Fatigue

Overview

Fatigue is very common in patients with chronic disease, and is often multifactorial. Provide patient and family education and counseling regarding realistic expectations in the treatment of fatigue, energy management, prioritization of meaningful activities, and permission to seek help. Multidisciplinary team involvement is often needed; allied health team members may include physiotherapist, respiratory therapist, occupational therapist, social worker, psychologist, or spiritual care provider.

Even if your patient does not have Kidney Disease consider using the ESAS-r:Renal to assess the severity of fatigue as well as other concomitant symptoms
Treat the patient’s fatigue if it is affecting their quality of life and daily function
Consider a review of their medications to see if anything might be exacerbating the fatigue and should be adjusted
Pacing and/or strengthening of peripheral musculature may be beneficial

Step 1 Consider the Underlying Causes of Fatigue

Sleep disturbances
Poorly controlled symptoms (e.g. pain, nausea/vomiting, shortness of breath, pruritus, restless legs syndrome)
Mood Disorders (e.g. depression, anxiety)
Metabolic disorders (e.g. anemia, hypokalemia, hyponatremia, hypomagnesemia, hypo/hypercalcemia, hypothyroidism/endocrine imbalance)
Malnutrition
Dehydration
Vitamin D Deficiency
Medications or medication withdrawal (assess recent medication changes)
Alcohol/drug use

Step 2 Non-pharmacological Management of Fatigue

General Principles

Non-pharmacological measures should be considered in all patients where the symptom is having an impact on quality of life or ability to function.
Provide patients with the Fatigue Patient Handout

Encourage the following behaviour:

Exercise (if appropriate)
Promote good sleep hygiene
- Wake up at the same time every morning
- Try not to go to bed until you feel sleepy
- Limit/avoid napping during the day
- Limit/avoid caffeine in the evening
- Save your bedroom for sleep (and sex) only
Energy Conservation Strategies
Nutrition and hydration management

Complimentary Treatments

Cognitive and psychological approaches (e.g. relaxation therapy, hypnosis, stress management, delegating and setting limits)
Complementary alternative medicine therapies (e.g. acupressure, acupuncture, massage, relaxation techniques, music and art therapy)

Step 3 Pharmacological Management of Fatigue

General Principles

Fatigue can be difficult to manage. If non-pharmacological therapy alone fails, and fatigue is having a severe impact on the patient’s quality of life and ability to function, although there is limited evidence, a trial of pharmacological therapy can be considered
The goal of therapy is to balance symptom control with careful protection of physical function and cognition
Avoid OTC sleep aids and benzodiazepines if possible
Other medications should be considered in patients with severe, persistent fatigue
Consider referral to palliative care for consultative support if moderate to severe fatigue persists

Methyphenidate First-line Agent

2.5 – 5 mg daily or 2 times daily (morning and noon)
Start at low dose and titrate as needed

Contraindicated in patients with glaucoma, agitation, anxiety, insomnia, and heart disease, or if using MAOIs

Contraindicated within 14 days of MAOI administration, thyrotoxicosis, pheochromocytoma, motor tics and/or family history or diagnosis of Tourette’s syndrome

Use with caution in patients with hypertension, liver disease, kidney disease and seizure

Modafinil First-line Agent

100 mg daily (morning)
Start at low dose and titrate as needed
Maximum dose: 100 mg 2 times daily (morning and noon)

Contraindicated in patients with angioedema and severe anxiety

Use with caution in patients using MAOI’s or warfarin, or with a history of depression and psychosis

Modafinil is CYP3A4 inducer and CYP2C19 inhibitor so caution is needed with medications metabolized by these two substrates

Co-administration of modafinil with opioids may result in a drop in plasma concentration of the opioid. Reduced opioid efficacy or withdrawal symptoms can occur

Dexamethasone First-line Agent

Off label use
8mg daily for a maximum of 2 weeks

Contraindicated in patients with uncontrolled infections

Use with caution in patients with hypertension, fluid retention, diabetes mellitus, or if immunocompromised. Also, heart failure (increased risk of fluid retention), acute myocardial infarction (risk of myocardial rupture), cirrhosis (risk of fluid retention), GI ulcer (increased risk of bleeding), diverticulitis (increased risk of GI perforation), Acute angle glaucoma (increase IOP)

No benefit shown beyond 7-15 days; adverse events with treatments beyond 7-15 days

Bupropion First-line Agent

Off label use
Start with 75 mg daily and titrate up to 150 mg daily

Contraindicated in patients with anorexia, epilepsy, or if using MAOI’s

Contraindicated in uncontrolled seizure or seizure disorders, bulimia or anorexia

Use with caution in patients with hypertension, insomnia, and anxiety

Also, use with caution in hepatic impairment, cirrhosis (requires dose adjustment), primary brain tumor (increases risk of convulsions), severe stroke (increases risk of seizures), alcoholism, glaucoma, hypoglycemia, hyponatremia, renal failure, and substance use disorder