Check out Fight Back Against Fatigue: A Psoriatic Arthritis Patient’s Guide for more information on this topic.
For roughly 30 to 40 percent of people with psoriatic arthritis (PsA), debilitating fatigue is one of the most difficult symptoms to live with. Fatigue in a chronic condition like psoriatic arthritis is more than just being tired. It is a medical symptom that prevents people from physically engaging in their routine activities and can affect mental health too.
MedLine Plus defines fatigue as “a lack of energy and motivation,” noting that both drowsiness and apathy (a feeling of not caring about what happens) are symptoms that often accompany fatigue.
Psoriatic arthritis (PsA) is a type of inflammatory arthritis that causes swelling, stiffness, redness, pain, and damage to the skin, nails, joints, and more. PsA occurs because your immune system is overactive, causing inflammation that can affect your joints, skin, and other parts of your body.
People with psoriatic arthritis often have to contend with joint pain and skin issues, but fatigue is also a high-ranking problem. In fact, many patients report that fatigue is one of the most challenging symptoms to manage, even above skin discomfort, according to a 2016 study published in the journal Joint Bone Spine.
And yet what causes fatigue in psoriatic arthritis (and how to treat it) is still very misunderstood by patients and health care providers alike. But why?
For starters, fatigue is one of those “invisible” chronic illness symptoms. It can be hard to quantify fatigue and doctors may not ask about it as much during visits compared to other PsA manifestations, like painful joints, back pain, enthesitis, skin plaques and rashes, nail changes, or swollen “sausage” fingers and toes.
What’s more, there is not usually a single cause of fatigue in psoriatic arthritis. Instead, this symptom is what experts consider “multifactorial” (due to many causes), which aren’t always easy to figure out.
“The causes of fatigue are interrelated, so it can be hard to tease them apart,” says Saakshi Khattri, MD, a board-certified dermatologist, rheumatologist, and internist at Mount Sinai in New York City.
In a disease like PsA, one cause of fatigue can lead to many others. For example:
“Psoriatic skin lesions can be associated with local pain and itching, which lead to sleep disorders, which can then cause or worsen fatigue,” Dr. Khattri explains. “Depression and fibromyalgia in patients with psoriatic arthritis can also contribute to fatigue, and there are other underlying comorbidities like anemia or hypothyroidism, as well as medication side effects.”
We talked to several psoriatic arthritis and fatigue experts to better understand the many causes behind your fatigue.
You can use the information in this article to have a more informed discussion about fatigue with your health care provider.
Fatigue is often a telltale sign of a psoriatic arthritis flare-up, a period acutely worsening joint and/or skin symptoms. The worse a flare gets, the worse the fatigue gets.
“Chronic inflammation in itself can result in fatigue because of increased levels of pro-inflammatory proteins,” explains Dr. Khattri.
During a flare, when inflammation is driving an uptick in skin and joint symptoms, your body is using a lot of extra resources, which makes you feel depleted for other activities, explains rheumatologist Alexis Ogdie, MD, Director of the Penn Psoriatic Arthritis Clinic in Philadelphia and Associate Professor of Medicine at the Hospital of the University of Pennsylvania. A 2020 study of more than 1,000 PsA patients, published in the Journal of Rheumatology, found that fatigue was driven by inflammation in about one-third of study participants.
Living with chronic pain is exhausting. Dealing with the daily mental and physical burden of PsA pain (with or without inflammation) can contribute to fatigue. Pain can make it hard to sleep and rest. Being in pain can also prevent you from exercising, which causes your body to get deconditioned and this can contribute to fatigue as well, explains Dr. Ogdie.
Anxiety and Depression
“About 30 to 40 percent of our PsA patients also have anxiety/depression, which can contribute to fatigue,” says Dr. Ogdie.
Depression and anxiety can stem from the mental burden of living with a chronic disease, and a growing body of research suggests that skin involvement as well as inflammation from arthritis can raise the risk of anxiety and depression in people with PsA specifically.
A study published in the Journal of Rheumatology found that the prevalence of both anxiety and depression was higher in patients with PsA than those with psoriasis without psoriatic arthritis, for instance, and was associated with higher actively inflamed joint count as well as disability, pain, and fatigue.
