I Am So Tired of Fatigue

Last updated: September 2022

Of all the things about rheumatoid arthritis I hate (and there are too many to list here), fatigue has to be one of the worst. RA-related fatigue is not being tired. You can relieve “tired” with enough rest. Instead, RA-related fatigue is the bone-wrenching, overwhelming feeling of wondering if you even have enough energy to breathe, much less move. It sucks all energy out of your body to the point that it is all but impossible to generate enthusiasm for anything. And there is no amount of rest, caffeine, or other remedy that has been known to cure it.

When I started my latest treatment regimen I told my rheumatologist I was doing better. The actual pain, stiffness and swollen joints hadn’t improved substantially but much of the fatigue had lifted and I felt so much better. I actually felt like I had the energy to want to do things.

Fatigue: the most misunderstood RA symptom

The Arthritis Foundation estimates that up to 98 percent of people with rheumatoid arthritis suffer from fatigue. The percentage grows (if that’s possible) if there are associated conditions such as fibromyalgia, obesity, or depression. In fact there is a lot of discussion (read “controversy”) about Chronic Fatigue Syndrome (CFS) which is often closely associated with fibromyalgia.

A major problem with treating fatigue is that many of its symptoms, such as muscle or joint pain, can also be caused by other conditions which must be ruled out. The fact that fatigue often accompanies these conditions makes it doubly difficult to identify and treat.

How can we accurately measure RA fatigue?

Anecdotal evidence and personal experience tells me that many rheumatologists fail to address fatigue directly. Instead, rheumatologists tend to focus on the more measurable aspects of the disease: number of swollen joints, lab results, joint deterioration, restricted movement, and similar metrics. I think part of this is because fatigue, like pain, cannot be objectively measured. Fatigue is subjective – a personal opinion of the patient – so there are no clear guidelines between patients or even with the same patient at different times.

Treat RA fatigue by reducing RA disease activity?

I believe the other part of rheumatologists not tackling fatigue head-on is that they believe if they can reduce disease activity, fatigue will also be reduced.

I personally have subscribed to that theory – make RA less active and the fatigue will also be less – so I was surprised to read a recent article that discussed several studies demonstrating that while biologics can be effective against disease activity (by a number of standard measurements), they aren’t always effective on addressing the debilitating effects of fatigue.

What factors contribute to RA fatigue?

There are a lot of things that can contribute to fatigue. Among these are pain and inflammation and to the point that a biologic reduces those, fatigue can also diminish. However, other things can cause fatigue such as depression and sleeplessness which biologics do not address. Nor can biologics or other treatments reverse permanent joint damage which can cause pain which can cause fatigue directly or lead to sleeplessness or depression which, in turn, can contribute to fatigue.

Interestingly, some of the medications used to treat RA and associated conditions, also contribute to fatigue via having drowsiness as a side effect. These include certain antidepressants, pain medications, NSAIDs, some DMARDs and antihistamines. While drug-induced drowsiness is not truly fatigue, being drowsy or fuzzy-headed can aggravate the symptoms of fatigue.

How can we improve feeling so tired with RA?

Treating underlying conditions

Because there are so many causes of fatigue, there is no single answer. There are some medications that might help. For example, if fatigue is caused by anemia, sleeplessness, or depression, there are prescription medications that can address those things.

Lifestyle changes

Otherwise, it is largely in the hands of the patient to make lifestyle changes to counteract the effects and possible causes of fatigue: exercise, proper diet, and good sleep habits.

Talk to your rheumatologist

To me, the main thing is to convey my fatigue to my rheumatologist. It’s important that my rheumatologist understand that this is a major factor that affects my life and that one of my goals in treatment is to relieve it and reclaim my energy and enthusiasm for life.


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