Do rheumatoid arthritis patients have a higher risk for sleep apnea?

Sleep disorders and other medical and socio-demographic factors in systemic scleroderma

We aimed to investigate sleep disorders in patients with systemic scleroderma (SSc) and its relationship with socio-demographic and medical factors and to provide a suitable solution to better control the disease and improve the quality of life in these patients. This cross-sectional study evaluated SSc patients seen at a rheumatology clinic from September 1, 2022, through April 1, 2023.The patients were examined by the main investigator of the project and entered the study after taking the medical history and meeting the criteria of ACR 2013 Classification Criteria. Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS) and STOP-Bang Questionnaire were employed to investigate sleep disorders. A total of 103 patients were included in the study. The average age of the patients was 48.42 ± 12.4 years. PSQI showed lower quality of sleep scores among SSc (68% of patients), which was significantly related to the degree of skin stiffness in patients, telangiectasia, interstitial lung disease (ILD) in computed tomography (CT) scan, patient age, duration of the disease, and pulmonary artery pressure (PAP). STOP-Bang Questionnaire revealed that obstructive sleep apnea (OSA) was significantly associated with telangiectasia, ILD, patient age, disease onset age, disease duration, body mass index and PAP. Insomnia had a statistically significant relationship with telangiectasia, ILD and patient age. Drowsiness during daily activities was not significantly related to any of the individual variables and disease-related variables. Sleep disorders are common in patients with systemic scleroderma. Telangiectasia, ILD and patient age were related to all sleep quality disorders and respiratory apnea and insomnia. Furthermore, the amount of skin involvement significantly causes disturbances in the quality of sleep of patients, where in the group with diffuse skin stiffness, 80% of patients exhibited disturbances in the quality of sleep. Therefore, paying attention to sleep health can be an effective factor in improving the quality of life of patients with SSc.

Heat of the night: sleep disturbance activates inflammatory mechanisms and induces pain in rheumatoid arthritis

Sleep has a homeostatic role in the regulation of the immune system and serves to constrain activation of inflammatory signalling and expression of cellular inflammation. In patients with rheumatoid arthritis (RA), a misaligned inflammatory profile induces a dysregulation of sleep-wake activity, which leads to excessive inflammation and the induction of increased sensitivity to pain. Given that multiple biological mechanisms contribute to sleep disturbances (such as insomnia), and that the central nervous system communicates with the innate immune system via neuroendocrine and neural effector pathways, potential exists to develop prevention opportunities to mitigate the risk of insomnia in RA. Furthermore, understanding these risk mechanisms might inform additional insomnia treatment strategies directed towards steering and reducing the magnitude of the inflammatory response, which together could influence outcomes of pain and disease activity in RA.

Factors That Influence Sleep Disturbance and the Mediating Effects of Depression on Sleep Disturbance in Patients With Rheumatoid Arthritis

Little is known about the nature of relationships between sleep disturbance and influencing factors in rheumatoid arthritis. The purpose of this study was to identify factors that influence sleep disturbance and to evaluate mediating effects of depression on sleep disturbance. A nonexperimental, descriptive, correlational study design was adopted. One hundred patients with rheumatoid arthritis were recruited. Inflammatory status and levels of pain, fatigue, functional disability, depression, and sleep disturbance were measured. The factors that directly influenced sleep disturbance were gender, rheumatoid arthritis duration, serum C-reactive protein level, fatigue, and depression. Depression was found to have mediating effects on the relationships between sleep disturbance and arthritis symptoms. Pain, fatigue, and depression were found to have significant direct or indirect impacts on sleep disturbance. Our findings may improve understanding of sleep disturbance and aid the development of effective nursing management strategies for patients with rheumatoid arthritis suffering from sleep disturbance.

Prevalence of Obstructive Sleep Apnea Is Increased in Patients With Inflammatory Bowel Disease: A Large, Multi-Network Study

Background

Crohn's disease (CD) and ulcerative colitis (UC) involve an inflammatory state where sleep dysregulation is common. Little is known about implications, if any, of inflammatory bowel disease (IBD) on the development of obstructive sleep apnea (OSA). This study aims to investigate if IBD patients are at higher risk for OSA.

Methods

This retrospective multivariate analysis utilized a commercial database named Explorys (IBM Watson). We identified patients from 1/2015 to 1/2020 with UC and CD. Cohorts of these patients with and without OSA were then created and prevalence values were obtained. A multivariate analysis was used to correct for several potential confounding variables.

Results

The overall prevalence of OSA was 7.8% in UC and 7.2% in CD, as compared with a prevalence of 4.3% in non-IBD patients (odds ratio [OR] for UC: 1.9 [95% CI 1.86-1.94, P < .0001], OR for CD: 1.72 [95% CI 1.69-1.76, P < .0001]). In multivariate analysis, age above 65, Caucasian race, male sex, obesity, smoking, hypertension, and diabetes were all independent risk factors for the development of OSA, with obesity being the most significant. After controlling for the listed variables in the multivariate analysis, IBD was an independent risk factor associated with OSA (OR 1.46, 95% CI 1.43-1.48).

