Fatigue in patients

Impaired action potential due to low ATP/AdP concn. ratio and high external K concn. 

Inhibition of Ca + binding to troponin by H. Inhibition by high P concentration or low ATP/ADP ratio. 

Fatigue accompanies viral infection, sepsis, trauma or major surgery. The cause of this fatigue is not known it may be peripheral, central or both. Studies on biopsy samples of patients with trauma show a reduction in the muscle ATP concentration, which could be responsible for peripheral fatigue, as explained above (Chapter 18 Table 13.3). Central fatigue has been identified in three different clinical conditions, post-polio syndrome, multiple sclerosis and after spinal cord injury, but has not been investigated in other conditions. 

A common complaint to the physician from elderly people is that they become fatigued easily even during mild physical activity such as washing, dressing or cooking. If severe they may require help with these daily tasks. The increasing proportion of elderly people in the population will be as increasing financial burden to social and health care 

Peripheral fatigne in elderly people is likely to be caused by several factors, such as age-related loss of muscle 

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Stone P, Hardy J, Huddart R, A Hern R, Richards M. Fatigue in patients with prostate cancer receiving hormone therapy. Eur J Cancer 2000 36(9) 1134-41. 

May aiso be usefui for the treatment of cognitive impairment, depressive symptoms, and severe fatigue in patients with HiV infection and in cancer patients... 

May be useful to treat fatigue In patients with depression as well as other disorders, such as multiple sclerosis, myotonic dystrophy, HIV/AIDS... 

The Food and Drug Administration approved modafinil in 1998 to treat excessive daytime sleepiness associated with narcolepsy and other sleep disorders. Sadna Kohli, Ph.D., MPH, at the University of Rochester, and colleagues wanted to see if the drug, which is marketed to improve wakefulness, would help with persistent fatigue in patients who had been treated for cancer. 

Majer M, Welberg LAM, Capuron L, Pagnoni G, Raison CL, Miller AH. IFN-alpha-induced motor slowing is associated with increased depression and fatigue in patients with chronic hepatitis C. Brain Behav Lnmun 2008 22(6) 870-80. 

The patient should be advised that despite the relative comfort of the treatment, there may be a post-treatment reaction. These reactions are relatively minor, transient, and self-limited, and generally consist of soreness, aching, and/or fatigue. In patients prone to bruising, or when there are certain other predisposing factors (i.e., medication), ecchymoses can occur. This can also occur if excessive pressure has been used. Generally, all of these side effects will resolve in 24 to 48 hours. 

Other studies have suggested that melatonin, a frequently used integrative medicine, can attenuate weight loss, anorexia and fatigue in patients with cancer. However, these studies were limited by a lack of blinding and absence of placebo controls. The prime purpose of this study was to compare melatonin with placebo for appetite improvement in patients with cancer cachexia. For this a randomised, double-blind, 28-day trial of melatonin 20 mg versus placebo in patients with advanced lung or GI cancer, appetite scores S 4 on a 0-10 scale (10=worst appetite), and history of weight loss S 5%, was performed [45 ]. 

Eikermann M, Koch G, Gerwig M, et al. Muscle force and fatigue in patients with sepsis and multiorgan failure. Intensive Care Med 2006 32 251-259. 

Murciano D, Aubier M, Lecocguic Y, et al. Effects of theophylline on diaphragmatic strength and fatigue in patients with chronic obstructive pulmonary disease. N Engl J Med 1984 311(6) ... 

Disulfiram produces a variety of adverse effects, which commonly include drowsiness, lethargy, and fatigue (Chick 1999). Other more serious adverse effects, such as optic neuritis, peripheral neuropathy, and hepatotoxicity, are rare. Psychiatric effects of disulfiram are also uncommon. They probably occur only at higher dosages of the drug and may result from the inhibition by disulfiram of a variety of enzymes in addition to ALDH. Included among the enzymes inhibited by disulfiram is dopamine P-hydroxylase, inhibition of which increases dopamine levels, which in turn can exacerbate psychotic symptoms in patients with schizophrenia and occasionally may result in psychotic or depressive symptoms in patients without schizophrenia. 

