Fatigue in Rheumatoid Arthritis

Dr Philip Helliwell, senior lecturer in rheumatology at Chapel Allerton Hospital in Leeds and consultant rheumatologist at St Luke’s Hospital in Bradford
Original article: 18/11/2001
Reviewed: 12/03/2009
Next review due: 12/03/2012

What is fatigue?

Everyone knows what fatigue is but how can it be described? Fatigue is subjective and personal. It is a feeling of both physical and mental weariness that can be severe and overwhelming for some people with rheumatoid arthritis. There is a difference between acute (short-term) and chronic (long-term) fatigue. Most people feel tired after a long day at work but recover after a night's rest. People with a disease like rheumatoid arthritis experience fatigue day after day irrespective of what they have been doing. In fact fatigue is one of the principal symptoms of rheumatoid arthritis, the others being pain, stiffness and loss of function.

What causes fatigue?

There a number of causes all of which can contribute to the feeling. Undoubtedly, the disease process (chronic inflammation of joints and other tissues) is the main cause. There has been some suggestion that there may be a relationship between fatigue and disease activity, measured by the number of swollen and tender joints and by the level of blood markers such as the ESR (erythrocyte sedimentation rate) or the CRP (C reactive protein). Cytokines (chemicals found in inflamed tissues) are the likely culprits. Similar chemicals are released in viral illnesses such as colds and 'flu and cause the profound fatigue often seen in these conditions.

A number of other factors also play their part. Pain, unremitting pain, wears you down and makes you tired. Pain also wakes you up at night causing poor quality disturbed sleep. Certain drugs used in arthritis may also make fatigue worse. Pain killers may cause drowsiness and interfere with concentration. Anti-inflammatory drugs may also interfere with concentration and cause a feeling of lightness in the head.

Loss of muscle bulk and muscle tone, both seen in rheumatoid arthritis as a result of inactivity and inflammation, will also contribute since more effort will be required to perform certain activities. What seemed easy before the onset of rheumatoid arthritis now seems difficult. This is called 'reduced functional ability'.

Anaemia is also a common cause of fatigue. People with RA are more susceptible to anaemia, which is a condition where your blood count is low, and the blood is therefore unable to carry enough oxygen. 8 out of 10 people with rheumatoid arthritis are anaemic, but you can be anaemic for other reasons, such as a lack of iron in your diet.

Some surveys have shown that women are more prone to severe fatigue (some say because they work harder!). Fatigue is also more prominent in the early stages of the disease, and is associated with higher levels of inflammation. As inflammation is controlled, and as people adapt to their disease, fatigue becomes less prominent. Finally, any condition causing long-term pain can cause depression and two symptoms of depression are physical and mental fatigue.

How is it measured?

There is no objective test allowing us to directly compare one person's fatigue with another. There are a number of questionnaires which give people the chance to express the severity of their symptoms in a variety of ways. One of these estimates fatigue in terms of severity, timing, distress, and interference with daily activities. Questionnaires are useful to gauge the extent of fatigue in a particular person, and provide a yardstick with which to measure the effect of treatment.

What medications may help?

As you would expect, control of disease activity will result in improvement of pain, stiffness and fatigue and an increase in general well-being. The hierarchy of drug treatment includes pain killers, anti-inflammatory drugs (NSAIDs) and disease modifying drugs (DMARDs). Pain killers, such as paracetamol, and NSAIDs will undoubtedly help control the symptoms just as they would if you had a cold or 'flu. DMARDs (such as methotrexate and sulfasalazine) have a more profound effect on the disease process and have the potential to reduce many of the chemicals released by inflammation. Specific drugs, targeted against the individual chemicals, are now available. These drugs are called 'biologicals' because they are specific antibodies designed and manufactured to counteract the effects of the inflammatory chemicals. The main 'biologicals' in current use are drugs which targets the chemical 'tumour necrosis factor' (TNF) and are therefore called 'anti-TNF' drugs. Initial studies with these drugs found that they can, in certain circumstances, completely reverse the symptoms of the disease after a few injections. Although such changes are dramatic they can also be achieved, with time, by the other DMARDs it is just that they take longer to begin to work. Corticosteroids (steroids or cortisone) given in large doses will also have a similar dramatic effect to anti-TNF drugs, but there is a limit to the amount of treatment you can have with steroids. Rheumatologists will often use a single large dose of steroid when starting the patient on another DMARD. As the effect of the steroid wears off the effect of the DMARD comes through so pain, stiffness and fatigue remain under control.

How can I help myself?

Other, non-drug treatments for fatigue are available. Many people consult their local health food shop but as there seems to be a lack of evidence that such products are effective they may not help everyone, and it is important that you check with your doctor or pharmacist before taking any complementary medicines, to ensure that they are safe and will not interfere with your medication. Eating a well balanced diet will provide all the vitamins you need and will help in controlling weight gain. Getting enough rest and pacing activities may help people regain some control over their disease, but exercise is also important, as it helps to strengthen your muscles, making physical activity easier.

If particular joints are troublesome, splinting (usually made by an occupational therapist) or an injection of steroid may prevent pain from disturbing sleep, and the usual advice on getting a good night’s sleep, such as not watching television just before you go to bed and making sure your bed and the temperature in the room are comfortable etc can also help. People who are depressed, even if it is a reaction to their disease, may feel improved vitality on anti-depressant medication. For more detailed information, see the further reading section below.

Conclusion

Fatigue in rheumatoid arthritis is a symptom with many causes. Treatment is available in a number of ways and can be provided by members of the rheumatology multidisciplinary team, consisting of nurses, doctors, physiotherapists and occupational therapists, as well as helping yourself by pacing your activities etc.