Conclusions

In this large population-based study, IBD was independently associated with increased prevalence of OSA. This has implications for screening for OSA in IBD, as well as management of other risk factors for OSA in IBD.

A comparative study between rheumatoid arthritis and osteoarthritis regarding association of insomnia with disease status

Background

Sleep disturbance is closely related to inflammation and pain. Good sleep quality is essential for patients’ psychological and physical states as well as their quality of life. The aim of this study was to detect how insomnia as a major sleep disturbance could add to the disease burden in rheumatoid arthritis (RA) and osteoarthritis patients (OA) and to determine the predictor parameters in each of them in order to orient the rheumatologist to this unnoticed symptom that could adversely affect the patients’ life. This study included: 20 RA patients, 20 primary knee OA patients together with 20 healthy controls. RA disease activity was assessed by the disease activity score (DAS-28). All participants were assessed for sleep disturbances by the Athens Insomnia Scale, quality of life (QoL) using the short form QoL (SF-36 QoL) scale, depression by the Beck depression inventory (BDI), and functional disability by the Health Assessment Questionnaire Disability Index (HAQ-DI). OA patients were assessed by the Knee OA Flare Up Score (KOFUS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Radiological evaluation for RA patients was done by the Simple Erosion Narrowing Score, while the Kellgren and Lawrence (K-L) radiological grading system was used for OA patients.

Results

Insomnia was found in 75% of the studied RA patients, 25% of the studied OA patients and none of the healthy control with significant difference (P < 0.001). Significant correlations of the insomnia scale with the number of tender and swollen joints (r = 0.66, 0.76 respectively and p = 0.001 both), DAS-28 (r = 0.71, P < 0.001), anti-CCP antibodies titre (r = 0.53, p = 0.02) and the BDI (r = 0.65, p = 0.002) among RA patients were found. Correlations among OA patients occurred with morning stiffness duration (r = 0.69, P = 0.001), number of affected joints (r = 0.81, P = 0.001), the BDI scale (r = 0.51, P = 0.02), the WOMAC index (r = 0.57, P = 0.009), the KOFUS score (r = 0.76, p < 0.001) and the K-L score (r = 0.67, P = 0.001). Linear regression analysis indicated that the predictors for insomnia in RA were DAS-28 and the BDI, while in OA were the number of affected joints and the KOFUS score.

Conclusions

Insomnia is a disease burden especially in RA patients being one of the leading causes of depression and is greatly affected by the disease activity. In general the burden of insomnia is much less in OA except in severe cases with markedly affected joints. Rheumatologists should be aware of this disorder that could affect patients’ health, mood, and functional activity.

Prevalence of obstructive sleep apnea among patients with rheumatoid arthritis and its association with age and body mass index: A systematic review and meta-analysis

AIM

The study aims to recognize the prevalence and possible risk factors of obstructive sleep apnea among individuals with rheumatoid arthritis (RA).

METHODS

We searched PubMed, Scopus, EMBASE, and Google scholar for potential studies published before the October 30, 2020. The study characteristics, obstructive sleep apnea (OSA) events, and various types of rheumatic diseases were extracted, and the meta-analysis method was used to pool the estimates.

RESULTS

We identified eight studies with 37 285 patients for this meta-analysis. The overall pooled prevalence of OSA was 29.8% (95% confidence interval [CI] 15.2-46.7; I²  = 99.6%) in the patients with RA. Age was higher in RA patients with OSA but this was not significant. Body mass index (BMI) was significantly associated with OSA in the RA population (standardized mean difference 1.08; P = 0.044). Assessment based on the Berlin Questionnaire^© for Sleep Apnea resulted in a more precise estimate of OSA prevalence with reduced heterogeneity (prevalence 45.3%; 95% CI 37.4-53.3; I²  = 58.8%).

CONCLUSION

Prevalence of OSA among the RA cohort was 29.8% with significant heterogeneity. However, the prevalence was 45.3% when studies were restricted to the OSA diagnosis based on the Berlin questionnaire with very low heterogeneity. Higher BMI is the principal risk factor of OSA development in RA. Hence, controlling BMI could be a preventive strategy for OSA among RA patients.

Ocular Complications of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA), the most common form of sleep-disordered breathing, is characterized by repetitive episodes of paused breathing during sleep, which in turn induces transient nocturnal hypoxia and hypercapnia. The high prevalence of OSA and its associated health consequences place a heavy burden on the healthcare system. In particular, the consequent episodic oxygenic desaturation/reoxygenation series and arousals from sleep in patients with OSA have the potential to trigger oxidative stress, elevated systemic inflammatory responses, and autonomic dysfunction with sympathetic activation. Given these adverse side-effects, OSA is highly correlated to many eye diseases that are common in everyday ophthalmic practices. Some of these ocular consequences are reversible, but they may permanently threaten a patient’s vision if not treated appropriately. Here, this article seeks to review the ocular consequences and potential pathophysiologic associations in patients with OSA. Understanding these OSA-related eye diseases may help clinicians provide comprehensive care to their patients.

