Fatigue: Information for clinicians

Ask how the fatigue affects daily life and what the patient would be doing if they had more energy. Help them to consider practical solutions.

Exclude reversible causes including:

• Medication side effects like opiates, some antiemetics (e.g. haloperidol), neuropathic agents (e.g. gabapentin, pregabalin), anxiolytics (e.g. benzodiazepines), mirtazapine. Consider dose reduction.
• Anaemia and electrolyte disturbances
• Pain or other symptoms interfering with sleep
• Anxiety or depression
• Poor nutrition or dehydration
• Deconditioning with muscle loss

However in the final weeks of a long term illness fatigue can be very severe and hard to improve. Fatigue often has more than one cause, including the underlying disease process.

• Full blood screen for reversible causes, e.g. FBC, TFT, U&E, B12/folate, LFTs, haematinics, Ca2+ and magnesium
• Realistic advice about nutrition, sleep and exercise - please see Tiredness: Information for patients and carers
• Mood review and medication review - can sedative medications be reduced?

• Steroids such as dexamethasone or prednisolone can really improve appetite and energy levels. Although the impact is often short lasting, it can be very helpful for important events or days out. Common practice is to start with dexamethasone 4mg once a day early in the morning (so it doesn't interfere with sleep) and continue with the lowest dose that still gives benefit
• Psychostimulants occasionally may help, e.g. methylphenidate, if no cardiac contraindications but the evidence base is weak

• If using steroids as a boost for a special occasion start the day before and give early in the morning (so not to interfere with sleep). A course of less than 2 weeks duration doesn't require tapering
• Consider a B12 trial: 6 × 1 mg hydroxocobalamin subcutaneously over 2 weeks may improve fatigue. Continue based on symptomatic response. Higher-risk groups include those with poor nutrition, excess alcohol or a history of B12 deficiency