obstructive sleep apnea in patients with rheumatoid arthritis: correlation with disease activity and...
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Obstructive Sleep Apnea in Patients with Rheumatoid Arthritis: Correlation with Disease
Activity and Pulmonary Function Tests
ByProf. Neven Fouda
Prof .Physical medicine ,Rheumatology and Rehabilitation
Ain Shams University EGYPT
,
Faculty of Medicine Ain Shams University
Cairo-Egypt
Rheumatoid Arthritis
Rheumatoid arthritis (RA) is a chronic inflammatory disease that is characterized by joint pain and swelling and can lead to disability and functional limitations.
In addition, more than half of patients with RA report sleep disturbance ,a rate of prevalence that is 2 to 3 times greater than that found in the general population.
Such disturbed sleep may be due to pain, depression , lack of exercise, or corticosteroid usage. .
Sleep disturbance in RA
sleep disturbance correlates with greater pain and disease activity .It is often thought that difficulties with sleep are due to RA-related pain. However, sleep disturbance and pain may be bidirectionally related..
Sleep dysfunction and primary sleep disorders are increasingly recognized in people with RA.The morbidity and mortality which may be associated with untreated sleep disorders raises the priority of this aspect of patient care.
Why
Obstructive Sleep
Apnea?
Obstructive sleep apnea(OSA)
Obstructive sleep apnea (OSA) is a significant public health concern and contributes to increased cardiovascular morbidity and mortality.
OSA is defined by the American Academy of Sleep Medicine as repetitive episodes of upper airway obstruction occurring during sleep and usually associated with a reduction in oxygen saturation .
Diagnosis of OSA
A number of tools and methods are available for the assessment of sleep health as self-reported questionnaire instruments. However, the gold standard for diagnosis of OSA is the overnight Polysomnography (PSG)
Aim of the study
To assess obstructive sleep apnea (OSA) as one of common primary sleep disorders in patients with Rheumatoid Arthritis (RA) and its correlation to disease activity and pulmonary function tests.
Patients and methods
The present study is a cross sectional one that included 30 female patients with RA, fulfilled modified American College of Rheumatology (ACR) criteria for classification of RA.
All the patients were on a stable disease-modifying drug regimen for three months before the study.
Patients and methods
Exclusion criteria:
- Patients on anti- tumor necrosis factor (TNF) or corticosteroids therapy.
-Patients on sedative or hypnotic drugs or with history of withdrawal of stimulants as coffee or tobacco .
-Patients with abnormalities in soft palate or upper airway.
- Pregnancy.
Patients and methods
All the patients were subjected to: Full history taking :(disease duration and
symptoms suggestive of OSA) Local examination of the chest ,Ear, nose
and throat. BMI (Kg/m2) was determined by weight
(Kg) and height (m) (Quelet index).
Patients and methods
Assessment of the disease activity (DAS 28) -The swollen and tender joints ( maximum of 28 tender and 28 swollen joints, TJC28, SJC28) ;
-The erythrocyte sedimentation rate(ESR) -A visual analogue scale (VAS) of 100 mm.
DAS28 = 0.56 (√tender 28) + 0.28 (√swollen 28) + 0.70 (In ESR) + 0.014* VAS.
Patients with DAS28 score ≤ 2.6 were considered in remission (Fransen J,van Riel P.L.C.M.2005).
Patients and methods
Laboratory assessment: Complete blood picture. Rheumatoid factor(RF).
Erythrocyte sedimentation rate(ESR). Highly sensitive C reactive protein(hs CRP).
Patients and methodsPulmonary function tests: The tests were done in pulmonary laboratory. The
best of 3 measures obtained while the patient is breathing room air by flow volume spirometry (Flow mate model 2500) are used to calculate the following parameters:
Forced vital capacity (FVC): amount of air that can be forcefully expelled from maximally inflated lung.
Forced expiratory volume in 1st second (FEV1): Volume of air expelled during the first second of FVC.
Ratio of FEV-1 to FVC (FEV1/FVC).