Family History of Rheumatic, Autoimmune, and Nonautoimmune Diseases and Risk of Rheumatoid Arthritis

OBJECTIVE

Since comorbidities such as autoimmune diseases may be associated with rheumatoid arthritis (RA) risk, we hypothesized that a family history of these other conditions might also predict RA. Therefore, we aimed to determine the association between family history of 79 comorbidities and RA.

METHODS

This case-control study identified 821 cases of RA in the Mayo Clinic Biobank (positive predictive value 95%) and matched 3 controls to each case based on age, sex, recruitment year, and location. Patients self reported family history and characteristics (adjusted). Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for RA risk according to the presence of family history for each comorbidity, adjusted for body mass index, race, and smoking.

RESULTS

Family history of several conditions was associated with developing RA, including rheumatic autoimmune diseases (ORadj 1.89 [95% CI 1.41-2.52]), pulmonary fibrosis (ORadj 2.12 [95% CI 1.16-3.80]), inflammatory bowel disease (ORadj 1.45 [95% CI 1.05-1.98]), hyper/hypothyroidism (ORadj 1.34 [95% CI 1.10-1.63]), and obstructive sleep apnea (ORadj 1.28 [95% CI 1.05-1.55]). Parkinson's disease and type 2 diabetes mellitus were associated with a statistically decreased risk of RA that did not reach the prespecified significance threshold of P < 0.01 (ORadj 0.70 [95% CI 0.49-0.98] and ORadj 0.81 [95% CI 0.67-0.97], respectively). Analyses among 143 cases of incident RA were similar and also suggested an association with a family history of autism (OR 10.5 [95% CI 2.51-71.3]).

CONCLUSION

Family history of several autoimmune and nonautoimmune comorbidities was associated with increased risk of RA, providing an opportunity to identify novel populations at risk for RA.

Prevalence of obstructive sleep apnea in patients with rheumatoid arthritis

STUDY OBJECTIVES

Although previous studies suggested an increased prevalence of obstructive sleep apnea (OSA) among patients with rheumatoid arthritis (RA), no existing large prospective study has addressed this association using objective measures. This study aims to assess the prevalence of OSA using polysomnography (PSG) in patients with RA and its relationship with RA activity.

METHODS

Patients with RA who presented at the rheumatology clinic at a university hospital from 2017 to 2018 were eligible. In the first stage, data from the Disease Activity Score 28, Berlin questionnaire, and Epworth Sleepiness Scale were obtained, along with personal data and a comprehensive medical history. The second stage involved a case-control study confirming OSA with PSG. OSA was defined as an apnea-hypopnea index (AHI) ≥ 5 events/h, whereas patients with an AHI ≥ 15 events/h were categorized as having moderate-severe OSA.

RESULTS

In total, 199 patients with RA were recruited, 110 patients (55%) underwent PSG, and 5 were excluded. The mean age was 48.93 ± 12.7 years, and the mean body mass index was 31.70 ± 9.74 kg/m²; 94% were female. In total, 67 participants (33.2%) were at high risk for OSA (36 [55.4%] underwent PSG), whereas 132 (66.8%) were at low risk (69 [51.5%] underwent PSG). The estimated prevalence of OSA (AHI ≥ 5 events/h) in the whole population was 58.1%, whereas the prevalence of moderate-to-severe OSA (AHI ≥ 15) was 22.9%.

CONCLUSIONS

This prospective PSG-based study demonstrated that OSA is more common in patients with RA than in the general population, but there appears to be no relationship with disease activity.

Comorbidities As Risk Factors for Rheumatoid Arthritis and Their Accrual After Diagnosis

OBJECTIVE

To determine the prevalence of comorbidities in rheumatoid arthritis (RA), discover which comorbidities might predispose to developing RA, and identify which comorbidities are more likely to develop after RA.

PATIENTS AND METHODS

We performed a case-control study using a single-center biobank, identifying 821 cases of RA (143 incident RA) between January 1, 2009, and February 28, 2018, defined as 2 diagnosis codes plus a disease-modifying antirheumatic drug. We matched each case to 3 controls based on age and sex. Participants self-reported the presence and onset of 74 comorbidities. Logistic regression models adjusted for race, body mass index, education, smoking, and Charlson comorbidity index.

