Sleep disorders and rheumatic diseases reinforce each other
In people with rheumatic diseases, lack of sleep can increase systemic inflammation and pain sensitivity and exacerbate the consequences of an already overactive immune system.
Sleep disorders and rheumatic diseases
- Good sleep is crucial for the immune function, and sleep deprivation is associated with systemic inflammation.
- Sleep disturbances also increase the pain response, e.g. in rheumatoid arthritis.
- This is a vicious cycle that needs to be taken into account in treatment, because rheumatoid arthritis and chronic pain often lead to sleep problems.
Sleep disturbances activate inflammatory mechanisms and trigger pain in RA
Disturbed sleep affects almost all major chronic diseases, including cardiovascular, metabolic and autoimmune diseases, such as rheumatoid arthritis (RA).
For being so prevalent, sleep deprivation still receives comparatively little attention. Due to high stress levels, light-emitting electronic devices, work hours, alcohol and caffeine consumption, and many other factors, more and more people are not getting the recommended minimum amount of sleep. According to CDC statistics, in 2020, one in three (33%) people in the general population slept less than 7 hours.1 On average, people slept only 5.5 h per night.2,3
The close link between sleep and the immune system is now well documented. Good sleep is critical for immune homeostasis: it serves to limit the activation of inflammatory signals and the expression of cellular inflammation.5 Sleep deprivation, on the other hand, is associated with signs of systemic inflammation, such as increased blood levels of tumour necrosis factor and interleukin-6.6
In RA patients, a shifted inflammatory profile leads to dysregulation of sleep-wake activity, which in turn leads to excessive inflammation and increased pain sensitivity.5
Mediated by the increase in inflammatory activity, sleep disturbances can also increase pain sensitivity. In patients with RA, sleep loss has been described to trigger increased pain responses and arthritis-related joint pain.5
Vicious cycle: Inflammation leads to sleep disturbances, which increase disease activity
Sleep-related disorders of all types are among the most common complaints in RA as well as in ankylosing spondylitis, systemic lupus erythematosus (SLE), Sjögren's syndrome, and fibromyalgia, with over half to two-thirds of patients with chronic pain complaining of them, depending on the study.4,6 A study of 4,200 RA patients clearly demonstrated that these disorders are associated with significantly increased disease activity and pain.7
"Inflammation can cause sleep disturbances, and sleep disturbances in turn amplify inflammation in a feedback loop maintained by sympathetic arousal mechanisms and downregulation of glucocorticoid receptor sensitivity," describes a recent publication in 'Nature Reviews'.5 Speaking of glucocorticoids, these were independently associated with an increased risk of sleep disturbances in the large RA study.7
The journal of the American College of Rheumatology (ACR) emphasises the risks of many sleeping pills, some over-the-counter, that desperate patients often turn to and advises against them, especially because of the proven link between long-term use of anticholinergic drugs or benzodiazepines and dementia, as well as the risk of falls, and encourages non-drug interventions instead.4
Studies of cognitive behavioural therapy for insomnia (consisting of stimulus control, sleep hygiene and cognitive therapy) have shown sustained improvements in sleep quality, including in people with rheumatic diseases, as well as reductions in markers of systemic inflammation (such as CRP and inflammatory cytokines).6
Chronic sleep problems should not be ignored but integrated into a comprehensive treatment approach
As rheumatologists have limited time with their patients, it can be helpful to work with a sleep specialist. It is not uncommon for chronic pain patients to develop poor sleep habits without realising it, such as staying in bed most of the day and taking repeated naps throughout the day. Sleep specialists can also look into other factors for sleep disorders, such as sleep apnoea, restless legs syndrome (RLS), depression or anxiety, which are more common among rheumatic patients than in the general population.4,6
"Rheumatologists know that poorly controlled pain often leads to sleep disturbances, but they often don't consider that the patient may have a separate sleep disorder that exacerbates the pain," says a board-certified sleep specialist and co-founder of a sleep disorders clinic.4
Sleep specialists can help rheumatologists differentiate what is cause and what is consequence and break the cycle of chronic pain and insomnia.4
- CDC. Short Sleep Duration. Centers for Disease Control and Prevention https://www.cdc.gov/sleep/data_statistics.html (2022).
- Average night’s sleep now less than six hours, survey shows. https://www.safetyandhealthmagazine.com/articles/19519-average-nights-sleep-now-less-than-six-hours-survey-shows.
- CDC - Data and Statistics - Sleep and Sleep Disorders. https://www.cdc.gov/sleep/data_statistics.html (2019).
- Tips for Treating Insomnia in Rheumatology Patients. The Rheumatologist https://www.the-rheumatologist.org/article/tips-for-treating-insomnia-in-rheumatology-patients/.
- Irwin, M. R., Straub, R. H. & Smith, M. T. Heat of the night: sleep disturbance activates inflammatory mechanisms and induces pain in rheumatoid arthritis. Nat Rev Rheumatol 19, 545–559 (2023).
- Rheumatology, T. L. A wake-up call for sleep in rheumatic diseases. The Lancet Rheumatology 4, e739 (2022).
- Katz, P., Pedro, S. & Michaud, K. Sleep Disorders Among Individuals With Rheumatoid Arthritis. Arthritis Care & Research 75, 1250–1260 (2023).