2023 EULAR recommendations to Managing Fatigue in Inflammatory Rheumatic and Musculoskeletal Diseases

by | Jan 26, 2024 | Blog, Rheumatology

Fatigue is a prevalent and challenging symptom for individuals with autoimmune diseases, especially rheumatic diseases.  It is marked by its invisible, pervasive, and unpredictable nature. Inflammatory rheumatic and musculoskeletal diseases (I-RMDs) encompass various chronic conditions such as rheumatoid arthritis (RA), psoriatic arthritis, axial spondyloarthritis, systemic lupus erythematosus, and Sjögren’s syndrome, among others. This article will help summarize the 2023 EULAR guidelines on managing fatigue in inflammatory rheumatic and musculoskeletal diseases.  EULAR is the European Alliance of Associations for Rheumatology.

While there isn’t a single definition for fatigue, it’s acknowledged that in the context of autoimmune rheumatic diseases, it differs from ordinary tiredness. Those with I-RMDs describe fatigue as overwhelming, intrusive, distressing, and depleting both physical and mental energy. This profound fatigue significantly impacts various aspects of daily life, leading individuals to feel isolated as they withdraw from social interactions, and their lives become increasingly constrained.

Supporting individuals with fatigue in I-RMDs poses a challenge due to the unclear and multifaceted nature of its causes and maintaining factors, compounded by the absence of a curative treatment. Existing research suggests the involvement of the immune system, central and autonomic nervous systems, and the neuroendocrine system in inducing and sustaining fatigue in I-RMDs. Moreover, emerging evidence points to contributions from sleep patterns, genetic susceptibility, metabolic disturbances, and other biological and physiological mechanisms.

Several factors, including physical functioning, physical activity, comorbidities, pain, obesity, anxiety, depression, stress, relationships, and work roles, may also influence fatigue. While the intricate interplay between these diverse factors and fatigue remains not entirely understood, there’s a consensus that fatigue in I-RMDs likely results from a combination of biological, psychological, and social mechanisms. It is suggested that these mechanisms can evolve and vary among individuals.

The body of evidence underscores the need for an optimal fatigue management approach that is tailored, flexible, and holistic. Despite the absence of specific recommendations for supporting individuals with I-RMDs and health professionals in fatigue management, recognizing this gap, studies have established a task force to formulate EULAR recommendations dedicated to the effective management of fatigue in people with I-RMDs.

While scrutinizing the available evidence and engaging in expert discussions, the task force pinpointed four overarching themes common to all recommendations. These themes were carefully crafted and unanimously established as Operational Actionable Points (OAPs).

Overarching Principles (OAP’s)

A  set of crucial principles in managing fatigue in people with I-RMDs, reflecting state-of-the-art management.

  1. Healthcare practitioners need to recognize that fatigue involves a multitude of biological, psychological, and social factors that interact with each other in complex ways.
  2. Regular monitoring of fatigue is essential for individuals with I-RMDs, and healthcare providers should include management options as integral components of their clinical care.
  3. Collaborative and mutually agreed-upon decisions regarding fatigue management should be made between individuals with I-RMDs and the healthcare professionals responsible for their health and well-being.
  4. When addressing fatigue, it’s imperative to take into account the preferences and requirements of individuals with I-RMDs, aligning these considerations with their clinical disease activity, comorbidities, and other unique psychosocial or contextual factors.
  5. Presence or worsening fatigue should trigger evaluation of inflammatory diseases activity status and consideration of starting or changing immunomodulatory treatment if indicated
  6. Psychoeducational interventions can be offered to help with fatigue.

In managing fatigue, it’s crucial to contextualize the management within an exploration of the factors that might contribute to an individual’s fatigue. This exploration encompasses considerations such as stress, disease activity, pain, sleep quality, comorbid long-term conditions, obesity, deconditioning, low levels of physical activity, low mood and withdrawal, as well as activity patterns.


These include offering tailored physical activity and/or tailored psychoeducational interventions and/or, if clinically indicated, immunomodulatory treatment initiation or change.

  1. In clinical consultations, healthcare professionals should integrate routine assessments of fatigue severity, its impact, and coping strategies.
  2. Individuals with I-RMDs experiencing fatigue should be provided with access to personalized physical activity interventions and motivated to participate in sustained physical activity as an integral component of their clinical care.
  3. In their clinical care, individuals with I-RMDs and fatigue should have the opportunity to access structured and customized psychoeducational interventions.
  4. The occurrence or escalation of fatigue should prompt an assessment of inflammatory disease activity status, leading to a thoughtful evaluation of the initiation or modification of immunomodulatory treatment if deemed clinically necessary.

Assessing fatigue and identifying its negative impact on individuals with I-RMDs should initiate a collaborative decision-making process regarding the provision and acceptance of management options. While shared decision-making has become integral to patient-centered rheumatology healthcare models, its implementation requires effort. Recent research highlights the necessity for education and training to empower health professionals in applying shared decision-making.

Systematic literature review (SLR) evidence predominantly focused on structured, time-limited physical activity and psychoeducational interventions as non-pharmacological interventions for fatigue. There is potential effectiveness of other non-pharmacological interventions, like cognitive-behavioral therapy for insomnia or weight management for obesity, even if current evidence is insufficient.

In summary, EULAR recommendations for managing fatigue in individuals with I-RMDs have been established. Key aspects include regular fatigue assessments and collaborative decision-making to determine optimal management options.


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