RESULTS

After adjustment for confounders and multiple comparisons, 11 comorbidities were associated with RA, including epilepsy (odds ratio [OR], 2.13; P=.009), obstructive sleep apnea (OR, 1.49; P=.001), and pulmonary fibrosis (OR, 4.63; P<.001), but cancer was not. Inflammatory bowel disease (OR, 3.82; P<.001), type 1 diabetes (OR, 3.07; P=.01), and venous thromboembolism (VTE; OR, 1.80; P<.001) occurred more often before RA diagnosis compared with controls. In contrast, myocardial infarction (OR, 3.09; P<.001) and VTE (OR, 1.84; P<.001) occurred more often after RA diagnosis compared with controls. Analyses restricted to incident RA cases and their matched controls mirrored these results.

CONCLUSION

Inflammatory bowel disease, type 1 diabetes, and VTE might predispose to RA development, whereas cardiovascular disease, VTE, and obstructive sleep apnea can result from RA. These findings have important implications for RA pathogenesis, early detection, and recommended screening.

Frequency of sleep disorders in patients with rheumatoid arthritis

Purpose: To determine the prevalence of common sleep problems among patients with rheumatoid arthritis (RA) and their relationship with the disease activity and quality of life.

Patients and methods: The study sample consisted of 101 patients who attended a rheumatology clinic at a university hospital between October 2015 and May 2016. All subjects were clinically examined and interviewed by physicians using a questionnaire. The collected information included sociodemographic characteristics, the patients’ medical histories, the Disease Activity Score (DAS28), the Berlin questionnaire to assess the risk of obstructive sleep apnea (OSA), the Epworth Sleepiness Scale to assess excessive daytime sleepiness (EDS), the Athens Insomnia Scale to assess insomnia, the International RLS Study Group score to diagnose restless legs syndrome (RLS), and the Health Assessment Questionnaire (HAQ) to assess the quality of life.

Results: The mean age of the participants was 48.7±14.6 years, and 95% of the participants were females. Approximately 60% of the participants were in the remission/low category of disease activity, and the average DAS28 score was 3.3±0.8 years. The prevalence rates of insomnia, EDS, sleep disturbance, risk of OSA, and RLS were 63%, 20%, 20%, 37%, and 63%, respectively. Furthermore, the distribution of sleep disorders was not affected by the disease activity. The association between the HAQ and sleep disorders among the RA patients was not significant.

Conclusion: Sleep disorders are common among RA patients and may require further attention by treating clinicians; nevertheless, these disorders are not associated with disease activity and do not affect the quality of life.

Obstructive sleep apnea and the metabolic syndrome: The road to clinically-meaningful phenotyping, improved prognosis, and personalized treatment

Obstructive sleep apnea (OSA) is an increasingly prevalent sleep disorder characterized by upper airway obstruction during sleep, resulting in breathing pauses, intermittent hypoxia, and fragmented sleep. In parallel, the constellation of adverse health outcomes associated with prolonged obesity, such as insulin resistance, elevated blood pressure, triglycerides, and reduced high-density lipoprotein cholesterol - termed metabolic syndrome -raises the risk of cardiovascular morbidity and mortality, type 2 diabetes, and all-cause mortality. Affecting 35-40% of U.S. adults, risk factors for metabolic syndrome, including obesity, middle age, sedentary behavior, and genetics, share considerable overlap with those for OSA. Thus, it has been difficult to disentangle cause, effect, and whether certain treatments, such as CPAP, can improve these outcomes. In this paper, we provide an update to our 2005 review which explored the association between OSA and metabolic syndrome, highlighting visceral obesity as the common etiological factor of both conditions. This update includes (a) recent data on physiological and biochemical mechanisms, (b) new data in nonobese men and women as well as children and adolescents, (c) insight from the latest treatment studies, (d) the role of aging in understanding clinically-meaningful phenotypes of the disorder, and (e) the potential diagnostic/prognostic utility of biomarkers in identifying OSA patients with the strongest cardiometabolic risk.

Influence of Obstructive Sleep Apnea in the Functional Aspects of Patients With Osteoarthritis

STUDY OBJECTIVES

It has been demonstrated in recent studies that obstructive sleep apnea (OSA) is the most prevalent sleep disorder in patients with osteoarthritis (OA), and thus the current study aimed to investigate the influence of OSA on knee extensor torque, pain, stiffness, and physical function in men with low-grade knee OA.

METHODS

The study included 60 male volunteers, aged 40 to 70 years, allocated into four groups: Group 1 (G1) Control (n = 15): without OA and without OSA; Group 2 (G2) (n = 15): with OA and without OSA; Group 3 (G3) (n = 15): without OA and with OSA; and Group 4 (G4) (n = 15) with OA and with OSA. All volunteers were examined using knee radiographs and polysomnography, responded to the Western Ontario McMaster Osteoarthritis Index (WOMAC) questionnaire, and completed a test on an isokinetic dynamometer to evaluate peak isometric knee extensor torque, both concentric and eccentric (90°/s and 180°/s).

RESULTS

Regarding the data from the WOMAC questionnaire (for pain, stiffness, and physical function), it was observed that G4 showed higher values compared to G1 or G3. For the concentric isometric and isokinetic peak knee extensor torque, lower values were observed in G4 compared to G1 or G3.