“Up to 30 percent of our PsA patients also have fibromyalgia, and fatigue is a major symptom of fibromyalgia,” says Dr. Ogdie.
Fibromyalgia is a common but poorly understood disorder associated with widespread body pain and sensitivity, accompanied by anxiety, depression, disrupted sleep, difficulty with memory and focus (“fibro fog”), and fatigue.
A 2019 study published in the journal Advances in Rheumatology found that patients with PsA and fibromyalgia reported higher levels of fatigue compared to those with PsA without fibromyalgia.
Fatigue is a hallmark symptom of anemia, which is common in people with PsA. There are two types of anemia: iron deficiency anemia (the most common type) and anemia of chronic disease (which is less common in the general population but may play more of a role in people with inflammatory arthritis like PsA).
Iron deficiency anemia is caused by a shortage of the mineral iron in both body tissues and blood. Iron is needed for your bone marrow to make hemoglobin; without adequate iron, your body can’t produce enough hemoglobin for red blood cells. A lack of hemoglobin means less oxygen reaches your tissues and muscles, depriving your body of energy and causing fatigue. One cause of iron-deficiency anemia is taking non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief and to reduce inflammation. In some people, this can cause ulcers or gastritis, which may lead to gastrointestinal bleeding, and eventually, iron-deficiency anemia.
Anemia of chronic disease (or anemia of inflammation) is triggered by chronic inflammation that prevents your body from using the stored iron to create new red blood cells. Inflammation can also affect the way your body produces erythropoietin, a hormone that controls the production of red blood cells.
While the link isn’t fully understood, a 2017 study published in the journal Immunologic Research has shown an increased prevalence of hypothyroidism (low thyroid) in people with psoriatic arthritis, especially among females.
Hypothyroidism causes the thyroid gland to become underactive, which means that it can’t make enough thyroid hormone necessary to keep your body running normally. Symptoms of hypothyroidism often include feeling cold, constipation, depression, dry skin, muscle aches, weight gain, slow movements and thoughts, and fatigue.
Cardiovascular Disease and Diabetes
Psoriatic arthritis is linked with having a higher risk for a number of other chronic health conditions, especially if you’re overweight or obese. Two common ones — cardiovascular disease and diabetes — are also culprits of fatigue.
While the mechanisms are not clearly understood, heart disease, especially heart failure, can cause you to feel fatigue and make it difficult to tolerate exercise. With diabetes, fluctuating blood sugar levels, as well as inflammation in the body caused by high blood sugar levels, can lead to fatigue.
Some disease-modifying antirheumatic medications (DMARDs) taken to treat PsA may also contribute to fatigue. For example, while methotrexate is effective in reducing pain and joint damage and improving joint function, patients who take methotrexate commonly report experiencing fatigue.
Data from 91 patients with psoriatic or rheumatoid arthritis in CreakyJoints’ ArthritisPower research registry presented during ACR Convergence 2020, the annual meeting of the American College of Rheumatology, showed that 43 percent of those surveyed reported experiencing fatigue as a methotrexate side effect.
The study found that for many patients, fatigue caused by methotrexate is “temporal,” or related to the timing of the medication, and typically subsides over time. Methotrexate is usually taken once a week, so people may experience worse fatigue in the first couple of days after they take it.
On the other hand, some medications for psoriatic arthritis may help relieve fatigue by treating the underlying inflammation and pain that contribute to symptoms. If you’re not sure whether your treatment might be contributing to symptoms of fatigue, it’s a good idea to review all of your medications with your health care provider.
Nearly 70 percent of patients with PsA experience poor sleep quality. Poor sleep is associated with increased pain, higher levels of inflammation, anxiety, and intense fatigue, according to a study in the journal Reumatologia.
“Sleep disorders can have a considerable impact on quality of life and create a vicious fatigue cycle,” says Dr. Khattri.
Patients with PsA can experience poor sleep due to joint pain and itching as well as from multiple comorbidities including cardiovascular events, diabetes, metabolic syndrome, psychiatric disorders, and obesity.
