Fatigue and Inflammatory Arthritis

Summary of a presentation at the Living with RA Workshop


Jessica R. Berman, MD

Associate Attending Physician, Hospital for Special Surgery
Associate Professor of Medicine, Weill Cornell Medical College
Associate Director, Academy of Medical Educators, Hospital for Special Surgery
Assistant Program Director, Rheumatology Fellowship, Hospital for Special Surgery

Introduction

The feeling of fatigue is common in our busy lives. Fatigue that is the result of inflammatory arthritis, however, is very different than everyday tiredness. This kind of fatigue can often be intense and overwhelming, and can have a noticeable impact on quality of life. Steps to help make inflammatory arthritis-related fatigue more manageable include learning to better understand how it affects you as an individual and discussing it regularly with your rheumatologist. 

What is Fatigue and What Are the Facts

Fatigue can be described as a severe lack of energy throughout the whole body, sometimes even after a full night of rest. It is very common among people with inflammatory arthritis, affecting 40% or more of those with RA.

Many people often describe fatigue as the most difficult part of their disease. In spite of this, the topic - unlike the subject of pain, for example - is rarely discussed between patients and their doctors.

Talking About Fatigue

Treating fatigue can be difficult for both patients and their doctors. Making a regular point of talking about it together can be a helpful step in treatment. Consider writing down a list of information to share with your doctor at your next appointment. This could include:

  • How you describe your fatigue
  • How often you feel fatigued during your daily activities
  • How fatigue impacts your day-to-day life
  • What you think causes your fatigue
  • What you do to manage your fatigue

Together, you and your doctor can assess, or measure, the way fatigue affects you personally. You may also better understand the causes of your fatigue.

Medications That Can Cause Fatigue

While fatigue is a common symptom of inflammatory arthritis, it may also be caused by other factors. Conditions such as anemia or an infection may contribute to it. It can also be a side-effect of certain medications. Drugs such as those taken for colds, blood pressure, pain, and depression can also cause fatigue. You should keep your doctor informed about any medications you are taking, as well as any changes in your medication regimen.

How Inflammatory Arthritis Can Cause Fatigue and How Anti-TNFs May Help

The immune system is very complicated, with many cells interacting with each other all the time. Some of these interactions produce what are called cytokines. One kind of cytokine is called Tumor Necrosis Factor, or TNF. TNF can sometimes cause cellular inflammation, which can in turn result in fatigue. Anti-TNF medications like Enbrel, Humira, and Remicade try to block TNF production, therefore decreasing inflammation. Less inflammation may mean less fatigue.

Measuring Fatigue

There are a number of ways you and your doctor can learn how fatigue affects you. Pain, for instance, is often rated on a scale. Fatigue can be measured in the same way.
Measuring your fatigue is a good way to determine how much it is a part of your day-to-day life, and whether it improves or gets worse over time. One way to measure fatigue for yourself is to keep a diary. Write down when during the day you feel the most tired, and also when you feel you have the most energy. It may help to use a scale to do this. For example, on a scale from 0-10, with 0 being no energy, and 10 being the most energized, how do you feel when you first wake-up? How do you feel at lunchtime? Over time, you may notice patterns in your fatigue. Identifying and understanding these patterns may help you and your doctor plan more effective ways to combat your fatigue.

What Your Doctor Can Do For You

One of the first things your doctor should do in assessing your fatigue is to look for other medical conditions you have that may be contributing. An undiagnosed iron deficiency, thyroid condition, or bleeding could all lead to fatigue. You and your doctor should also talk about your nighttime sleep. Do you generally sleep well or is your sleep interrupted? Are you sleeping on the right pillows? Is your mattress firm enough? Small changes in your nighttime sleep habits can make a big difference in daytime fatigue.

What You Can Do For Yourself

  • Go easy on yourself and respect your bodyís limits. Accept that you are human, and that fatigue can be limiting. Consider making a to-do list and then cross off the least important items and save those for a time when you are feeling more energized. Make daily household chores and outside errands easier when you can. Limit trips to the grocery store by storing frozen foods or ready-to-eat meals that can be easily prepared on days when you may be feeling more tired. 
  • On days when you are up for it, consider exercising. Exercise can improve muscle strength and release endorphins in the body, which can make people feel more energized. Before beginning any exercise routine, however, be sure to discuss it with your doctor.
  • There are also ways in which you can use your mind to help combat pain and fatigue. Cognitive behavioral therapy, or CBT, is a way of changing your thoughts to help change the way you feel. Certain therapists who are trained in CBT can provide this kind of help. Other activities, such as meditation and yoga (if joints allow), can also be effective. 
  • Making healthy choices about your eating and sleeping habits can also go a long way to managing fatigue. Respect your body when it needs rest. Create a bedroom environment that is conducive to sleep. Leave the TV in the living room. TV watching at bedtime can be stimulating and make it hard to fall asleep. 
  • In the workplace, take breaks, walk around, and ask for help when needed. You may be entitled to certain considerations, for example, a different chair, or a wrist pillow to use while typing. In certain cases, you may also be able to do part of your job from home. Consider speaking with your boss about accommodations that may help you to do your job more effectively.

Lastly, do not be afraid to ask family and friends for help. Most people will be happy to help with errands or other chores when you are not feeling up to them. Occasionally, someone may not understand why you are feeling so tired. You may have to help teach them about how and why fatigue affects you, and that it is a symptom of your arthritis.

Summary

Fatigue is very common with RA and it often has a big impact on quality of life. In spite of this, the topic is often overlooked in doctor/patient visits. When you see your doctor, remind him or her to discuss this with you. Doctors are still learning about the relationship between fatigue and inflammatory arthritis and the subject should be explored often as part of treatment.

Patients should learn about how fatigue impacts them personally and what they can do to adapt. Doctors and patients should make it a point to work together to become better educated about fatigue, and to find the best ways to manage it for each individual.

 

Resources

How to Beat Fatigue  http://www.arthritistoday.org/

Fatigue in Patients with Rheumatoid Arthritis: What is Known and What is Needed. Repping-Wuts. Rheumatology 2009; 207-09

Sick and Tired of Feeling Sick and Tired: Living with Invisible Chronic Illness. Paul J. Donoghue

Summary by Dayna Kurtz, LMSW

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