CONCLUSIONS

Patients who have knee OA in the early grades, when associated with OSA, have higher changes of the peak extensor torque, pain, stiffness, and physical function, compared with patients who did not have OSA.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov, Identifier: NCT01422967, Title: Changes Of Sleep on the Sensoriomotor and Cytokine In Patients With Osteoarthritis, URL: https://clinicaltrials.gov/ct2/show/NCT01422967.

Risk of Obstructive Sleep Apnea and Its Association with Cardiovascular and Noncardiac Vascular Risk in Patients with Rheumatoid Arthritis: A Population-based Study

OBJECTIVE

To define the incidence of obstructive sleep apnea (OSA) in patients with rheumatoid arthritis (RA) and determine whether OSA diagnosis predicts future cardiovascular disease (CVD) and noncardiac vascular events.

METHODS

Medical information pertaining to RA, OSA, CVD, and vascular diagnoses was extracted from a comprehensive medical record system for a geographically defined population of 813 patients previously diagnosed with RA and 813 age- and sex-matched comparator subjects.

RESULTS

The risk for OSA in persons with RA versus comparators was elevated, although not reaching statistical significance (HR 1.32, 95% CI 0.98-1.77; p = 0.07). Patients with RA were more likely to be diagnosed with OSA if they had traditional risk factors for OSA, including male sex, current smoking status, hypertension, diabetes, dyslipidemia, and increased body mass index. Features of RA disease associated with OSA included large joint swelling and joint surgery. Patients with RA with decreased renal function were also at higher risk of OSA. The increased risk of overall CVD among patients with RA who have OSA was similar to the increased CVD risk associated with OSA in the comparator cohort (interaction p = 0.86). OSA diagnosis was associated with an increased risk of both CVD (HR 1.9, 95% CI 1.08-3.27), and cerebrovascular disease (HR 2.4, 95% CI 1.14-5.26) in patients with RA.

CONCLUSION

Patients with RA may be at increased risk of OSA secondary to both traditional and RA-related risk factors. Diagnosis with OSA predicts future CVD in RA and may provide an opportunity for CVD intervention.

Risk of obstructive sleep apnoea in patients with rheumatoid arthritis: a nationwide population-based retrospective cohort study

OBJECTIVE

Sleep disorders are prevalent medical disorders in patients with rheumatoid arthritis (RA). However, whether patients with RA are at an increased risk of developing obstructive sleep apnoea (OSA) is unclear.

DESIGN

Using population-based retrospective cohort study to examine the risk of OSA in patients with RA.

SETTING

We used claims data of the National Health Insurance Research Database (NHIRD) of Taiwan.

PARTICIPANTS

We identified a RA cohort with 33 418 patients newly diagnosed in 2000-2010 and a randomly selected non-RA comparison cohort with 33 418 individuals frequency matched by sex, age and diagnosis year.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incident OSA was estimated by the end of 2011. The HRs of OSA were calculated using the Cox proportional hazards regression analysis.

RESULTS

The overall incidence rate of OSA was 75% greater in the RA cohort than in the non-RA cohort (3.04 vs 1.73/10 000 person-years, p<0.001), with an adjusted HR (aHR) of 1.75 (95% CI 1.18 to 2.60). Stratified analyses by sex, age group and comorbidity revealed that the incidence rates of OSA associated with RA were higher in all subgroups.

CONCLUSIONS

This population-based retrospective cohort study suggested that patients with RA should be monitored for the risk of developing OSA.

Influence of obstructive sleep apnea syndrome in the fluctuation of the submaximal isometric torque of knee extensors in patients with early-grade osteoarthritis

OBJECTIVE

The aim of this study was to investigate whether obstructive sleep apnea (OSA) alters the fluctuation of submaximal isometric torque of the knee extensors in patients with early-grade osteoarthritis (OA).

METHOD

The study included 60 male volunteers, aged 40 to 70 years, divided into four groups: Group 1 (G1) - Control (n=15): without OA and without OSA; Group 2 (G2) (n=15): with OA and without OSA; Group 3 (G3) (n=15): without OA and with OSA; and Group 4 (G4) (n=15) with OA and with OSA. Five patients underwent maximal isometric contractions of 10 seconds duration each, with the knee at 60° of flexion to determine peak torque at 60°. To evaluate the fluctuation of torque, 5 submaximal isometric contractions (50% of maximum peak torque) of 10 seconds each, which were calculated from the standard deviation of torque and coefficient of variation, were performed.

RESULTS

Significant differences were observed between groups for maximum peak torque, while G4 showed a lower value compared with G1 (p=0.005). Additionally, for the average torque exerted, G4 showed a lower value compared to the G1 (p=0.036). However, no differences were found between the groups for the standard deviation (p=0.844) and the coefficient of variation (p=0.143).

CONCLUSION

The authors concluded that OSA did not change the parameters of the fluctuation of isometric submaximal torque of knee extensors in patients with early-grade OA.

