Rheumatoid arthritis and fatigue
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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One study published a few years ago stated, "The fatigue levels that affect rheumatoid arthritis (RA) patients are due mainly to pain and depression, not to RA disease activity levels..." (Pollard LC, Choy EH, Gonzalez J, et al. Fatigue in rheumatoid arthritis reflects pain, not disease activity. Rheumatology 2006)
The authors report also that TNF inhibitors are more effective than disease-modifying anti-rheumatic drugs (DMARDs) for relieving fatigue in established RA.
The data suggested that in patients with RA, pain and depression contribute more to fatigue than disease activity. Interestingly, after adjustment for depression, pain remains the biggest determinant of fatigue.
The researchers studied two groups of 238 and 274 RA patients and examined treatment responses in 30 patients starting TNF-inhibitor therapy and in 54 starting DMARD therapy. They used visual analog scales (VAS) and the Medical Outcomes Study Short Form 36 (SF-36) to measure fatigue. They also recorded disease activity score for 28 joints (DAS28), morning stiffness, health assessment questionnaire (HAQ), physician global assessment, erosive disease, nodules, rheumatoid factor, and concomitant medications and illnesses.
This analysis showed that:
• Over 50% of RA patients had high fatigue levels (VAS >50 mm).
• Over 80% of RA patients had clinically significant fatigue (VAS >20 mm).
• Mean SF-36 energy and vitality score was 51 (vs 61-65 in normal population).
• Pain had the strongest association with fatigue, followed by HAQ score and depression.
• TNF-inhibitor treatment significantly reduced VAS fatigue scores (p=0.009), but DMARDs did not (p=0.176).
They found no association between fatigue and age or disease duration, indicating that peripheral features such as muscle mass, which decreases with age, and disease duration are unimportant. Therefore, fatigue in RA is likely to be central in origin, the authors concluded.
As a clinician, I disagree. I feel the more likely cause of fatigue is disease activity. Once the disease activity has been put into remission, the fatigue goes away.
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