What are the best strategies for managing fatigue in an adult patient with a chronic condition, such as anemia or diabetes?

Fatigue Management in Adults with Chronic Conditions

Begin by screening all patients with chronic conditions like anemia or diabetes for fatigue using a 0-10 numeric rating scale, then systematically identify and treat reversible causes before implementing targeted non-pharmacologic interventions, particularly moderate aerobic exercise and cognitive behavioral therapy.

Initial Screening and Assessment

Screen for fatigue severity using a simple 0-10 numeric scale at every clinical encounter. 1 Scores of 0-3 indicate mild fatigue requiring only basic education, while scores of 4-10 demand comprehensive evaluation. 1 This straightforward approach takes minimal time during routine visits and immediately stratifies patients by intervention needs.

For patients scoring 4 or higher, perform a focused fatigue history documenting:

• Onset, pattern, and duration of symptoms 1
• Changes over time and factors that worsen or improve fatigue 1
• Impact on daily functioning, including work capacity, household tasks, and social relationships 2

Identify and Treat Reversible Contributing Factors

The most critical step is systematically evaluating and treating all identifiable causes before considering fatigue-specific interventions. 1 This cause-specific approach directly improves morbidity and quality of life.

Laboratory Evaluation

Order targeted testing based on clinical presentation: 1

• Complete blood count with differential - Compare current hemoglobin/hematocrit to baseline values; assess all cell lines 1
• Comprehensive metabolic panel - Evaluate electrolytes, hepatic and renal function 1
• Thyroid-stimulating hormone (TSH) - Screen for thyroid dysfunction 1
• Nutrient assessment - Check ferritin, vitamin B12, folate, vitamin D, magnesium, and zinc in at-risk patients 1

Treat Identified Medical Conditions

Address these common contributors according to established guidelines: 1

• Anemia - Treat with iron supplementation or erythropoietin as indicated; isolated iron deficiency without anemia does not significantly contribute to fatigue 1
• Sleep disturbances - Use cognitive behavioral therapy for insomnia, which is the treatment of choice and effective long-term 1
• Depression and anxiety - Consider selective serotonin reuptake inhibitors (fluoxetine, paroxetine, or sertraline) for patients with confirmed depression 1, 3
• Pain - Optimize pain management per guidelines 1
• Medication side effects - Review and discontinue or adjust sleep aids, pain medications, or antiemetics that may perpetuate fatigue 1
• Nutritional deficiencies - Restore deficient nutrients and refer to dietitian when appropriate 1

Evaluate Disease Control

For patients with diabetes, inflammatory bowel disease, or other chronic conditions, assess whether the underlying disease is adequately controlled. 1 Active inflammation significantly increases fatigue rates and requires optimization of disease-specific treatment.

Evidence-Based Non-Pharmacologic Interventions

Once reversible causes are addressed, implement these interventions with the strongest evidence for reducing fatigue:

Physical Activity (Highest Priority)

Prescribe 150 minutes of moderate aerobic exercise weekly (such as brisk walking, cycling, or swimming) plus 2-3 strength training sessions per week. 1 This recommendation from the American Society of Clinical Oncology has the strongest evidence for reducing fatigue and improving functional capacity. 1

Walking programs are safe for most patients and can begin without formal exercise testing. 1 However, refer patients with neuropathy, cardiomyopathy, or significant deconditioning to physical therapy or an exercise specialist before starting. 1

Critical caveat: Exercise can be harmful in patients with severe, uncontrolled anemia or myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), where it may trigger postexertional malaise. 2, 4 Ensure anemia is adequately treated before recommending exercise programs.

Cognitive Behavioral Therapy

Refer patients with persistent moderate-to-severe fatigue to providers trained in cognitive behavioral therapy (CBT) specifically for fatigue management. 1 CBT addresses cognitive, behavioral, and emotional factors that perpetuate fatigue and has demonstrated benefit both during and after treatment of chronic conditions. 1 Web-based CBT programs may offer more accessible alternatives to in-person therapy. 1

Mindfulness-Based Interventions

Consider mindfulness-based programs or yoga, which have evidence for reducing fatigue in chronic disease populations. 1 These interventions are particularly useful when combined with other strategies. 1

Psychoeducational Support

Provide all patients with education about: 1

• The difference between normal fatigue and chronic disease-related fatigue
• Expected persistence of fatigue and realistic recovery timelines
• Self-monitoring strategies using the 0-10 scale
• Energy conservation techniques

Pharmacologic Considerations

Do not routinely prescribe wakefulness agents, psychostimulants, or antidepressants specifically for fatigue. 1 The 2024 ASCO guideline update definitively states these medications are not effective for reducing fatigue and should not be recommended for this indication. 1 The biological mechanisms underlying chronic fatigue—including neurotransmitter dysregulation, neuroendocrine dysfunction, immune dysregulation, and metabolic abnormalities—are not adequately targeted by these agents. 1, 5

Exception: Antidepressants (SSRIs) are appropriate when treating comorbid depression, which may secondarily improve energy. 1, 3

For specific populations:

• American ginseng may be considered for patients undergoing active cancer treatment 1
• Acupressure may benefit post-treatment cancer survivors with persistent fatigue 1
• Corticosteroids may be considered only for patients with advanced cancer 1

Structured Follow-Up and Reassessment

Schedule regular follow-up visits rather than sporadic urgent appointments for effective long-term management. 3 Reassess fatigue severity at each visit using the same 0-10 scale. 1, 2

If fatigue persists despite treating identified causes: 1

• Re-evaluate for new or missed contributing factors
• Ensure adherence to prescribed interventions
• Consider referral to specialists (hematology, endocrinology, mental health, physical medicine) as clinically indicated 1
• Implement additional non-pharmacologic interventions from the evidence-based options above

For anemia-related fatigue specifically, reassess after 2 weeks of iron treatment—hemoglobin improvements should correlate with reduced fatigue. 2 If no improvement occurs after 4 weeks, perform additional testing including mean corpuscular volume, red cell distribution width, and serum ferritin. 2

Common Pitfalls to Avoid

Do not assume fatigue is solely due to the primary chronic condition. 2, 6 Multiple overlapping causes typically contribute, and each requires independent assessment and treatment. 2, 6

Do not order extensive laboratory testing without clinical indication. 3 Results affect management in only 5% of patients, and if initial screening is normal, repeat testing is generally not indicated. 3

Do not recommend exercise to patients with severe untreated anemia or suspected ME/CFS. 2, 4 In these populations, exercise may worsen symptoms and quality of life.

Do not fail to reassess fatigue after treating contributing factors. 2, 6 Regular follow-up identifies persistent fatigue requiring additional intervention and prevents missed opportunities to improve quality of life.