Prevention of cardiovascular disease in rheumatoid arthritis

The increased risk of cardiovascular disease (CVD) in rheumatoid arthritis (RA) has been recognized for many years. However, although the characteristics of CVD and its burden resemble those in diabetes, the focus on cardiovascular (CV) prevention in RA has lagged behind, both in the clinical and research settings. Similar to diabetes, the clinical picture of CVD in RA may be atypical, even asymptomatic. Therefore, a proactive screening for subclinical CVD in RA is warranted. Because of the lack of clinical trials, the ideal CVD prevention (CVP) in RA has not yet been defined. In this article, we focus on challenges and controversies in the CVP in RA (such as thresholds for statin therapy), and propose recommendations based on the current evidence. Due to the significant contribution of non-traditional, RA-related CV risk factors, the CV risk calculators developed for the general population underestimate the true risk in RA. Thus, there is an enormous need to develop adequate CV risk stratification tools and to identify the optimal CVP strategies in RA. While awaiting results from randomized controlled trials in RA, clinicians are largely dependent on the use of common sense, and extrapolation of data from studies on other patient populations. The CVP in RA should be based on an individualized evaluation of a broad spectrum of risk factors, and include: 1) reduction of inflammation, preferably with drugs decreasing CV risk, 2) management of factors associated with increased CV risk (e.g., smoking, hypertension, hyperglycemia, dyslipidemia, kidney disease, depression, periodontitis, hypothyroidism, vitamin D deficiency and sleep apnea), and promotion of healthy life style (smoking cessation, healthy diet, adjusted physical activity, stress management, weight control), 3) aspirin and influenza and pneumococcus vaccines according to current guidelines, and 4) limiting use of drugs that increase CV risk. Rheumatologists should take responsibility for the education of health care providers and RA patients regarding CVP in RA. It is immensely important to incorporate CV outcomes in testing of anti-rheumatic drugs.

Prevalence and related factors for high-risk of obstructive sleep apnea in a large korean population: results of a questionnaire-based study

Background and Purpose

A population-based door-to-door study of cross-sectional methods for assessing the prevalence and factors related to a high risk of obstructive sleep apnea (OSA) was conducted using the Korean version of the Berlin Questionnaire (K-BQ).

Methods

Pooled data collected from Community Health Surveys by the Korea Center for Disease Control and Prevention were analyzed. Of 8,140 respondents from the population, 7,955 were finally included in this study.

Results

Of the 7,955 included subjects, 15.7% of the men and 9.8% of the women were at high risk of OSA. Significant differences were found in the following factors between the subjects with a high risk of OSA: gender, age, marital status, educational level, occupation, and presence of smoking, harmful alcohol use, and chronic diseases. Male sex, harmful alcohol use, and the presence of chronic diseases were identified as factors independently associated with a high risk of OSA.

Conclusions

This is the first study to confirm the usefulness of the K-BQ to study the prevalence of OSA in the Korean general population. The findings demonstrate that harmful alcohol use and chronic diseases are very common characteristics among those with a high risk of OSA.

Restless legs syndrome as a comorbidity in rheumatoid arthritis

Rheumatoid arthritis (RA) is a multisystem disease with a complex immunologic pathophysiology. Likewise, sleep disorders can involve a complicated interplay between the neurologic pathways, immune system, and respiratory system. Recent studies have shown an elevated prevalence of sleep abnormalities in connective tissue disorders compared to the general population. Restless legs syndrome (RLS) may be present in up to 30% of RA patients. These findings may be related to cytokine release and other immunomodulatory responses. TNF- α levels relate to sleep physiology and anti-TNF- α therapy may improve sleep patterns. Most of the patients with this disorder can distinguish their RLS sensations from their arthritic symptoms. RLS is a common comorbidity seen with RA, and prompt recognition and treatment can improve patient quality of life.

Improved Sleep Efficiency after Anti-Tumor Necrosis Factor α Therapy in Rheumatoid Arthritis Patients

BACKGROUND

Poor sleep health is increasingly recognized as contributing to decreased quality of life, increased morbidity/mortality and heightened pain perception. Our purpose in this study was to observe the effect on sleep parameters, specifically sleep efficiency, in rheumatoid arthritis (RA) patients treated with anti-tumor necrosis factor alpha (anti-TNF-α) therapy.

METHODS

This was a prospective observational study of RA patients with hypersomnolence/poor sleep quality as defined by the Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI). Study patients underwent overnight polysomnograms and completed questionnaire instruments assessing sleep prior to starting anti-TNF-α therapy and again after being established on therapy. The questionnaire included the ESS, PSQI, the Berlin instrument for assessment of obstructive sleep apnea (OSA) risk, restless legs syndrome (RLS) diagnostic criteria, and measures of disease activity/impact.

