This chronic condition can take a toll on your energy levels. Learn what’s causing it and how to fight back.
Fatigue is more than simply feeling tired—it’s an all-consuming physical and mental exhaustion that can negatively impact your daily life. And unfortunately, fatigue is super common in people living with rheumatoid arthritis (RA), a chronic inflammatory disease. Fatigue affects up to 80% of people with RA, with high levels of fatigue affecting more than 50%, according to the Arthritis Foundation—and that’s on top of the other painful symptoms of RA, like joint inflammation and stiffness.
We spoke to the experts to learn more about the causes of fatigue in people with RA, as well as tips and treatment options to help fight it so you can get back some of your much-needed energy.
Why Are RA and Fatigue Linked?
“Fatigue is extremely common in RA, and there are many different processes that can happen to cause it,” says Laura Howe, MD, a rheumatologist at UCHealth Rheumatology Clinic – Greeley in Greeley, CO. One main cause of fatigue is directly related to the disease process itself, in which the immune system mistakenly attacks the body, resulting in inflammation.
“This is called cytokine fatigue, or autonomic nervous system fatigue, and it is the same fatigue you see in bad infections like the flu or that we are seeing with long COVID,” Dr. Howe explains. Basically, the immune system goes into overdrive in RA, using up your energy to produce proteins called cytokines. Cytokine signals reach the brain and result in major mental and physical fatigue, along with reducing your motivation, according to a study in Frontiers in Immunology.
“Typically, if the fatigue someone has is related to RA, the joint activity should parallel the level of fatigue,” says Brett Smith, DO, rheumatologist with Blount Memorial Physicians Group – Rheumatology in Maryville, TN and East Tennessee Children’s Hospital in Knoxville. “This means if your joints are in remission, you should not be experiencing high levels of fatigue—[so if you are,] that should prompt a workup for alternative causes of fatigue.”
So in addition to this main type of fatigue, what are the other indirect causes of fatigue in those diagnosed with RA? Here are some of the potential culprits:
Pain-related fatigue. One of the most common causes for fatigue that Dr. Howe sees in her patients is related to the other most-common RA symptom: pain. “Because pain is worse at night and in the morning, you see fatigue related to not sleeping due to pain,” Dr. Howe says. If you’re up all night or tossing and turning due to physical discomfort, that can leave you feeling like a zombie trying to get through the day.
Depression-related fatigue. RA and autoimmune diseases in general can increase your risk of depression, and one big symptom of depression is fatigue, says Dr. Howe.
Medication side effects. Unfortunately, certain RA medications can make fatigue worse. For example, says Dr. Smith, methotrexate can cause fatigue as a side effect. Other RA meds can increase your risk of infections, which can also make you extra tired as your body tries to fight them off, Dr. Howe adds.
Weakness. Another fatigue-related complication of RA is related to muscle loss, says Dr. Howe. As your muscles wear down, it can make it harder to complete physical tasks, leaving you feeling even more depleted.
Anemia. With inflammatory arthritis like RA, it’s not uncommon to develop iron-deficiency anemia—research estimates up to 30% to 60% of people with RA are anemic, per a study in BMC Geriatrics. “With iron deficiency, we see a lot of fatigue,” Dr. Howe says.
Sleep Strategies for RA Fatigue
One of the first things you can do to help manage your fatigue is to up your sleep hygiene game. Sleep hygiene is important when it comes to optimizing your energy levels during the day and making sure you get the best sleep possible. And while improving your sleep habits alone isn’t a cure-all for RA-related fatigue, taking stock of where your routine can be improved may help you feel more rested.
So what goes into good sleep hygiene? Dr. Howe suggests taking these steps:
Have consistent sleep/wake times.
Avoid eating within two hours of bedtime.
Stop the caffeine after 2 pm so you’re not wired right before bed.
Keep your bedroom a sleep-only zone.
Additionally, relaxation techniques like deep breathing or yoga nidra can help you wind down before bed (you can find guided meditations for these on apps like Calm or even by doing a quick YouTube search).
Tips to Manage Fatigue With RA
You may not be able to totally prevent fatigue in RA, but you can find ways to manage it, starting with the strategies here.
“Overall, the best first assessment is to make an appointment with your rheumatologist to see if the fatigue is related to the RA being active,” Dr. Smith says. If that is ruled out, then your doctor can start to hunt for other root causes to target.
“For example, if it’s anemia, you need to treat that,” Dr. Howe says. “If it’s related to being up at night due to pain, we need to manage pain better.”
Other tips to help tame the fatigue beast include lifestyle changes:
Exercise. It might seem counterintuitive, but physical activity can actually help combat fatigue from RA. “Exercise is really important—it can help turn down the autonomic nervous system response, and it can also help sleep and mood,” Dr. Howe says. That said, you want to start “low and slow” when exercising with your RA, working up your physical activity levels gradually, she advises.
Mind your mood. Because depression can often be a culprit when it comes to fatigue in RA, making sure you are caring for your mental health is a must, Dr. Howe says. Talk to your doctor about what resources they can connect you with, such as referrals to mental health therapists or support groups. Antidepressants may also be a helpful tool, per the Arthritis Foundation.
Consider diet changes. Eating healthy foods and staying hydrated can also help beat back fatigue. “Removing items from our diet that can cause disturbance of the gut microbiome, such as sugars, red meat and alcohol, can be helpful,” says Dr. Smith. Dr. Howe agrees: She reports success in her patients with an elimination diet, in which you remove certain foods from your diet and add them back one by one to see what may be contributing to your inflammation. Your rheumatologist can refer you to a dietitian to help guide you in this process.
In addition to these changes, taking breaks when you need them and using assistive devices as needed can help you conserve energy throughout the day, Dr. Smith adds.
The Bottom Line
It’s all too common to feel zapped of energy when you’re living with RA. And while you might hesitate to bring it up with your doctor, don’t brush it aside if it’s interfering with your daily life, Dr. Smith says. Working with your healthcare team can help you manage fatigue so that you have motivation to do the daily activities that are important to you.
“With fatigue, it’s important to have a dialogue with your physician as early as possible,” says Dr. Howe. “It can also help us see whether there are other things going on we should be looking for.”