Fatigue is an extremely common aspect of living with rheumatoid arthritis (RA). More than 30,000 myRAteam members report fatigue as a symptom. RA fatigue also can have a huge effect on quality of life. “I suffer from severe fatigue. It is debilitating. Some days I cannot get out of bed,” a myRAteam member said. Another replied, “Yes, every day it happens! Fatigue! It's worse than the pain!”

However, researchers are just beginning to find ways to measure the effect of rheumatoid arthritis fatigue on people’s lives. People with RA fatigue often feel uncomfortable bringing up their levels of fatigue with their rheumatologists, or if they do, they feel ignored. As one myRAteam member explained, “At my last RA appointment, I brought up how fatigued I feel on a regular basis, and my doctor said that my fatigue is not necessarily from my RA. I feel shrugged off.” Friends and family may also not understand that their loved one isn’t just tired.

How Is RA Fatigue Different From "Normal" Fatigue?

Fatigue from rheumatoid arthritis doesn’t just go away after a cup of coffee or a quick nap. Instead, it’s a chronic lowering of energy levels that affects quality of life. In one small study of 15 people with rheumatoid arthritis, one person described severe fatigue as like a “wipeout,” with energy draining from the body, leaving them unable to do anything but sleep. Another person said the tiredness of rheumatoid arthritis was similar to having the flu. This chronic fatigue happened often enough that people were unable to enjoy leisure activities and complete ordinary tasks, like getting groceries or tending to their children.

What’s more, RA fatigue isn’t just physical. People with rheumatoid arthritis often experience mental fatigue — loss of concentration and confusion — and emotional fatigue. People experiencing emotional fatigue find that events or emotions they may have dismissed before suddenly make them feel angry, sad, or upset.

Feeling physical, mental, and emotional fatigue doesn’t mean that people with rheumatoid arthritis are weak or lazy. These are very normal responses to rheumatoid arthritis.

What Causes Fatigue in Rheumatoid Arthritis?

Several factors cause rheumatoid arthritis fatigue. One of these factors is the disease itself. Inflamed tissues release chemicals called cytokines. These cytokines normally help the body attack bacteria and viruses, but in people with rheumatoid arthritis, these cytokines cause the body to attack healthy tissue. However, the excess cytokines still create the same worn-down tiredness people experience during a bout of a cold or the flu.

Anemia is also common in people who have rheumatoid arthritis — anywhere from 10 percent to two-thirds of people with RA have the condition. Anemia is a lack of red blood cells. The inflammation rheumatoid arthritis causes also limits red blood cell production. Without enough red blood cells, people with rheumatoid arthritis aren’t able to get enough oxygen into their blood, causing tiredness.

In addition, people with rheumatoid arthritis are at greater risk of developing other conditions that can cause fatigue. The emotional burden of living with rheumatoid arthritis can cause depression, which creates an extra layer of tiredness. People with rheumatoid arthritis are also more likely to develop fibromyalgia. The symptoms of fibromyalgia are similar to those of rheumatoid arthritis — fatigue, as well as body pain and poor sleep. Researchers think fibromyalgia is caused by flaws in the way the brain and spinal cord interpret pain signals. The inflammation and subsequent pain of rheumatoid arthritis can make the brain more sensitive to these pain signals, causing fibromyalgia to develop.

Joint pain also can make it difficult to participate in physical activity, which creates a vicious cycle. The less physical activity you participate in, the more likely you are to feel chronic fatigue, which makes it even harder to get up and get moving. A lack of physical activity may also cause sleep apnea, which can contribute to fatigue.

Treatments for rheumatoid arthritis also can cause fatigue. Methotrexate is a disease-modifying antirheumatic drug (DMARD) that is considered a first-line treatment for rheumatoid arthritis. It reduces inflammation, but can cause fatigue itself because it lowers levels of folic acid (also known as vitamin B9). These low levels of folic acid can cause fatiguing anemia, just like inflammation does.

Medication for RA Fatigue

There are several ways to decrease RA fatigue and improve quality of life. Treating rheumatoid arthritis overall can ease symptoms of tiredness. A class of DMARDs called biologics can have some effect on RA fatigue. These drugs include Enbrel (Etanercept), Humira (Adalimumab), Remicade (Infliximab), Orencia (Abatacept), and Rituxan (Rituximab). A 2016 study found that biologic DMARDs can lead to a “small to moderate” improvement in fatigue symptoms, although researchers were unsure whether the drugs directly affected fatigue or lowered fatigue by reducing overall inflammation or disease activity. Treating rheumatoid arthritis can also ease anemia symptoms, as lowering inflammation can help the body produce more red blood cells.