Some patients with mastocytosis report flushing, shortness of breath, palpitations, nausea, diarrhea, hypotension or even syncope [9, 24]. Lethargy and fatigue lasting several hours may follow. Gastrointestinal complaints are common in patients with SM [9, 24]. Abdominal pain is the most frequent symptom, followed by nausea. 

Nesiritide has been shown to improve symptoms of dyspnea and fatigue. In a randomized clinical trial, the safety and efficacy of adding nesiritide to standard care was compared to placebo and nitroglycerin.53 Nesiritide was found to significantly decrease PCWP more than nitroglycerin and placebo over 3 hours. Nesiritide improved patients self-reported... 

Symptoms of bradyarrhythmias include dizziness, fatigue, lightheadedness, syncope, chest pain (in patients with underlying myocardial ischemia), and shortness of breath and other symptoms of heart failure (in patients with underlying left ventricular dysfunction). 

Monitor for adverse effects of 3-blockers—heart rate, blood pressure, fatigue, masking of symptoms of hypoglycemia and/or glucose intolerance (in patients with diabetes), wheezing or shortness of breath (in patients with asthma or chronic obstructive pulmonary disease), etc. 

Sulfasalazine is associated with various adverse effects, most of which are thought to be due to the sulfapyridine component. Common adverse effects that may be dose related include headache, dyspepsia, nausea, vomiting, and fatigue.19 Idiosyncratic effects include bone marrow suppression, reduction in sperm counts in males, hepatitis, and pulmonitis. Hypersensitivity reactions may occur in patients allergic to sulfonamide-containing medications. 

Side effects associated with benzodiazepines in PD patients are similar to those observed in other disorders. Sedation, fatigue, and cognitive impairment are the most commonly reported side effects.49 Benzodiazepines should be avoided in patients with current substance abuse, a history of such, dependence, or sleep apnea. Additionally, caution should be used in older adults because they have more pronounced psychomotor and cognitive effects. 

Consider replacement therapy in patients with a TSH level of greater than 2.5 but less than 10 milliunits/L who have subtle symptoms (e.g., mild fatigue, lethargy, etc.), elevated cholesterol, or positive anti-TPOAbs. 

Androgens are important for general sexual function and libido, but testosterone supplementation is only effective in patients with documented low serum testosterone levels. In patients with hypogonadism, testosterone replacement is the initial treatment of choice, as it corrects decreased libido, fatigue, muscle loss, sleep disturbances, and depressed mood. Improvements in ED may occur, but they should not be expected to occur in all patients.23 The initial trial should be for 3 months. At that time, re-evaluation and the addition of another ED therapy is warranted. Routes of administration include oral, intramuscular, topical patches or gel, and a buccal tablet. 

Bone marrow suppression ZDV Onset Few weeks to months Symptoms Fatigue, risk of T bacterial infections due to neutropenia anemia, neutropenia 1. Advanced HIV 2. High dose ZDV 3. Preexisting anemia or neutropenia 4. Concomitant use of bone marrow suppressants Avoid in patients with high risk for bone marrow suppression avoid other suppressing agents monitor CBC with differential at least every 3 months Switch to another NRTI D/C concomitant bone marrow suppressant, if possible for anemia Identify and treat other causes consider erythropoietin treatment or blood transfusion, if indicated for neutropenia Identify and treat other causes consider filgrastim treatment, if indicated... 

Hypokalemia and hypomagnesemia may cause muscle fatigue or cramps. Serious cardiac arrhythmias may occur, especially in patients receiving digitalis therapy, patients with LV hypertrophy, and those with ischemic heart disease. Low-dose therapy (e.g., 25 mg hydrochlorothiazide or 12.5 mg chlorthalidone daily) rarely causes significant electrolyte disturbances. 

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