What is the approach to managing fatigue?

Approach to Managing Fatigue

Begin with systematic screening using a 0-10 numeric rating scale at every clinical visit, then implement a structured evaluation and treatment algorithm based on fatigue severity and identification of treatable contributing factors. 1

Initial Screening and Severity Assessment

• Screen all patients for fatigue using a brief numeric rating scale (0-10) at every clinical encounter, with scores ≥4 triggering more comprehensive evaluation 1, 2
• Mild fatigue (1-3) requires basic education and counseling about energy conservation strategies 1
• Moderate to severe fatigue (≥4) mandates expanded focused evaluation including disease status review, systems review, and in-depth fatigue assessment 1

Comprehensive Evaluation for Moderate-Severe Fatigue

Medication Review

• Review ALL medications including over-the-counter drugs, herbals, vitamins, and supplements for fatigue-inducing effects 1, 3
• Identify recent medication changes that temporally correlate with fatigue onset 1
• Beta-blockers commonly cause bradycardia and subsequent fatigue—consider dose adjustment or alternative agents 1, 3
• Assess for polypharmacy interactions, particularly combinations of narcotics, antidepressants, antiemetics, and antihistamines that compound drowsiness 1

Identify Treatable Contributing Factors

• Screen for depression using validated tools (PHQ-9), as depression accounts for 18.5% of persistent fatigue cases 3, 4
• Evaluate sleep disorders and sleep hygiene (consistent sleep/wake times, bedroom environment, evening alcohol/caffeine use) 1, 2, 3
• Assess for pain, emotional distress, and symptom clusters that frequently accompany fatigue 1, 2
• Order comprehensive metabolic panel to identify electrolyte imbalances 3
• Check thyroid function, as hypothyroidism is a reversible cause 1, 5
• Evaluate for anemia, which is a major treatable contributor to fatigue 1, 5
• Screen for alcohol or substance abuse, which aggravate sleep disturbance and fatigue 1
• Review comorbidities and optimize their management 1

Clinical Context Assessment

• Determine patient's clinical status: active treatment, post-treatment, or end-of-life care, as this influences management strategies 1

Treatment Algorithm

Step 1: Treat Identified Contributing Factors First

• Address all treatable factors identified during evaluation before implementing general fatigue interventions 1
• Optimize beta-blocker dosing or switch agents if contributing to fatigue 3
• Treat depression with SSRIs (fluoxetine, paroxetine, or sertraline) 1, 6
• Implement sleep hygiene interventions and treat sleep disorders 1, 2, 3
• Correct anemia, thyroid dysfunction, or metabolic abnormalities per relevant guidelines 1, 5
• Reduce or eliminate evening alcohol consumption to improve sleep architecture 3

Step 2: Patient Education and Counseling

• Reassure patients that treatment-related fatigue does NOT indicate disease progression or treatment failure, as this fear causes underreporting 2
• Educate patients BEFORE starting fatigue-inducing treatments (chemotherapy, radiation, biotherapy) that fatigue may occur as a treatment consequence 1, 2
• Instruct patients to maintain a daily fatigue diary using the 0-10 scale to track patterns and identify peak energy periods 1, 2

Step 3: Nonpharmacologic Interventions (Implement Concurrently)

Energy Conservation Strategies

• Teach patients to schedule essential activities during peak energy periods identified through diary tracking 1, 2
• Prioritize essential activities and delegate or postpone nonessential tasks when experiencing moderate-severe fatigue 1, 2
• Implement labor-saving techniques: use reachers for grasping, rolling carts for transport, wear bathrobe instead of toweling off 2
• Limit daytime naps to <1 hour to avoid disrupting nighttime sleep 2

Exercise Prescription

• Exercise is the most strongly evidence-based intervention for fatigue and should be initiated as tolerated 2, 3
• Start with low-level activities (10-15 minute walks) if patient is significantly deconditioned, gradually increasing over time 1, 3
• Prescribe combination of moderate-intensity endurance exercises and resistance training with light weights 2
• Exercise cautiously in patients with bone metastases, thrombocytopenia, anemia, fever, or active infection 2
• Structured physical activity plans improve outcomes across all fatigue types 6, 7

Psychosocial Interventions

• Offer cognitive behavioral therapy (CBT) as a Category 1 evidence-based intervention for persistent moderate-to-severe fatigue 2
• Consider mindfulness-based stress reduction, psychoeducational therapies, or supportive-expressive therapies 2
• Implement CBT specifically for sleep disturbances to improve fatigue levels 2

Nutritional and Sleep Optimization

• Refer to nutritional consultation to address dietary deficiencies or alterations 2
• Establish consistent sleep/wake times, eliminate electronic devices before bedtime, avoid evening caffeine and alcohol 2, 3
• Aggressively screen for and treat sleep disorders as common contributors 2

Step 4: Pharmacologic Interventions (When Nonpharmacologic Measures Insufficient)

• Consider methylphenidate ONLY after ruling out other treatable causes, used cautiously after characterizing treatment- and disease-specific morbidities 1, 2
• Optimal dosing and schedule for psychostimulants remain unestablished 2
• Treat underlying conditions with specific agents (levothyroxine for hypothyroidism) 1, 2
• Short-term methylprednisolone may help in advanced cancer, though requires further research 1
• Evidence for megestrol acetate, L-carnitine, and other agents remains insufficient or contradictory 1

Monitoring and Reassessment

• Schedule regular follow-up visits (every 2-4 weeks initially) rather than sporadic urgent appointments 3, 6
• Reassess fatigue using standardized scales at each visit to document improvement and guide treatment modifications 1, 2, 3
• If fatigue remains unresolved after 3 months despite treating contributing factors and implementing interventions, refer to supportive care specialists 3
• Ongoing reevaluation with appropriate modifications is integral to effective fatigue management 1

Critical Pitfalls to Avoid

• Do NOT assume fatigue indicates disease progression—this misconception leads to underreporting and delayed intervention 2
• Avoid excessive laboratory testing if initial workup is normal—repeat testing rarely changes management (affects only 5% of cases) 6
• Do NOT prescribe exercise to patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), as it triggers postexertional malaise and causes harm 7
• Avoid exclusively somatic focus in unclear cases to prevent overdiagnosis—cancer accounts for only 0.6% of persistent fatigue 4
• Do not overlook medication review—beta-blockers and polypharmacy are frequently missed contributors 1, 3
• Failing to reassess after interventions misses treatment failures and prevents timely adjustments 5