How do I treat fatigue?

Treatment of Fatigue

Physical activity is the most effective intervention for managing fatigue, with a gradual increase in exercise being recommended as the first-line approach. 1, 2

Initial Assessment and Screening

• Screen all patients for fatigue severity using a standardized 0-10 scale, with scores of 4 or greater requiring comprehensive evaluation 1
• For moderate to severe fatigue (scores 4-10), conduct a focused fatigue history including onset, pattern, duration, and exacerbating/alleviating factors 1
• Evaluate for common contributing factors, including emotional distress, sleep disturbance, pain, and medication effects 1
• Basic laboratory evaluation should include complete blood count, comprehensive metabolic panel, and thyroid function tests 1

Treatment Algorithm

Step 1: Address Underlying Causes

• Treat any identified medical conditions contributing to fatigue (anemia, depression, sleep disorders, etc.) 3
• Review and adjust medications that may be causing fatigue 1
• Address nutritional deficiencies if present 2

Step 2: Non-Pharmacologic Interventions (First-Line)

• Physical Activity (Category 1 evidence)

  • Gradually increase exercise to 150 minutes of moderate aerobic activity per week plus 2-3 strength training sessions 2, 3
  • Start with low-intensity exercise and gradually increase based on tolerance 3

• Energy Conservation Strategies

  • Maintain a daily/weekly diary to identify peak energy periods 3
  • Prioritize essential activities and delegate less important tasks 3
  • Plan activities according to energy levels 2

• Psychosocial Interventions (Category 1 evidence)

  • Cognitive behavioral therapy has strong evidence for reducing fatigue 2, 3
  • Mindfulness-based approaches can effectively reduce fatigue levels 2

• Sleep Hygiene Improvements

  • Establish consistent sleep and wake times 2
  • Create a restful sleep environment 2
  • Avoid caffeine, alcohol, and electronic devices before bedtime 2
  • Limit daytime naps to less than one hour to avoid disturbing nighttime sleep 3

Step 3: Pharmacologic Interventions (When Appropriate)

• For cancer-related fatigue, psychostimulants like methylphenidate may provide some benefit in selected cases 3
• Corticosteroids like methylprednisolone may help with short-term fatigue management in advanced cancer 3
• Treat specific underlying conditions with appropriate medications (e.g., levothyroxine for hypothyroidism) 3

Special Considerations

• Cancer-Related Fatigue

  • Regular screening and assessment are essential 3
  • Tailor interventions to each patient's specific needs and clinical status (active treatment, post-treatment, end-of-life) 3
  • Provide education about fatigue as a potential consequence of treatment 3

• Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

  • Exercise can be harmful as it may trigger postexertional malaise 4
  • Focus on pacing activities to not exceed limited energy capacity 4
  • Prioritize treatment of comorbidities and symptoms based on severity 4

Monitoring and Follow-up

• Regularly reassess fatigue levels and treatment effectiveness 1
• Schedule regular follow-up visits rather than sporadic urgent appointments 5
• Adjust management strategies based on response and changes in clinical status 1

Common Pitfalls to Avoid

• Failing to screen regularly for fatigue, as it is often underreported 1
• Neglecting non-pharmacological interventions, particularly physical activity 1
• Excessive focus on somatic causes leading to overdiagnosis and unnecessary testing 6
• Conducting investigations beyond history, physical examination, and simple laboratory tests without additional symptoms or findings 6