Fatigue and Rheumatoid Arthritis: What Your Doctor Should Know

A Common Symptom Seldom Discussed

A tired man with his head resting on his arms sitting at a table
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Fatigue greatly impacts people with rheumatoid arthritis (RA). Most people know that RA is associated with joint pain and joint stiffness. Mistakenly, people think that it is simply localized to one or more affected joints with the consequence being physical limitations. Fact is, RA is a systemic disease, meaning the disease affects the entire body, not just the joints. This is the case with many inflammatory types of arthritis or other inflammatory diseases.


Despite its impact on people with RA, fatigue is an intangible symptom, making it difficult to define, discuss, or solve. Add to that the variability of fatigue — it varies from person to person as well as within an individual person. According to Arthritis Research and Therapy (2015), fatigue is a problem for between 40 to 80 percent of people with RA or spondyloarthritis. Fatigue is severe for 75 percent of patients with spondyloarthritis and 50 percent of those with rheumatoid arthritis.

How Is Fatigue in Rheumatoid Arthritis Defined?

Fatigue is a state of exhaustion accompanied by diminished strength, weariness, malaise, irritability, and sleepiness. There is also a cognitive aspect, so fatigue is much more than the simple tiredness most people experience. With usual tiredness, a period of rest is sufficient to recover. But with RA or other inflammatory diseases, rest is not enough to bring about recovery from the associated fatigue.


What Causes Fatigue in Rheumatoid Arthritis?

A well-known association exists between fatigue and pain. High levels of pain correlate with a high level of fatigue. The association between disease activity and fatigue, however, is not well-established in medical literature.

Researchers consider fatigue in RA to be multidimensional.

While fatigue associated with RA may be related to certain disease characteristics, including pain, inflammation, disease activity, and joint damage, it may also be related to aspects of physical function, such as disability, health-related quality of life, and quality of sleep. There may be an association with cognitive or emotional issues, too, such as depression or anxiety. Other factors, including age, gender, or work situation may contribute as well. 

In a review of studies that considered the possible cause of fatigue in RA, published in Arthritis Care and Research in 2013, most found an association between pain and fatigue. A few studies did not, perhaps due to study design. Inflammatory activity, as evidenced by sedimentation rate or DAS28, did not show a clear association with fatigue in RA. Of personal characteristics, the length of time a person had RA seemed to correlate with fatigue. Physical functioning and disability, as well as sleep quality, were found to correlate with fatigue in RA.

Depression was a significant factor in many studies that considered the cause of fatigue in RA. 

So, it seems there is no single, identifiable cause for fatigue in RA. It is a consequence of overlapping and underlying factors, most likely involving pain, disability (decreased physical function), and depression.

Do Rheumatologists Address Fatigue?

Many patients do not bring up fatigue when they visit their rheumatologist, perhaps because they think it is part of the disease and that little can be done. According to survey results published in Clinical Rheumatology in 2008, while most rheumatologists feel that fatigue should be addressed even when pain is well-controlled, many feel that other health care professionals are dealing with it. Survey results revealed that 72 percent of rheumatologists communicated about fatigue during a patient's first consultation, while that dropped to 33 percent for subsequent consultations. Better communication about fatigue, on the part of both patient and doctor, is clearly needed.

What Can Be Done?

From a medical perspective, reducing inflammation in RA or other inflammatory diseases may decrease pain and fatigue. Increased levels of pro-inflammatory cytokines (IL-1, IL-6, TNF-alpha) may be involved, so controlling inflammation is a priority. 


Repping-Wuts et al. Rheumatologists' knowledge, attitude an current management of fatigue in patients with rheumatoid arthritis (RA). Clinical Rheumatology. 2008; 27:1549-55.

Louati et al. Fatigue in chronic inflammation — a link to pain pathways. Arthritis Research & Therapy. 2015; 17:254. 

Nikolaus et al. Fatigue and Factors Related to Fatigue in Rheumatoid Arthritis: A Systematic Review. Arthritis Care & Research. 2013; Vol. 65. 1128-1146.

Pollard LC et al. Fatigue in rheumatoid arthritis reflects pain, not disease activity. Rheumatology (Oxford) 2006; 45(7)885-889.

Wolfe F et al. Fatigue, rheumatoid arthritis, and anti-tumor necrosis factor therapy: an investigation in 24,831 patients. Journal of Rheumatology. 2004; 31(11):2115-2120.

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