Montoya’s Tripartite Approach (MonTAch) to the Treatment of Myalgic Encephalomyelitis or Chronic Fatigue Syndrome (ME/CFS/Long COVID)
I. Lifestyle modifications focused on decreasing inflammation through changes in diet, good sleep hygiene, and creating low-stress environments. Avoiding post-exertional malaise episodes (PEMs) is critical.
II. Modulation of the hyperinflammatory milieu underlying ME/CFS/Long COVID symptoms by the introduction of anti-inflammatory drugs.
III. Suppression of herpes viruses that periodically reactivate and perpetuate the hyperinflammatory milieu.
Given the inflammatory nature of ME, CFS, or long COVID, and the high likelihood that reactivation of latent herpes viruses can contribute to the perpetuation of this inflammation, I have found a tripartite approach helpful in attempting to improve the health of ME/CFS/Long COVID patients. It is unlikely that one component alone will work. In my experience, the combination of at least two of the three components is necessary for a clinically meaningful result. Ideally, the three components should be offered and initiated in each patient. Once a combination of measures are found not to have adverse events and subtle clues emerge of their benefit, the next most important step is to stay in that regimen for at least one year. Most patients who recover successfully require the same regimen between one and five years. It is a work that requires continuously listening to the patient, and humility and patience from both, the patient, and the treating providers.
Of note, not all patients with post-acute sequelae SARS-CoV-2 infection (PASC) syndrome share similar pathogenesis of ME/CFS. Here Long COVID refers to the Long COVID patients who do not have target organ damage as a result of SARS-CoV-2 infection and have symptoms indistinguishable from ME/CFS.