet patient needs nor those of NICE. He said the Guideline did not promote innovation and only a "passive" intervention such as CBT and Graded Exercise. "There was not much of an evidence base to go on, and in NICE it was evidence that drove guidance."

Doctor Speedy weighs in with Is it NICE guidelines or NONSENSE guidelines? and the ME Association's Dr. Charles Shepherd pointed out during a meeting with Dr. Martin McShane of NHS England "that graded exercise therapy was causing harm to patients and that if a drug was causing harm, guidelines would be reviewed immediately."

A FOI request to NICE about the US developments was submitted to NICE in 2016 and they responded to it in 2016 in which they dismissed foreign work on ME/CFS.

NICE 10 year surveillance (2017)
In June 2017 stakeholders were advised that NICE would consider reviewing the guidelines. In July NICE stated they decided not to review the guidelines.

A petition to NICE, The NICE guideline for CFS/ME is not fit for purpose and needs a complete revision, gathered over 15,000 signatures.

All patient stakeholders requested that guidelines be reviewed.


 * The MEAction Network's response to NICE stated the NICE guidelines be reviewed and "Given the context of this discrimination, we ask that the updated NICE guidelines be made clearer to account for the limitations of the evidence, patient reports of long term relapse following graded exercise, and the importance of genuine patient choice without reprisal."


 * Invest in ME Research's response to NICE stated the NICE guidelines be reviewed.


 * Forward-ME's response to NICE stated the NICE guidelines be reviewedand included "Because the current guideline directs patients squarely towards behavioral management, it clearly does obstruct patients’ access to biological testing, treatment and support. To avoid this ethical violation, we request that the guideline be revised to present a truthful, neutral picture of the current debate about the nature and management of CFS/ME."


 * Hope 4 ME & Fibro NI's response to NICE stated the NICE guidelines need to be reviewed.


 * ME Association's response stated the NICE guidelines be reviewed.


 * Action for ME stated the NICE guidelines be reviewed and "strongly disagrees with the proposal not to update the guideline for the following reasons...There is not, at the present time, a conclusive evidence base for treatments for CFS/M.E., including those recommended in the guideline, such as CBT and/or GET."


 * Tymes Trust's response to NICE stated the NICE guidelines be reviewed.

The ME Association described the public response to its petition as "The biggest expression of no confidence in a NICE guideline ever recorded".

A letter was also sent to the Chief Executive of NICE Sir Andrew Dillon.

Prof. David Tuller in his investigation stated NICE did not disclose the names of the topic experts to the Countess of Mar and the ME Association and himself were also awaiting for a response to the names.

A letter to the Chief Medical Officer was sent by the MEA.

Dr Charles Shepherd of the ME Association wrote to NICE in July 2017 to ask for further information on the team that decided to not review the guidelines but NICE refused. He followed up with another email in August but this also did not respond to the request asked and stated" remain very disappointed that NICE is unwilling to release the names of members of a group who have been involved in producing what is a very unpopular conclusion regarding the possible updating of the NICE guideline on ME/CFS" and correspondence continued

Dr Diane O'Leary, of the Kennedy Institute of Ethics at Georgetown University, Washington DC, said at the Forward-ME parliamentary meeting that the "Guideline as it stands is unethical."

Dr Tuller's own FOI request was rejected on 31 July 2017 for the names of the experts.

Dr David Tuller also wrote to the NICE Chief Executive, Sir Andrew Dillon, with 15 questions of which none were responded to.

Dr David Tuller submitted an additional FOI request for the NICE Topic Expert Reports which were provided to him. Tuller examined these and said " this set of comments is the best NICE could drum up in seeking external guidance for this critical review process is deeply worrying."

Due to the shock that the NICE guidelines were not reviewed, MEAction supporters raised a parliamentary petition called an Early Day Motion (271) in September to put further pressure on NICE.

On September 20, 2017, NICE announced that a full review would take place, effectively overturning the previous expert advice not to review the guideline.

The Times newspaper reported on September 24th it as Mutiny by ME sufferers forces a climbdown on exercise treatment and the article described the patient revolt over the reassessment of NICE Guidelines was over the validity of the PACE trial.

Prof. David Tuller reported on it Trial By Error: NICE Rejects Current Guidance, Plans "Full Update".

Jennifer Brea was interviewed in The Times for the Unrest documentary in which she criticized the British approach on CBT/GET and the NICE guidelines in the UK as “not an easy place to have ME”. The Telegraph quoted Jennifer Brea saying, in reference to the NICE guidelines, "I hope the UK will look at the science and update the guidelines."

Prof Tuller also wrote another letter to Sir Andrew Dillon questioning why CFS/ME was also stated under Improving Access to Psychological Therapies (IAPT) and furthermore in another NICE guideline Suspected Neurological Conditions where CFS/ME was wrongly categorised as medically unexplained symptoms.

Learn more
NICE guideline [NG206] (2021-present)
 * [https://www.nice.org.uk/guidance/ng206 Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management
 * NICE ME/CFS guideline [NG206] (PDF)
 * NICE guidelines CG53 stakeholder comments (PDF) - 2017