By Ruben Gamundi, Tim Horn, and Richard Jefferys
Fatigue-a general term used to describe feelings of exhaustion, sleepiness, and lack of energy-is a common problem among HIV-infected people. Fatigue is not a disease, but rather a symptom of disease. Some people suffer from isolated or intermittent bouts of exhaustion. Others experience chronic fatigue, which may greatly interfere with work or other day-to-day activities.
Many health care providers do not know how to manage HIV-positive patients who report fatigue. Often, patients are told that their fatigue is either psychosomatic or an unavoidable consequence of being infected with HIV.
What is fatigue?
While the concept of fatigue seems obvious in everyday usage, there are several medical definitions of the term. Fatigue may include:
� Physical fatigue, which refers to unusual tiredness after physical exertion
� Mental fatigue, which is difficulty focusing on activities that require concentration
� Motivational fatigue, which is defined as a lack of will or desire to engage in emotional or physical activities
There are also acute and chronic types of fatigue. Acute fatigue is generally short-lived, sudden in onset, and relieved by rest. Chronic fatigue lasts a long time (usually six months or longer), may be insidious in onset, and is usually not relieved by rest.
How common is fatigue?
Among people living with HIV and AIDS, the prevalence of fatigue is quite high. In two studies, 54 percent and 67 percent of people reported fatigue as a symptom at some point during their course of disease.
Discussing fatigue with a health care provider
There is nothing to be ashamed of or embarrassed about feeling fatigued. Even though experiences of fatigue are common symptoms of an underlying complication, care providers may dismiss these symptoms as being unavoidable problems associated with HIV. Yet, fatigue is often a sign of an underlying problem and, if evaluated properly, its cause can be determined and treated.
If you feel fatigued, be sure to tell your health care provider. If you think your symptoms are dismissed too quickly, be sure to discuss with him or her the possibility of being tested for potential causes.
The causes of fatigue
There are numerous possible causes of fatigue among people with HIV infection. Inadequate rest, poor diet, or lack of exercise Many people with HIV fail to get an adequate amount of rest and/or exercise and do not eat properly. Working, or playing, too hard is often accompanied by poor nutrition and insufficient rest and exercise. In addition, sleep disturbances may be associated with anxiety and depression, the use of diuretics, caffeine, alcohol, nicotine, antihistamines, decongestants, illegal drugs, or lack of exercise.
Psychological causes
Anxiety and depression are often associated with fatigue and are also common among people with HIV. Virtually every HIV-infected person goes through periods of feeling upset, worried, anxious, or depressed.
Alcohol, tobacco, and illegal drugs
While no one is entirely sure whether alcohol consumption, cigarette smoking, or drug use speeds up HIV disease progression, many users and doctors report that the use of these substances is often associated with fatigue. While these substances may not directly cause fatigue, substance abuse is often a cause of anxiety, depression, sleep disorders, and poor diet, all of which can cause fatigue. Moreover, alcohol and certain drugs may increase the side effects of anti-HIV treatment.
Infections
Many of the infections associated with HIV can be associated with fatigue. Fatigue can be the first sign of an opportunistic infection.
Adrenal insufficiency
The adrenal glands are responsible for producing many essential hormones that regulate how the body functions. Adrenal insufficiency-inadequate production of adrenal hormones-can be caused by certain anti-HIV drugs, the HIV infection itself, or by opportunistic infections such as TB.
Anemia
Anemia, or an abnormally low number of red blood cells, is one of the most common causes of fatigue in people with HIV. As many as 70 to 80 percent of HIV infected patients develop anemia at some time during the course of infection. There are many potential causes of anemia in people with HIV:
� Decreased production of red blood cells:
� Inadequate hormone production
� Many drugs used to treat HIV infection
� Increased loss or destruction of red blood cells
� Bleeding-In women, excessive menstrual blood loss can lead to anemia and iron deficiency.
Check list
The following checklist may help identify other conditions which, if properly identified and treated, may help fight fatigue:
� How long has the fatigue been present?
� Did it come on suddenly?
� Are there other symptoms such as cough,
fever, weight loss, or diarrhea?
� Do you feel lightheaded or dizzy when you
stand up suddenly?
� Was the fatigue accompanied by depression?
� Was the fatigue accompanied by decreased
sexual function?
� Have you ever had your adrenal hormone and
testosterone levels checked?
� Did the fatigue begin when you started or
switched to new medication(s)?
� Have you made any changes in your diet?
� Do you exercise?
� Are you having problems sleeping?
� Do you drink alcohol?
� Do you smoke?
� Do you use any illegal drugs?
Treatments for fatigue
There are many different treatments for fatigue. Treatment should always be aimed at correcting the underlying cause of the fatigue once it has been determined.
I. Healthy habits
� Diet and nutrition
In order for the body to perform normal functions, energy is required. The source of fuel to create this energy is the diet or, more technically, nutritional intake. One of the body's responses to poor nutrition (i.e., an inadequate fuel supply) is to conserve energy. The brain gets a biochemical message to reduce activity, and attempts to expend energy can cause increased weakness and fatigue.
Dietary changes can help improve nutritional status. Certain vitamins and minerals have also been shown to be low in HIV-positive people and are often associated with weight loss and fatigue. These include low levels of vitamins B-12, A, and C, folate, carotene, and zinc. Through a proper medical evaluation, you can find out which dietary elements you are lacking and determine the cause of the deficiency.
