How is fatigue managed?

Management of Fatigue

Fatigue should be managed through a tailored approach that addresses underlying causes, incorporates physical activity, energy conservation strategies, and cognitive-behavioral interventions, with pharmacologic options reserved for specific indications. 1

Assessment and Screening

• Fatigue is a subjective experience that requires systematic assessment using patient self-reports
• Screen for fatigue at initial visits, during treatment, and at follow-up appointments
• Use a 0-10 numeric rating scale (moderate fatigue ≥4, severe fatigue ≥7)
• Evaluate for common contributing factors:
  • Medical conditions (anemia, hypothyroidism, pain, sleep disorders)
  • Medications (opioids, antihistamines, beta-blockers)
  • Emotional distress (anxiety, depression)
  • Physical deconditioning
  • Nutritional deficiencies
  • Comorbidities

Management Algorithm

Step 1: Treat Underlying Causes

1. Correct medical conditions:

   • Treat anemia if hemoglobin is low
   • Manage hypothyroidism with levothyroxine (note: monitor for adverse effects including fatigue if overdosed) 2
   • Address pain with appropriate analgesics
   • Treat sleep disorders (insomnia, sleep apnea)

2. Review and modify medications:

   • Adjust timing of sedating medications
   • Consider alternatives for medications with fatigue as a side effect

Step 2: Non-Pharmacologic Interventions

1. Physical Activity (highest level of evidence):

   • Implement structured exercise program combining endurance and resistance training
   • Start with low intensity and gradually increase based on tolerance
   • Aim for 150 minutes of moderate-intensity activity per week when possible

2. Energy Conservation Strategies:

   • Set priorities and realistic expectations
   • Schedule activities during peak energy times
   • Delegate non-essential tasks
   • Use labor-saving devices
   • Limit naps to 1 hour to avoid interfering with nighttime sleep 1

3. Cognitive-Behavioral Interventions:

   • Address negative thought patterns about fatigue
   • Develop coping strategies
   • Set achievable goals
   • Consider referral to psychologist or therapist trained in CBT

4. Sleep Hygiene:

   • Maintain consistent sleep schedule
   • Create restful sleep environment
   • Avoid caffeine and electronics before bedtime
   • Limit daytime napping

Step 3: Pharmacologic Interventions (for specific indications)

1. Psychostimulants:

   • Methylphenidate may be considered for cancer-related fatigue after ruling out other causes 1
   • Limited evidence for effectiveness in post-treatment cancer survivors 1

2. Wakefulness agents:

   • Modafinil may be considered for patients with advanced disease or during active treatment 1
   • Not recommended for routine use in disease-free survivors

Special Considerations

Cancer-Related Fatigue

• Particularly common during and after cancer treatment (30-60% during treatment, 20-30% post-treatment) 1
• Often persists for months or years after treatment ends 1
• May require disability support and advocacy from healthcare providers 1

Inflammatory Rheumatic and Musculoskeletal Diseases

• Fatigue is prevalent in 50% of patients with inflammatory rheumatic conditions 1
• Associated with increased healthcare costs, work disability, and reduced quality of life 1
• Requires multidisciplinary approach including rheumatologists, nurses, occupational therapists, and psychologists

Common Pitfalls to Avoid

1. Underrecognizing fatigue - Fatigue is often under-reported, underdiagnosed, and undertreated despite being highly distressing to patients 1

2. Focusing only on physical causes - Fatigue is multifactorial with biological, psychological, and social mechanisms 1

3. Overlooking impact on quality of life - Fatigue significantly impacts all aspects of life including physical, emotional, social, and occupational functioning 1, 3

4. Dismissing fatigue as inevitable - Many patients and providers incorrectly assume fatigue is an unavoidable consequence of disease or treatment 1

5. Relying solely on pharmacologic management - Evidence supports non-pharmacologic approaches as first-line interventions, with medications reserved for specific indications

By implementing this comprehensive approach to fatigue management, healthcare providers can significantly improve patients' quality of life, functional status, and overall well-being.