RESULTS

A total of 12 RA patients met inclusion criteria, of which 10 initiated anti-TNF-α therapy and underwent repeat polysomnograms and questionnaire studies approximately 2 months later. Polysomnographic criteria for OSA were met by 60% of patients. Following anti-TNF-α therapy initiation, significant improvements were observed by polysomnography (PSG) for sleep efficiency, increasing from 73.9% (SD 13.5) to 85.4% (SD 9.6) (p = 0.031), and 'awakening after sleep onset' time, decreasing from 84.1 minutes (SD 43.2) to 50.7 minutes (SD 36.5) (p = 0.048). Questionnaire instrument improvements were apparent in pain, fatigue, modified Health Assessment Questionnaire (mHAQ), and Rheumatoid Arthritis Disease Activity Index (RADAI) scores.

CONCLUSIONS

Improved sleep efficiency and 'awakening after sleep onset' time were observed in RA patients treated with anti-TNF-α therapy.

Pain-related diseases and sleep disorders

Pain and sleep share mutual relations under the influence of cognitive and neuroendocrine changes. Sleep is an important homeostatic feature and, when impaired, contributes to the development or worsening of pain-related diseases. The aim of the present review is to provide a panoramic view for the generalist physician on sleep disorders that occur in pain-related diseases within the field of Internal Medicine, such as rheumatic diseases, acute coronary syndrome, digestive diseases, cancer, and headache.

Do sleepy rheumatoid arthritis patients have a sleep disorder?

OBJECTIVE

Subjective reports of sleep dysfunction are common in people with rheumatoid arthritis (RA). Our objective was to determine whether excess sleepiness in RA is associated with polysomnographic (PSG) abnormalities.

METHODS

Twelve RA participants with abnormal sleep scores were identified in clinic and age/gender matched to RA participants with normal Epworth Sleepiness Scale (ESS) scores. A total of 25 participants were recruited. All participants underwent overnight PSG studies with measurement of apnoea-hypopnoea indexes (AHI). Questionnaire instruments, including the ESS, Berlin questionnaire for sleep apnoea risk, visual analogue scale for fatigue, modified Health Assessment Questionnaire (mHAQ) and the Center for Epidemiologic Studies - Depression (CES-D) score, along with RA assessments, were reapplied on the PSG study night.

RESULTS

Seven men and 18 women participated. Ten participants had abnormal ESS scores and 15 had normal ESS scores on the PSG night. PSG data revealed that 68% of patients had abnormal AHI (≥ 5). Abnormal ESS (> 10) had an 80% positive predictive value (PPV) for abnormal AHI; the negative predictive value (NPV) of normal ESS was 40%. By contrast, high-risk categorization for obstructive sleep apnoea (OSA) by the Berlin questionnaire had a PPV of 77.8%, and for low-risk status, an NPV of 37.5%.

CONCLUSIONS

In the present study population, there was a high prevalence of abnormal AHI consistent with OSA. An abnormal ESS had high positive predictive value for an abnormal AHI.

Sleep duration pattern and chronic diseases in Brazilian adults (ISACAMP, 2008/09)

OBJECTIVE

The aim of the present study was to assess sleep patterns in the adult population of the city of Campinas (Brazil) according to socioeconomic/demographic variables, chronic diseases, and symptoms.

METHODS

A population-based cross-sectional study was conducted using data from the Campinas Health Survey (ISACAMP) carried out in 2008 and 2009. A total of 2637 individuals aged 18 years or older (obtained from a probabilistic sample) were analyzed. Associations between sleep pattern and the independent variables were determined using the chi-square test. Multinomial logistic regression models were used to adjust for confounders.

RESULTS

The prevalence of six or fewer hours of sleep was greater among individuals aged 40 years or older and among divorced or single individuals. The sleep pattern of nine or more hours was more prevalent among those with less than 40 years of age, among those who were divorced, or single, among those with a lower level of schooling, those who did not work and housewives. Both short and long sleep patterns were more prevalent among individuals with heart disease, vascular problems, rheumatism/arthritis/arthrosis, osteoporosis, or emotional problems. The prevalence of the short sleep duration was greater among individuals with back problems and those with three or more health conditions. A strong association was found between sleep duration and sleep quality.

CONCLUSIONS

Socio-demographic factors and health diseases were associated to sleep duration. This issue should be considered in health promotion strategies.

Sleep problems and fatigue in chronically ill women

The objective of this study was to understand the quality and quantity of sleep in women with multiple sclerosis (MS) or rheumatoid arthritis (RA), who also had young children, and how their sleep behaviors were associated with their fatigue. A cross-sectional sample of mothers with MS and RA and a well comparison group completed mailed surveys. Participants included 103 mothers with MS, 68 mothers with RA, and 91 well mothers. Mothers answered questions about their sleep, fatigue, pain, and depression. Women with chronic illnesses reported more problems going to sleep than did well women, with pain, depression, or both as significant covariates. Women with chronic illnesses reported that their sleep was interrupted less often by their children than did well women. Sleep quality and quantity were worse for women with RA who were experiencing a flare. Mothers with chronic illnesses experienced more sleep problems, which was associated with their pain and depression.

