Up to 85% of patients with primary biliary cholangitis (PBC) experience fatigue during the course of the disease1

  • Patients are reluctant to complain about fatigue to their physicians, creating a discrepancy between self-assessed and verbally reported fatigue2
  • Only 21% of patients present with fatigue at diagnosis3
  • Among the PBC population, women experience significantly greater fatigue than case-matched men4
  • Fatigue affects patients with PBC regardless of cholestasis severity or stage of disease, and may not be improved with treatment or liver transplant5,6
    • Fatigue impairs quality of life, interferes with daily activities and, without intervention, may lead to depression1,7,8

It is essential to identify causes of fatigue beyond PBC.9

  • No specific interventions have been found to reverse fatigue caused by PBC6,9
  • Though fatigue caused by PBC may not be treatable, associated causes of fatigue should be actively excluded—or identified and treated6,9
RULE OUT/ADDRESS Associated causes of fatigue (disease or medication) should be actively excluded or addressed:

  • Anemia5
  • Depression5
  • Sleep disorder5
  • Pruritus, which can cause insomnia5
  • Hypothyroidism5
    • Up to 20% of patients with PBC suffer from untreated hypothyroidism, which can cause fatigue10
  • Medications that can cause or contribute to fatigue (eg, excessive antihypertensive medication or antihistamines)9
CONSIDER GUIDELINES AND RECOMMENDATIONS Treat any identified associated causes of fatigue9 and, for general fatigue, guidelines and recommendations include

  • Lifestyle interventions, such as exercise and rest11
  • Maintaining regular physical activity12,13
  • Modafinil (100-200 mg) or methotrexate for patients with severe fatigue11,14-16

Supportive clinical care is recommended to improve patients’ capacities to cope with fatigue.9

References:  1. Huet P-M, Deslauriers J, Tran A, Faucher C, Charbonneau J. Impact of fatigue on the quality of life of patients with primary biliary cirrhosis. Am J Gastroenterol. 2000;95(3):760-767. doi:10.1111/j.1572-0241.2000.01857.x.  2. Al-Harthy N, Kumagi T, Coltescu C, Hirschfield GM. The specificity of fatigue in primary biliary cirrhosis: evaluation of a large clinic practice. Hepatology. 2010;52(2):562-570. doi:10.1002/hep.23683.  3. Prince M, Chetwynd A, Newman W, Metcalf JV, James OFW. Survival and symptom progression in a geographically based cohort of patients with primary biliary cirrhosis: follow-up for up to 28 years. Gastroenterology. 2002;123(4):1044-1051. doi:10.1053/gast.2002.36027.  4. Carbone M, Mells G, Pells G, et al. Sex and age are determinants of the clinical phenotype of primary biliary cirrhosis and response to ursodeoxycholic acid. Gastroenterology. 2013;144(3):560-569. doi:10.1053/j.gastro.2012.12.005.  5. Lindor KD, Gershwin ME, Poupon R, Kaplan M, Bergasa NV, Heathcote EJ. Primary biliary cirrhosis. Hepatology. 2009;50(1):291-308. doi:10.1002/hep.22906. (AASLD guidelines) 6. Hohenester S, Oude-Elferink RPJ, Beuers U. Primary biliary cirrhosis. Semin Immunopathol. 2009;31(3):283-307. doi:10.1007/s00281-009-0164-5. 7. Witt-Sullivan H, Heathcote J, Cauch K, et al. The demography of primary biliary cirrhosis in Ontario, Canada. Hepatology. 1990;12(1):98-105. doi:10.1002/hep.1840120116. 8. Cauch-Dudek K, Abbey S, Stewart DE, Heathcote EJ. Fatigue in primary biliary cirrhosis. Gut. 1998;43(5):705-710. doi:10.1136/gut.43.5.705.  9. European Association for the Study of the Liver. EASL clinical practice guidelines: management of cholestatic liver diseases. J Hepatol. 2009;51(2):237-267. doi:10.1016/j.jhep.2009.04.009.   10. Elta GH, Sepersky RA, Goldberg MJ, Connors CM, Miller KB, Kaplan MM. Increased incidence of hypothyroidism in primary biliary cirrhosis. Dig Dis Sci. 1983;28(11):971-975.  11. Bach N, Odin JA. Primary biliary cirrhosis. In: Ahmad J, Friedman SL, Dancygier H, eds. Mount Sinai Expert Guides: Hepatology. West Sussex, England: John Wiley & Sons, Ltd; 2014;151-159.  12. Cook NF, Boore JRP. Managing patients suffering from acute and chronic fatigue. Br J Nurs. 1997;6(14):811-815. doi:10.12968/bjon.1997.6.14.811.  13. Graydon JE, Bubela N, Irvine D, Vincent L. Fatigue-reducing strategies used by patients receiving treatment for cancer. Cancer Nurs. 1995;18(1):23-28. doi: 10.1097/00002820-199502000-00004.  14. J Babatin MA, Sanai FM, Swain MG. Methotrexate therapy for the symptomatic treatment of primary biliary cirrhosis patients, who are biochemical incomplete responders to ursodeoxycholic acid therapy. Aliment Pharmacol Ther. 2006;24(5):813-820. doi:10.1111/j.1365-2036.2006.03048.x.  15. Jones DEJ. Fatigue in cholestatic liver disease: is it all in the mind? J Hepatol. 2007;46(6):992-994. doi:10.1016/j.jhep.2007.03.006.  16. Gan SI, de Jongh M, Kaplan MM. Modafinil in the treatment of debilitating fatigue in primary biliary cirrhosis: a clinical experience. Dig Dis Sci. 2009;54(10):2242-2246. doi:10.1007/s10620-008-0613-3.