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.
Nutritional status can be measured in several ways. Regular weighing is a rough measure. There are also blood tests of nutritional markers such as serum albumin, potassium and other important vitamins and minerals (see our lesson on Understanding Your Chem-Screen Test). Newer measures of body tissue composition include Bioelectrical Impedance Analysis (BIA) and a test called DEXA (measures bone density). Energy is mainly stored in muscle tissue which, when measured, is known as lean body mass.
Dietary changes can help improve nutritional status. Protein, fatty acids and carnitine are thought to be important dietary elements, and insufficient amounts can contribute to muscle fatigue. 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. Working with an HIV-experienced nutritionist can produce an individualized nutrition plan to help address these deficiencies and combat fatigue.
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 doctor. 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.
Other 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." Along with many other potential ill effects, fatigue is an inevitable consequence of this kind of disruption of normal sleep patterns.
Medical Treatments for Fatigue
Depending on the cause, there are several medical interventions commonly used to fight fatigue:
Hormonal/Steroid therapy
Hormonal therapy – using pharmaceutical compounds that mimic naturally occurring hormones – continues to show 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, researchers have already reported promising results.
Testosterone: Testosterone therapy has been used, both in medical practice and clinical trials, 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: Testosterone is a naturally occurring anabolic steroid. Anabolic means it helps 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 under study, in both men and women, include nandrolone (Deca Durabolin) and oxandrolone (Oxandrin). Preliminary study results have been encouraging, but researchers currently remain uncertain as to the best use of anabolic steroids in HIV. Anabolic steroids, especially oral compounds, can cause liver disease and should be used with caution. Moreover, like testosterone replacement therapy, anabolic steroids can cause virilization in women (development of 'masculine traits' such as thickened facial hair and voice deepening).
Growth Hormone: Human growth hormone (Serostim) is another anabolic agent. 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 as determined by treadmill tests. 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 Adderall, and Dexedrine are among the drugs being tried. However, these drugs contain "speed" -- amphetamines, in most cases -- which means that they are potentially addictive.
Modafinil (Provigil) is a non-addictive stimulant used to treat narcolepsy, a neurological disorder marked by uncontrollable attacks of daytime sleepiness. It is currently being studied as an anti-fatigue treatment for HIV-positive people. Like other psycho-stimulants, modafinil is processed by the liver, which means possible drug interactions with anti-HIV medications.
Treating infections
Any time an infection is present, the body draws upon various energy stores (such as fat and muscle) to fuel itself. When energy stores are depleted and not replaced, energy is thrown off. For example, 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, causing fatigue.
HIV infection, opportunistic infections, and various other AIDS-related complications (such as lymphoma and Kaposi's sarcoma) 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. As mentioned in the previous sections, 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.
Researchers are also looking at structured treatment interruptions, or drug holidays, to see if temporarily stopping therapy will help control side effects, including anemia. It is still not known whether, or how many times, one can stop and start antiviral treatments without causing problems, such as drug resistance.
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 (amount of virus in the blood) 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 anemia.
Erythropoietin
Procrit (recombinant erythropoietin) is a manufactured version of naturally occurring erythropoietin, which is produced by the kidneys. Erythropoietin helps stimulate bone marrow production of red blood cells, thus increasing hemoglobin levels and alleviating symptoms such as fatigue that are associated with anemia. Procrit is manufactured by recombinant DNA technology and has the same biological effects as naturally occurring erythropoietin. The Food and Drug Administration has approved the drug for the treatment of anemia in AZT-treated HIV-infected individuals.
Procrit can be given once, twice, or three times a week. It is given by injection, either directly under the skin or through an intravenous (IV) line. People taking Procrit may give themselves injections or have a friend or family member do it for them. A doctor or nurse can teach patients how to give themselves injections safely and easily. The drug is usually taken for a minimum of eight weeks and it may take between four and six weeks for results to be seen.
Procrit is most useful in anemic patients who have relatively low erythropoietin levels in their blood. A normal erythropoietin level in a non-anemic person is between 5 and 24 micro units per milliliter of blood (mU/mL). When anemia does occur, erythropoietin levels increase sharply, sometimes to levels in the thousands. Clinical trials have established that an HIV-infected person with a level of erythropoietin less than 500 mU/ml who is also taking a standard dose of AZT (600 mg/day) will be more likely to benefit from taking the Procrit than someone with higher levels of erythropoietin. Clinical trials have also demonstrated that patients who received Procrit required fewer blood transfusions, had higher hematocrit levels, and generally felt more energetic and were less fatigued than patients who received placebo. Any adverse effects were believed to be related to the disease progression of AIDS, not to the treatment with Procrit.
Alternative Treatments for Fatigue
While there have been many anecdotal reports suggesting alternative, non-pharmaceutical treatments are effective for alleviating fatigue, very few well-designed clinical trials have been conducted to determine whether they are safe or effective. Another problem is that it is unusual for health insurance programs to pay for alternative treatments, thus placing financial burden on the consumer.
Suggested alternative therapies for fatigue include: yohimbine and ginseng, both natural stimulants; carnitine, which mimics a muscle-building amino acid made by the body; and DHEA, a synthetic version of a naturally occurring hormone that triggers testosterone production. Its important to note that supplements contain Ma Huang (a Chinese herb) -- found in ephedra alkaloid, Mormon tea, and herbal ecstasy, to name a few -- has been classified as "dangerous" by the U.S. Food and Drug Administration (FDA). It can cause increases in blood pressure and irregular heartbeat.
Alternative treatments should be used carefully, considering that little is known about their potential short-term or long-term side effects. Moreover, alternative treatments may cover-up or mask an underlying problem that is causing the fatigue.
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