Components of sleep quality and sleep fragmentation in rheumatoid arthritis and osteoarthritis

OBJECTIVES

Poor sleep is increasingly recognized as contributing to a decreased quality of life, increased morbidity/mortality and heightened pain perception. The purpose of the present study was to assess components of sleep quality and self-identified contributors to sleep fragmentation in rheumatoid arthritis (RA) and osteoarthritis (OA) patient populations.

METHODS

Consecutive RA and OA clinic patients were invited to participate in a self-administered questionnaire study which included the validated multi-domain Pittsburgh Sleep Quality Index (PSQI), visual analogue scales for pain, fatigue, global functioning, modified Health Assessment Questionnaire (mHAQ), stress scores, the Centre for Epidemiologic Studies-Depression (CES-D) score, the 36-item short form (SF-36) quality of life measure, the Rheumatoid Arthritis Disease Activity Index (RADAI), the Epworth Sleepiness Scale (ESS), Berlin score for obstructive sleep apnoea (OSA) risk and the International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria.

RESULTS

The study population included 145 RA and 78 OA patients. PSQI global scores were >5 in 62% of RA and 67% of OA patients. Multivariate analysis identified global functioning and the CES-D to be independent predictors for higher global PSQI scores in RA patients, whereas in OA patients predictors were the mHAQ and SF-36 mental component summary. Abnormalities in subjective sleep assessment, sleep latency, sleep duration, sleep efficiency, daytime dysfunction and increased sleep-aid medication use were observed in both populations. The most common abnormality reported by both RA and OA patients was increased sleep fragmentation. The most frequent self-identified cause for sleep disturbance was 'need to use the washroom' by 51% of RA and 49% of OA patients, and, second most common, 'pain' was identified as a cause for awakening by 33% of RA and 45% of OA patients.

CONCLUSIONS

A high prevalence of abnormal sleep quality in both RA and OA patient populations was observed. The most common abnormality was sleep fragmentation, with an increased sleep disturbance score. 'Need to use the washroom' and 'pain' were the most common self-identified reasons for awakening from sleep. A review of sleep hygiene, optimization of urological status, and rheumatological disease symptomatic control may prove beneficial in terms of sleep health.

Depression in patients with rheumatoid arthritis: description, causes and mechanisms

Two sets of contributory factors to depression among patients with rheumatoid arthritis (RA) are generally examined - the social context of the individual and the biologic disease state of that person's RA. This article will review the evidence for both. RA affects patients both physically and psychologically. Comorbid depression is common with RA and leads to worse health outcomes. Low socioeconomic status, gender, age, race/ethnicity, functional limitation, pain and poor clinical status have all been linked to depression among persons with RA. Systemic inflammation may also be associated with, cause, or contribute to depression in RA. Understanding the socioeconomic factors, individual patient characteristics and biologic causes of depression in RA can lead to a more comprehensive paradigm for targeting interventions to eliminate depression in RA.

Prevalence and correlates of sleep disturbance in systemic sclerosis--results from the UCLA scleroderma quality of life study

OBJECTIVE

Rheumatologic disorders are associated with sleep disturbances. This study examines sleep disturbance correlates in patients with SSc.

METHODS

Participants are 180 SSc patients in an observational study. At baseline, patients completed the Medical Outcomes Study Sleep measure (MOS-Sleep scale). In addition, patients were administered other patient-reported outcome (PRO) measures including the 36-item short form (SF-36), HAQ disability index (HAQ-DI), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-Fatigue), Center for Epidemiologic Studies Depression (CESD) scale and a University of California at Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Questionnaire (UCLA SCTC GIT 2.0). Descriptive statistics were assessed for six scales of MOS-Sleep and the 9-item sleep problem index (SLP-9; a composite index). We computed Spearman's rank-order correlations between the MOS-Sleep scales and the HAQ-DI, FACIT-Fatigue, CESD, SSc-SCTC GIT 2.0 and SF-36 scales. In addition, we developed a regression model to assess predictors of SLP-9 scores. Covariates included demographics, physician variables of disease severity and patient-reported variables of worsening symptoms and the PRO measures.

RESULTS

SSc patients reported a mean (s.d.) of 7.1 (1.73) h of sleep a night. Patients reported worse scores on four of six scales (except for snoring and sleep quantity) compared with the US general population (P < 0.001). SLP-9 was correlated with worsening pain and dyspnoea over the past 1 month, reflux scale of the UCLA SCTC GIT 2.0, CESD and FACIT-Fatigue (ρ 0.26-0.56). In the stepwise multivariate regression model, the CESD, worsening dyspnoea and reflux scale were significantly associated with SLP-9 index.

CONCLUSION

Sleep disturbances are common in SSc and are associated with worsening dyspnoea, depressed mood and severity of reflux symptoms.