VBCR - February 2016, Vol 5, No 1 - Lupus
Alice Goodman

A recent systematic review suggests that taking action in a variety of nonpharmacologic ways can reduce fatigue associated with systemic lupus erythematosus (SLE). The evidence was strongest in favor of aerobic exercise and psychological interventions, although no conclusions about specific types of exercise or psychotherapy can be drawn from the report. Although the studies of nonpharmacologic interventions in SLE are few and heterogeneous, the encouraging news is that there are ways to reduce fatigue.

According to the review, aerobic exercise, including walking, jogging, cycling, swimming, or using Wii Fit, can be recommended on a regular basis to improve fatigue in patients with SLE. Nevertheless, it is difficult to draw conclusions about which specific exercise protocol is the most beneficial, wrote lead author Tasmania del Pino-Sedeño, PhD, Canary Foundation of Health Research (FUNCANIS), Canary Islands, Spain, and coauthors.

"A number of psychological interventions also appeared effective in reducing fatigue in patients with SLE," the researchers stated. These interventions include cognitive-behavior therapy, psychoeducational programs, relaxation, and self-management. The researchers noted that the broad range of psychological interventions makes it difficult to identify the best approach.

Dietary restriction and ultraviolet A light exposure appear to be promising treatments, but it is premature to confirm their efficacy in reducing fatigue. Further studies in larger numbers of patients are needed to evaluate these approaches.

The presentation of SLE is broad and varies in signs and symptoms as well as severity. Due to advances in disease management, patients with SLE are living longer, and the focus is increasingly being drawn to improved health-related quality of life (HRQOL).

Fatigue is a common symptom of SLE, present in up to 90% of patients. Even though fatigue is considered a minor symptom, it can have a major impact on patients' physical, emotional, and cognitive domains and on HRQOL, the authors wrote.

Recommendations for management of fatigue typically combine pharmacologic and nonpharmacologic interventions, but no specific drug has been established as a standard of care. A number of nonpharmacologic therapies are used to treat fatigue, including relaxation, programmed exercise, education and counseling, rehabilitation, and energy conservation. But the actual effect of these interventions on fatigue is not well-studied in patients with SLE.

The authors conducted a MEDLINE search of English-and Spanish-language randomized controlled trials and observational studies that assessed the effectiveness of nonpharmacologic strategies for reducing fatigue in adults with SLE, even if fatigue was not a primary outcome. Comparison groups could be given standard of care, placebo, no treatment, or alternative treatment.

Of 319 potentially relevant reports, 12 studies with a total of 549 patients were selected for inclusion. More than half the studies were randomized controlled trials, 1 was a nonrandomized controlled design, and 4 were prospective observational studies. Five main categories of nonpharmacologic interventions were considered: exercise, behavioral and psychological approaches, diet, acupuncture, and psychotherapy.

Fatigue was the primary outcome of 7 of the trials. A total of 6 different instruments were used to measure fatigue, with 2 studies using more than 1 measurement.

Five studies tested the effects of exercise (aerobic and/or strengthening exercises) on fatigue. Most interventions were fully or partially home-based. Duration of exercise programs ranged from 8 weeks to 8 months, with most taking place 3 times per week for 30 to 60 minutes. In all studies, fatigue decreased significantly with an exercise intervention, with moderate to high effect sizes. Results were not always consistent across the different instruments used to quantify fatigue.

Five different behavioral/psychological interventions were studied, and all studies showed significant reductions in fatigue on at least 1 measure. Interventions included cognitive-behavioral therapy, psychoeducational intervention, relaxation, self-management, and counseling. The number of sessions varied widely.

A small randomized trial looked at a low glycemic index diet and a calorie-restricted diet to reduce fatigue in patients with SLE and to determine if weight loss was of benefit. Both diets significantly reduced fatigue from baseline, with a moderate effect size for a low glycemic diet and a low effect size for the calorie-restricted diet. Both diet groups lost weight compared with baseline.

In addition, in a small study that assessed daily low-dose dermal ultraviolet A radiation, 5 days a week for 3 weeks, fatigue was significantly reduced in patients with SLE.


  1. Del Pino-Sedeño T, Trujillo-Martin MM, Ruiz-Irastorza G, et al. Effectiveness of nonpharmacologic interventions for decreasing fatigue in adults with systemic lupus erythematosus: a systematic review. Arthritis Care Res (Hoboken). 2016;68:141-148.
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