PATIENTS AND METHODS
Polysomnography (PSG) (overnight sleep test)
Polysomnography (PSG)
The PSG consisted of 14 channel recording from surface leads 2 electro _ encephalography 2 electro- oculography Chin electromyography Electro_ cardiography sensors for nasal airflow (thermistor), Tracheal sounds (microphone) Thoracic and abdominal Respiratory effort (piezo-electric) Finger pulse oximeter Leg movements Body position and light.
Patients and methodsData obtained from this study are:-Apnea index (AI): Complete cessation of airflow breathing at the nostrils and mouth for at least 10 seconds or longer. -Hypopnea index (HI): Decrease in rate and depth of breathing by 50% for 10 seconds or longer. -Apnea-Hypopnea index (AHI): Average number of apnea and hypopnea per hour of sleep.OSA is diagnosed if AHI is 5 or more . (American Academy of Sleep Medicine Task Force Report 1999)
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Results
30 casesTwelve patients
(40)%
symptoms of OSA.
30 cases
Ten patients (33.3%)
obstructive pattern
(FEV-1/FVC ratio <80)
Results Fourteen of our patients
( 46.7%) met the diagnostic criteria for diagnosis of OSA by polysomnography
(AHI ≥ 5).
OSA has been linked to inflammatory ,coagulation and endothelial changes, which can also be found in patients with RA and possibly suggest common underlying pathological mechanisms.
OSA(14 )
Non(16)
OSA(46.7%)
Non(53.3%)
Results
30 RA cases
Symptomatic (12)((40%
Asymptomatic(18)((60%
OSA(8)(66%)
No OSA(4) (33%)
OSA(6) (33%)
33% of asymptomatic patients had OSA.OSA in women may differ symptomatically . These differences may contribute to underestimation of OSA in women.
No OSA(12) (66%)
Results
30 RA cases
OSA(14)(46.7%)
No OSA(16) (53.3%)
Active(7) (50%)
Remission(7)(50%)
Active(3)(18.75%)
Remission(13)
(81.25%)
ResultsComparison between RA patients with and without OSA as regards demographic, clinical ,laboratory and pulmonary function data
sig RA Without OSA
(n=16)
RA with OSA (n=14)
p>0.05 39.9 ± 6.6 41.2 ±5.11 Age (years)
p<0.001(HS) 4.0 ±1.72 7 ±1.94Disease duration (years)
p<0.001(HS) 20.3±1.55 30.8 ±2.48 Body mass index
p>0.05 58.11±12.9 54.34±10.7 ESR(mm/h)
p<0.001(HS) 4.9±0.3 6.7±0.6 hsCRP (mg/L)
P<0.05(S.) 3) 18.75( 7) 50( Active cases N(%)
p>0.05 5) 31.3( 5) 35.7( Abnormal PFT N(%)
p>0.05 7)43.8( 6) 42.9( Positive RF N(%)
Correlation between apnea- hypopnea index (AHI) and highly sensitive C reactive protein (hs CRP)
due to the effects of: hypoxemia Reoxygenation Hypercapnia and
arousals which activate systemic inflammation.
Correlation between apnea- hypopnea index(AHI) and disease activity score 28 (DAS 28)
These observations reinforce the concept of a relationship between disease activity / functional status and perception of sleep health in patients with RA.
Results
Correlation between apnea- hypopnea index (AHI) and body mass index (BMI) .
Salah El DIN Citadel
Conclusion
OSA is commonly associated with patients with RA .These findings possibly suggest common underlying pathological mechanisms which may be linked to chronic inflammation.
Conclusion
Co-existence of OSA in RA patients may influence the disease activity and the level of circulating inflammatory markers in these patients .
Considering diagnosis and treatment of this sleep disorder in RA patients may help in improved clinical care ,better prognosis and avoid rheumatoid-associated morbidities.
Conclusion
It is not expected that rheumatologists would diagnose and treat OSA .However, study of OSA in patients with RA may offer additional insight into why these patients are more apt to develop CVD.
Therefore, treatment of co-existing OSA in patients with RA may prove beneficial in terms of future cardiovascular and respiratory morbidity, as well as potentially improving measures of fatigue, pain and inflammatory markers.
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Recommendations
More researches are needed also to elucidate the impact of OSA on measures of therapeutic response to RA therapies and to clarify if anti-TNF therapy alter sleep disturbance or if OSA contribute to poor response to anti-TNF therapy in RA patients.
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