Managing Fatigue in Your Patients With MS

Andrew N. Wilner, MD


June 20, 2016

Andrew N. Wilner, MD: This is Dr Andrew Wilner, reporting for Medscape. Today I have the pleasure of interviewing Dr John Carter, Associate Professor at the Mayo Clinic, and a specialist in multiple sclerosis (MS).

Dr Carter, I understand that you'll be leading a course at this year's American Academy of Neurology meeting regarding the topic of fatigue and MS. Is fatigue a big problem for the management of people with MS?

John Carter, MD: Actually, I'll be leading a symptomatic therapy course. We'll be covering several areas of MS symptom management that are important for neurologists to be aware of, including management of MS fatigue, sleep disorders, spasticity, bladder and bowel dysfunction, and gait difficulties.

In terms of the management of MS fatigue, this is an interesting area that has received a lot of research. There are some different theories about why MS patients become fatigued. These include autonomic abnormalities that MS patients may experience that might predispose them to such symptoms as orthostatic lightheadedness and other difficulties.

Another leading theory is that the MS inflammatory process itself is relevant in terms of the inflammatory infiltrates and cytokines, such as gamma-interferon, that could also be involved in fatigue.

Finally, another theory that I think is quite interesting is functional MRI studies have shown that MS patients have to activate larger areas of their cortex in order to perform tasks that normal individuals would be able to perform with much greater efficiency. That theory suggests that just the increased cognitive work of this reorganization and activation of larger areas of the cortex might be involved in fatigue.

Dr Wilner: So when I'm in the clinic, 45 minutes behind schedule, and I have an MS patient who's complaining, "I'm just tired all the time," from a practical point of view, what should I do?

Dr Carter: The first question I ask a patient who has that complaint is whether they awaken feeling tired—whether they have restorative sleep or not. MS fatigue has a diurnal pattern. Most patients with MS who are fatigued and do not have a coexisting sleep disorder will usually wake up feeling well rested. They will have their maximum energy in the morning, and then later in the afternoon, they'll complain that they suddenly lose their energy. They often use the description, "like somebody pulled a plug," and all of a sudden they become very fatigued.

So when I hear an MS patient saying that they're tired all the time and wake up feeling tired, I immediately begin to suspect a sleep disorder. There have been a number of publications looking at sequential or selected clinic populations that have shown a much higher incidence of sleep disorders than one would expect from that demographic.

Dr Wilner: I think that's also true in epilepsy, in that, of course, not getting enough sleep can provoke seizures.

Dr Carter: Right.

Dr Wilner: It may be that functional status in MS patients would also be adversely affected if the patient doesn't get enough sleep.

Dr Carter: Right. So before I start embarking on different pharmacologic therapies for MS fatigue that have variable evidence for their efficacy, I start out with a question about sleep and pursue any sleep disorders that I might suspect on the basis of the history. Once I've ruled that possibility out, then we talk a little bit more about both pharmacologic and nonpharmacologic therapy.

For nonpharmacologic therapy, I think a graded aerobic exercise program is extremely important. Also, many patients prefer to take a nap strategically in the afternoon, as opposed to taking a stimulant medication. Simple measures such as those can help a great deal with fatigue management.

If you are going to use pharmacotherapy, we have several medications which are not US Food and Drug Administration (FDA)-approved for MS fatigue, but which nonetheless have evidence for efficacy. This includes such medications as amantadine, modafinil, [and] armodafinil; others, such as Ritalin (methylphenidate); and things like that. But I'm also careful as I move up the ladder of escalating therapy with stimulants, because of the obvious potential risks of using those.

Dr Wilner: Would an increase in fatigue be a reason to reimage a patient or reassess them regarding disease exacerbation?

Dr Carter: Certainly, that's a very good question. Some patients will say during an MS exacerbation that they have much more fatigue, so at times that may be not only a symptom of exacerbation but part of the symptom complex. In that case, treating their exacerbation may be all that you need to do.

The other issue to question patients about is the effect of their therapies on fatigue. For example, some patients who are on injectable beta-interferon complain of fatigue as a result of their therapy. That's another wrinkle in that whole management question. And other medications, such as baclofen and similar things that we commonly use, may cause fatigue and drowsiness.

Dr Wilner: Dr Carter, I want to thank you for sharing your wealth of experience with patients with MS, and I look forward to learning even more at your course. Thanks very much.

Dr Carter: Thank you.


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