Assessing Fatigue in Rheumatoid Arthritis
By: Dr. Abe Kopolovich, DPT, MBA
An estimated 36%-44% of role limitations in RA have been attributed to fatigue, as well as 64% of mental health symptoms and 52%-57% of problems with physical and social functioning.
Along with the joint pain, stiffness, and swelling that characterize rheumatoid arthritis (RA), many patients have a range of other symptoms that affect their overall disease burden and quality of life. Fatigue is one of the most common symptoms among individuals with RA, with prevalence rates of 40%-80% observed in this population. Patients have identified fatigue as one of the most important disease outcomes in RA, and the Outcome Measures in Rheumatology Clinical Trials (OMERACT) group has recommended that all RA studies include fatigue as an outcome domain.
Fatigue can interfere with personal relationships and activities of daily living. An estimated 36%-44% of role limitations in RA have been attributed to fatigue, as well as 64% of mental health symptoms and 52%-57% of problems with physical and social functioning.1 Patients have indicated that work disability is one of the most significant consequences of fatigue. A longitudinal study linked fatigue in RA to activity impairment.
In addition, fatigue has been found to account for 51% of the general perception of health worsening in RA patients.1 Regardless of the level of inflammatory control, patients are likely to perceive their disease activity unfavorably in the presence of persistent fatigue. Fatigue is reportedly the main driver of patient global assessment, which “has a significant weight in current disease activity indices used to guide treatment decisions, thus conveying an indirect impact of fatigue in heightened medication cost and risk of overtreatment,” wrote Santos et al in a paper published in November 2019 in Rheumatology.
Despite the substantial role of fatigue in RA, there is currently no recommended gold standard instrument for measuring this symptom or its impact. While fatigue was previously viewed as stemming from disease activity in RA, findings from recent studies “support a multifactorial etiology for fatigue, involving an array of co-morbid factors, such as disability, psychological well-being, social support” and others, according to the authors. Thus, the accurate assessment of fatigue in RA presents multiple challenges.
What is known about the link between fatigue and RA and its impact on patients?
Fatigue is a very common symptom in RA, as is pain. Both fatigue and pain may be related to disease activity but can become chronic and fixed even if disease activity is reduced and/or the person is in remission. We do know that in early RA, optimal improvement in fatigue lags behind other outcomes such as swollen joints by approximately 6 months. If a person has chronically disrupted sleep due to pain, inflammation, fear, anxiety, and so on, you can’t get them better overnight. The relationship between fatigue and RA disease activity has a very low correlation, so fatigue is multifactorial.
What are the recommended approaches for clinicians regarding the assessment and management of fatigue in RA patients?
We need to address patients’ concerns regarding fatigue. Good sleep hygiene is important – for example, going to bed at the same time each night, exercising but not right before bed, avoiding alcohol and caffeine later in the day, turning screens off well before bed, and sleeping in a cool, quiet room. There are helpful online apps including meditation, deep breathing, and other “tricks” that may enhance sleep. Trying to avoid sleeping pills is a good idea, as they don’t lead to deep restorative sleep. If medications are needed, low-dose amitriptyline may be helpful. Pacing and exercise may help.
If someone can’t sleep after about 45 minutes, they should get up and do something such as read a book. Use the bed and bedroom for sleep, not work. I think acknowledging the problem and admitting there are not great solutions does help the patient. Also, give the patient homework to help with their sleep, letting the patient take control and explore the options. Look for other causes of fatigue that may be treated differently such as sleep apnea, depression, and anemia. Try to avoid narcotics if a person has pain, as they can contribute to fatigue.
What are other relevant considerations for clinicians regarding this topic, and what are remaining needs in this area?
Evidence-based treatment of fatigue in RA is not great, so borrow ideas from fatigue in other conditions. We need to find treatments for fatigue that are unrelated to RA flares/inflammation. The fatigue can be a big enough problem to cause work disability and poor function.
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