Certain sleep disorders — for instance, obstructive sleep apnea (OSA) and restless leg syndrome — (RLS) are also common in patients with PsA:
Obstructive sleep apnea, marked by abnormal breathing during sleep, is common among people with PsA. A 2016 study published in Sleep Medicine Reviews found that 36 to nearly 82 percent of PsA patients have sleep apnea compared to just 2 to 4 percent of those without the disease.
“A common cause of fatigue is obstructive sleep apnea, which is often related to obesity in patients with PsA,” says Lihi Eder, MD, PhD, a rheumatologist at Women’s College Research Institute in Toronto and an Assistant Professor in the Department of Medicine at the University of Toronto.
Restless leg syndrome, a sleep disorder that causes uncomfortable sensations in your legs such that you have to move them, may occur in more than 60 percent of people with psoriatic arthritis compared to 20 percent of people with psoriasis, a German study found. This is more than five times the prevalence of RLS in the general U.S. population. Why restless leg syndrome occurs more frequent in PsA patients is unclear, however, scientists suspect pro-inflammatory proteins (called cytokines) that are produced by the immune system when you have PsA play a role. Iron deficiency anemia has also been linked to RLS.
Overall Mental Burden
The mental burden of managing your everyday life and a chronic disease like psoriatic arthritis also plays a role in fatigue. Psoriatic arthritis tends to hit people between age 30 and 50, “often in the prime of their life when they have young families and are busy at work,” says Susan Bartlett, PhD, a Professor of Medicine at McGill University in Canada. “There’s a lot of coordination for doctor’s visits, labs, imaging, and everything that goes with it. There’s getting authorization for medication, interacting with your physician’s office and pharmacy, picking up your medication. It’s a lot.”
Managing Psoriatic Arthritis Fatigue
The first step in managing fatigue is identifying the possible causes. You’ll need to work with your health care provider to figure out why you’re feeling so wiped out.
Depending on your overall health and underlying medical conditions, treatment suggestions may include the following:
- Lifestyle changes (diet, exercise, weight loss, practicing self-care, knowing your limits)
- Medication adjustments (changing the dose, timing, or class of medication)
- Therapy and mental/emotional help through support groups
“It’s not a quick conversation. There are a lot of things that can be causing fatigue,” says Dr. Bartlett. “But it’s much easier to do something about your fatigue, once you dig down and identify the root cause.”
Read tips on talking to your doctor about fatigue.
This article is part of Fight Back Against Fatigue: A Psoriatic Arthritis Patient’s Guide and was made possible with support from Janssen Pharmaceuticals, Inc.
Fallahi P, et al. Increased incidence of autoimmune thyroid disorders in patients with psoriatic arthritis: a longitudinal follow-up study. Immunologic Research. June 2017. doi: https://doi.org/10.1007/s12026-017-8900-8.
Fatigue. MedLine Plus. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/003088.htm.
Gudu T, et al. Fatigue in psoriatic arthritis – a cross-sectional study of 246 patients from 13 countries. Joint Bone Spine. July 2016. doi: https://doi.org/10.1016/j.jbspin.2015.07.017.
Gupta MA, et al. Psoriasis and sleep disorders: A systematic review. Sleep Medicine Reviews. October 2016. doi: https://doi.org/10.1016/j.smrv.2015.09.003.
Interview with Alexis Ogdie, MD, Director of the Penn Psoriatic Arthritis Clinic in Philadelphia and Associate Professor of Medicine at the Hospital of the University of Pennsylvania
Interview with Lihi Eder, MD, PhD, a rheumatologist at Women’s College Research Institute in Toronto and an Assistant Professor in the Department of Medicine at the University of Toronto
Interview with Saakshi Khattri, MD, a board-certified dermatologist, rheumatologist, and internist at Mount Sinai in New York City
Interview with Susan Bartlett, PhD, a Professor of Medicine at McGill University in Canada
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Ulus Y, et al. The impact of the presence of fibromyalgia on fatigue in patients with psoriatic arthritis: comparison with controls. Advances in Rheumatology. December 2019. doi: https://doi.org/10.1186/s42358-019-0104-6.