New guidelines for managing fatigue in rheum patients

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EULAR recommendations feature regular assessment of fatigue and shared decision-making about the best management options.

A multidisciplinary taskforce has developed EULAR recommendations for managing fatigue in inflammatory rheumatic and musculoskeletal diseases. 

Despite affecting a majority of rheumatology patients at some point, up to now there have been no formal guidelines to support health professionals and patients manage fatigue. 

“Fatigue is prevalent in people with I-RMDs and is one of the most challenging symptoms to cope with due to its invisible, pervasive and unpredictable nature,” wrote the authors in the Annals of the Rheumatic Diseases

“In rheumatology, people with I-RMDs and health professionals have identified access to fatigue interventions as an unmet need and priority. However, there are no recommendations to support people with I-RMDs and health professionals with fatigue management.  

“Acknowledging this current lack of guidance, we convened a taskforce to develop EULAR recommendations for the management of fatigue in people with I-RMDs.” 

The taskforce, convened by Professor Emma Dures of the University of the West of England, comprised rheumatologists, patient partners, nurses, occupational therapists, psychologists and physiotherapists. 

They then conducted a systematic literature review to investigate evidence for the safety and efficacy of pharmacological and non-pharmacological interventions in reducing fatigue. 

The general findings were that physical activity or exercise, psychoeducational interventions and some pharmacological interventions, especially biologic agents, are efficacious and generally safe in reducing fatigue. 

Based on the findings from the systematic review, the group then considered potential overarching principles and recommendations, with those making the final cut agreed by consensus. 

Overarching principles 


The first overarching principle (OAP), “Health professionals should be aware that fatigue encompasses multiple and mutually interacting biological, psychological and social factors”, highlights the complexity of fatigue and the need to consider specific factors that apply to patients as individuals. 

Routine monitoring 

The second OAP is: “Fatigue should be routinely monitored in people with I-RMDs, and management options should be offered as part of their clinical care”. It recognises the high prevalence and long-term nature of fatigue and the need to monitor it and offer management options, potentially by referring to colleagues better able to support patients.  

Shared decision-making 

The next OAP, “Decisions on managing fatigue should be shared and agreed on, between the person with an I-RMD and the professionals providing care for their health and well-being”, acknowledges the importance of shared decision-making as integral to patient-centred care. It also allows for a broader range of health and wellbeing professionals, such as mental health therapists and fitness instructors.  

Individual variation 

The final OAP, “In managing fatigue, the needs and preferences of people with I-RMDs should be considered together with their clinical disease activity, comorbidities and other individual psychosocial and/or contextual factors”, emphasises the variation in fatigue experience both between individuals and within individuals over time. 


Regular assessment 

The first recommendation is that “Health professionals should incorporate regular assessment of fatigue severity, impact and coping strategies into clinical consultations”.  

It should be a part of usual clinical care, perhaps using a single-item instrument as a screening tool and progressing to a multidimensional assessment if required. 

Physical activity 

The second recommendation, “As part of their clinical care, people with I-RMDs and fatigue should be offered access to tailored physical activity interventions and encouraged to engage in long-term physical activity” reinforces existing EULAR recommendations around physical activity for disease management and reflects long-standing evidence of efficacy, feasibility and safety.  

It also points out that while much of the evidence comes from supervised time-limited interventions, there’s also evidence of benefit for unsupervised general physical activity, and it should be encouraged as a long-term lifestyle change. 

Psychosocial interventions 

The third recommendation, “As part of their clinical care, people with I-RMDs and fatigue should be offered access to structured and tailored psychoeducational interventions”, points to the benefits of structured, time-limited interventions that go beyond simply providing access to information (in leaflets, websites etc).  

It also acknowledges that more than one such session may be required, so should be discussed regularly with patients.  

Pharmacological management 

The final recommendation, “The presence or worsening of fatigue should trigger evaluation of inflammatory disease activity status and consideration of immunomodulatory treatment initiation or change, if clinically indicated”, highlights the role of anti-inflammatory and disease modifying antirheumatic medications in reducing fatigue.  

Given that fatigue can occur in high disease activity, low disease activity and even disease remission, changes in fatigue severity or impact should trigger an evaluation of a patient’s disease activity and changes to medication if required. 

Future needs 

One of the issues that emerged related to instruments used to measure fatigue, both in research and clinical settings. The group identified 26 different instruments in their literature reviews but were unable to provide recommendations as to which to use: “Addressing this complex issue is beyond the scope of this taskforce”. 

The taskforce also noted that there may be non-pharmacological interventions that currently lack evidence but could be useful for a given patient depending on the factors involved in their fatigue, such as cognitive behavioural therapy for insomnia or weight management in obesity.  

“In conclusion, EULAR recommendations have been developed to manage fatigue in people with I-RMDs,” wrote the authors. 

“Central to these are regular assessment of fatigue and shared decision-making about the best management options at that time.  

“Dissemination will focus on promoting these recommendations to people with I-RMDs and their networks, health professionals and other stakeholders involved in the provision of healthcare services, including patient organisations.” 

Annals of the Rheumatic Diseases 2023, online 22 November 

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