If you’re taking Methotrexate and feeling tired, folic acid supplements can reduce side effects by treating the Methotrexate-related anemia. Your doctor can prescribe an activated version of folic acid, called folinic acid, that can help if lower levels of supplements don’t work. Always talk to your doctor or rheumatologist before you begin taking any new supplements.

Lifestyle Changes to Manage RA Fatigue

Lifestyle changes can combat RA fatigue, especially mental and emotional fatigue. A gentle exercise regimen can improve energy levels and well-being. Stretching, short walks, aquatic therapy, and yoga are all recommended exercises for people with RA. Exercise can reduce the symptoms of conditions associated with rheumatoid arthritis, such as depression and fibromyalgia.

A healthy diet also helps smooth out energy highs and lows. Lowering sugar levels and pacing meals throughout the day can help avoid reactive hypoglycemia, otherwise known as a “sugar crash.” One myRAteam member said, “A healthy snack can give a boost — my favorites for that are unsalted nuts, dried apricots, or one or two dark chocolate candies.”

Other Approaches to Managing Fatigue in RA

One way to manage RA fatigue is to keep a schedule. Arrange your day to get the most done when you know you’ll have the most energy. One myRAteam member said, “I do what I can in the morning because, if I don't get my chores done early, I'm too tired in the afternoon. I try to rest more in the afternoon.”

Often, the psychological anxiety of having an “invisible illness” — a condition other people do not immediately recognize — adds to the fatigue of rheumatoid arthritis. Counseling and therapy can relieve this anxiety and help you learn better ways to manage your emotions and communicate with others. Researchers have even found therapy can relieve fatigue. In a 2011 study, people with RA who participated in cognitive-behavioral therapy reported feeling less tired. They also reported better sleep.

Above all, self-care is essential to managing RA fatigue. It’s OK to know your limits. Sometimes, you may simply need to stop and sit down or take a rest.

You Are Not Alone With RA Fatigue

If you have rheumatoid arthritis and suffer from RA fatigue, you don’t have to suffer in silence. Sharing your personal experiences, as well as how you combat RA fatigue, can improve your quality of life.

Here are a few question-and-answer threads on myRAteam about fatigue:

• "Help with brain fog."
• "Does anyone take any medication for their fatigue?"
• "Does depression cause fatigue or does fatigue cause depression?"

Here are some conversations about fatigue:

• "My tired is tired of being tired."
• "The fatigue …"
• "I am feeling my stiffness and so drained."

Do you experience fatigue with RA? What has helped you to rest or to get your energy back? Comment below or start a conversation on myRAteam.

References

1. Exercise and Fatigue in Rheumatoid Arthritis — Israel Medical Association Journal
2. Patients’ Perceptions of Fatigue in Rheumatoid Arthritis: Overwhelming, Uncontrollable, Ignored — Arthritis Care & Research
3. Managing Fatigue — Versus Arthritis
4. Cytokines and Their Side Effects — American Cancer Society
5. How to Manage, Treat Anemia of Inflammation in Patients with Rheumatic Disease — The Rheumatologist
6. Anemia — National Heart, Blood, and Lung Institute
7. RA With a Side of Fibromyalgia — Arthritis Foundation
8. Causes and Consequences of Fatigue in Rheumatoid Arthritis — Current Opinion in Rheumatology
9. Physical Inactivity Is Associated with Moderate-Severe Obstructive Sleep Apnea — Journal of Clinical Sleep Medicine
10. Folic Acid and Folinic Acid for Reducing Side Effects in Patients Receiving Methotrexate for Rheumatoid Arthritis — Journal of Rheumatology
11. Rheumatoid Arthritis Treatment — Johns Hopkins Arthritis Center
12. Biologic Interventions for Fatigue in Rheumatoid Arthritis — Cochrane Library
13. Best Exercises for Rheumatoid Arthritis — Arthritis Foundation
14. Exercise Is an All-Natural Treatment to Fight Depression — Harvard Health Publishing
15. Fibromyalgia: Does Exercise Help or Hurt? — Mayo Clinic
16. Reactive Hypoglycemia: What Can I Do? — Mayo Clinic
17. Self-Management of Fatigue in Rheumatoid Arthritis: A Randomised Controlled Trial of Group Cognitive-Behavioural Therapy — British Medical Journal: Annals of the Rheumatic Diseases

Jessica works to empower patients through the creation of content that illuminates treatments' effects on the everyday lives of people with chronic conditions. Learn more about her here.