� Exercise
Being unfit can reduce energy levels, and many studies have found exercise to be beneficial to people with HIV. Exercise programs should always be individualized based on current fitness levels. Resistance exercises such as weight lifting can help build up muscle tissue. Muscle tissue stores the protein required to make energy. Aerobic exercise can also be helpful. Speak with your health care provider or a nutritionist about getting involved in a fitness program.
� Sleep
Problems sleeping can cause daytime fatigue. Some people have trouble falling asleep, while others wake up frequently during the night. Changes in sleep patterns should be reported to your health care provider. Medical causes of sleep problems can include depression, anxiety, and drug side effects. These conditions can usually be diagnosed and treated. Lifestyle also affects the amount you sleep. Making sure you have enough sleep can be difficult when your life is busy or your medication schedule requires you to wake up at night. Addressing these problems should be part of a comprehensive plan for treating fatigue.
Non-medical drugs can affect your ability to sleep. The caffeine in coffee, tea, and cola drinks is a stimulant and can hinder sleep. Likewise, alcohol can cause sleep disturbances. Monitoring caffeine and alcohol intake to avoid excess is a good idea. Recreational drugs such as speed, crystal meth and ecstasy can produce long periods of wakefulness followed by a profound "crash."
Depending on the cause, there are several medical interventions commonly used to fight fatigue.
� Hormonal therapy. Using pharmaceutical compounds that mimic naturally-occurring hormones shows promise as a treatment option for HIV-infected people who are experiencing fatigue, depression, sexual dysfunction, and weight loss. While clinical trials of hormonal drugs for people with HIV are still in their infancy, promising results have already been reported by researchers.
� Testosterone. Testosterone therapy has been used to treat HIV-infected people with fatigue, decreased sex drive, and weight loss. Testosterone replacement in men with HIV has been reported to improve energy, mood and sex drive. Replacement is usually given as a biweekly injection or via a patch.
� Anabolic Steroids. Anabolic means to help create muscle tissue. Synthetic versions of anabolic steroids have also been used to promote the development of lean body mass and improve energy levels. Anabolic steroids, especially oral compounds, can cause liver disease and should be used with caution. Moreover, like testosterone replacement therapy, anabolic steroids can cause development of masculine traits such as thickened facial hair and voice deepening in women.
� Human growth hormone. Growth hormone is approved for the treatment of wasting in people with HIV/AIDS. In one 12-week study, HIV-infected people being treated for weight loss had improved energy levels after growth hormone treatment. Growth hormone has also been shown to increase both weight and lean body mass in people with HIV.
� Stimulants. A few small studies are investigating the use of psycho-stimulant drugs to treat fatigue. Ritalin, Cylert, and dexedrine are among the drugs being tried. One concern about using this approach is that the underlying cause of the fatigue may simply be masked by the action of the stimulant drug.
� Treating infections. Any time an infection is present, the body draws upon various energy stores (such as fat and muscle) to fuel itself. Someone who is fighting an infection usually burns a lot more energy while at rest than someone who is healthy. Over time, energy can become depleted and, as a result, cause fatigue. HIV infection, opportunistic infections, and various other AIDS-related complications are commonly associated with fatigue. HIV and its complications put stress on the immune system and energy stores. Treatments are necessary to combat the disease, but also help alleviate these stresses and disease-related symptoms. Any infection or complication that causes fatigue, weight loss, fever or other symptoms should be aggressively diagnosed and treated.
� Dealing with drug side effects Despite all the benefits offered by antiretroviral drugs and treatments for AIDS-related complications, they have a number of undesirable side effects. Many anti-HIV/AIDS drugs can contribute to the development of anemia and fatigue. Depending on the severity of the side effect(s), there are several steps that patients and their doctors may want to consider taking.
One option may be to substitute the offending drug with a similar drug that may not cause the same side effects. This is often the most desirable option, but may not be possible for patients without alternative drugs to choose from. For example, an anemic patient who has tried and failed virtually every available antiviral drug and is showing a good response to a combination of drugs that includes AZT may not have alternative drugs to choose from.
Another option may be to lower the dose of the drug causing the side effect. Unfortunately, dose reduction may be a problem, since lower doses of the drugs may be less effective and may promote drug resistance.
The least desirable option is a "drug holiday." A drug holiday simply means stopping any or all drugs that may cause side effects for a short period. Unfortunately, if a patient stops actively treating an opportunistic infection, it is unlikely to get better and may become much worse.
In recent years, we've learned that treating HIV is a constant battle that should not be stopped. Every time treatment is halted, even for brief periods, HIV has an opportunity to build up its strength and become resistant to drug treatment. It is not known whether, or how may times, one can stop and start antiviral treatments without developing resistance. Rather than repeatedly interrupting therapy if a side effect such as anemia develops, it is generally recommended that therapy be changed altogether or that the side effect be treated directly without switching the drug regimen.
� Blood transfusions: Blood transfusions have long been considered to be a safe and effective way of treating anemia caused by various AIDS/HIV-related complications and medications. Patients with fatigue associated with anemia generally feel better almost immediately after receiving blood transfusions. However, blood transfusions can have drawbacks. A recent study has shown that blood transfusions may increase an HIV-infected person's viral load and may speed up disease progression, although chances of this occurring in patients taking combination antiviral therapy are slim. It is also important to realize that, while transfusions may have an immediate impact on fatigue and anemia, the benefits are usually short-lived and do not treat the underlying cause of the anemia.
Conclusion
Fatigue is a common symptom that has many treatable causes. Although we do not suggest that you can determine all the causes of your own fatigue, you can provide your health care provider with important information that can help him/her identify the causes and recommend an appropriate action or treatment.
Also check these sites:
Unofficial site of Gulf Coast Community Care
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