How common are sleep disorders in patients with rheumatoid arthritis (RA)? And to what extent are they related to factors such as disease activity, pain intensity or antirheumatic therapy? These questions were the focus of a survey of almost 100 outpatients at the Kaiser-Franz-Josef-Spital Social Medicine Center in Vienna. The results suggest that more attention should be paid to the issue.
Studies have shown that up to 70% of RA patients suffer from sleep disorders, some of which are associated with higher disease activity. Sleep disorders associated with chronic pain are associated with an increased risk of depressive symptoms, which in turn can exacerbate sleep disorders. Subjective patient data on sleep disorders are supported by polysomnographic examinations. Doctors should be aware of this problem - also because there are indications that certain biologics such as Abatacept can favorably influence some aspects of sleep quality.
As part of the study presented here, 95 patients from the rheumatism outpatient clinic of the Social Medical Centre at the Kaiser-Franz-Josef-Spital in Vienna were interviewed. The following parameters were collected as part of routine controls using questionnaires or validated instruments:
Patients of working age between 18 and 65 years had been suffering from RA for about nine years on average. 80% of them received disease-modifying antirheumatic drugs (DMARDs). 21.4 % were functionally impaired. The median pain intensity was 3.0 on a VAS ranging from 0-10. The majority of patients never took painkillers (67.0%) or sleeping pills (83.5%) to sleep better.
Overall, the patients felt rested and well-rested in the morning. However, 56.8% reported insufficient sleep duration, averaging 6.5 hours per night over the last four weeks. Patients with moderate to high disease activity slept significantly less at night (6.0 hours) than patients with low disease activity (6.7 hours) (p=0.009). However, the proportion of patients with high, moderate or low disease activity or in remission was comparable among patients with optimal and non-optimal sleep duration. With the exception of sleep duration, no sleep parameter was clearly associated with disease activity.
The pain intensity was different: Patients with insufficient sleep duration had significantly stronger pain with a median VAS value of 3.75 than patients with optimal sleep duration with a value of 2.5 (p=0.003). With 30.2 % vs. 7.3 %, they also showed more frequent functional impairments (p=0.006). Compared to patients with optimal sleep duration, they received significantly fewer DMARDs (77.2 % vs. 92.7 %) or non-steroidal anti-inflammatory drugs (7.4 % versus 24.4 %). The inflammation markers and the duration of the disease were not associated with sleep.
One of the limitations of this study is that it does not permit any causal or generalizable conclusions due to its design and the relatively small number of cases. However, their results suggest that more attention should be paid to the relationship between pain and sleep disorders in patients with RA. The authors of the publication encourage the regular collection of pain and sleep parameters as part of the clinical examination. However, this would only make sense if it also had therapeutic consequences.
There are currently no consensus recommendations or evidence-based algorithms for the pharmacotherapy of sleep disorders in RA. However, according to meta-analysis data, non-drug procedures including physiotherapy, meditation and sleep deprivation are also associated with significant improvements in sleep quality. Future long-term studies should investigate the extent to which measures to improve night sleep can contribute to reducing depression, pain and functional impairment in RA patients.
Source:
Grabovac I, Haider S, Berner C et al. Sleep Quality in Patients with Rheumatoid Arthritis and Associations with Pain, Disability, Disease Duration, and Activity. J Clin Med 2018; 7: 336