Can Rheumatoid Arthritis Increase My Risk of Obstructive Sleep Apnea?

If you've got rheumatoid arthritis, there's a high likelihood that you have trouble sleeping. The Centers for Disease Control and Prevention estimates that more than 25 percent of the U.S. population reports occasionally not getting enough sleep, and nearly 10 percent experiences chronic insomnia. Among those with RA, more than 50 percent have complained about insomnia.

Rheumatoid arthritis is an inflammatory condition that can cause chronic pain, and it's difficult to sleep if you're in pain. But if you have RA and can't get a good night's sleep, your problems may not simply be caused by pain. Your insomnia may be due to obstructive sleep apnea.

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The Cleveland Clinic defines OSA as repetitive episodes of complete or partial blockage of the upper airway during sleep, called apnea. In other words, people with OSA start and stop breathing throughout the night, usually because the muscles in the back of the throat intermittently relax, causing those muscles and surrounding tissues to collapse.

During these episodes of apnea, the level of oxygen in the blood drops until it signals the brain that you need to breathe again. Breathing usually resumes with an abrupt gasp or snort. People with severe OSA can have several hundred such episodes each night.

OSA can cause a number of symptoms, including episodes of falling asleep or excessive sleepiness during the day or evening when you should be awake, unrefreshing sleep, fatigue, insomnia, gasping, choking, loud snoring and waking up holding one's breath.

If left untreated, OSA can have serious, possibly life-threatening consequences, such as high blood pressure, heart disease, stroke, automobile accidents caused when a driver falls asleep, diabetes and depression.

According to the American College of Cardiology, about 25 percent of men and 10 percent of women in the U.S. have OSA. In people with RA, this rate may be even higher. One study showed that 50 percent of participants with RA were at risk of obstructive sleep apnea , compared with 31 percent of a control group. Other studies showed similarly elevated risks for OSA in people with RA.

No one really knows exactly why people with RA have a higher risk of OSA. It could be the result of underlying conditions associated with inflammation, such as poor muscle tone, reduction of the size of the upper airway due to destruction of the temporomandibular joints in the jaw, an underdeveloped lower jaw or narrowing of the spaces between the cervical vertebrae, causing compression of the brain stem. The causes could also include sleep fragmentation and the effects of drugs for RA.

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However, Dr. Roger Kornu, a rheumatologist in Orange County, California, does not believe that disintegration of the TMJ or cervical spine is a problem in his RA patients.

"We just do not see [these] complications very much at all," he says.

"Disease of the C1 and C2 vertebrae can occur, but it is rare these days. Patients who are diagnosed earlier (which we do now) are treated earlier and they just do much better," he says.

He also attributes overall improvement to aggressive treatment with the newer biologic medications, like etanercept, adalimumab, infliximab and others.

"There are patients to consider who would be at risk, but [it] would be a small number, and would include [patients with] long-standing disease and high [disease] markers," he says.

"We would be more aggressive in treating those patients, anyway."

However, Dr. Kornu's comments may illustrate one of the findings of the studies: Obstructive sleep apnea is under-recognized in people with RA.

"Rheumatologists know that poorly controlled pain can often cause difficulty sleeping, but they often don't think about the patient having a separate sleep disorder that might be fueling the pain," says registered nurse and sleep specialist Terry Cralle.

People with RA often complain of overwhelming fatigue, which has been assumed to be the result of RA's inflammatory process. But OSA also causes fatigue, raising the possibility that the RA patient's fatigue may be the result of OSA, at least in part.

Also, both OSA and RA are associated with increased risks of cardiovascular disease, including heart attack and stroke. Unrecognized OSA in someone with RA may make cardiovascular disease even worse, potentially shortening lifespan.

Finally, the issue may be a chicken-and-egg situation. Both OSA and RA produce elevated levels of certain cytokines, chemical components that increase inflammation, so it is possible that OSA may actually lead to autoimmune disorders such as RA.

So, if you have RA and either have difficulty sleeping or snore, or if you have unremitting fatigue, consider asking your rheumatologist to refer you to a sleep center for a sleep evaluation.

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The good news is that obstructive sleep apnea can usually be treated. The preferred method of treatment is to use a mask-like device, called a continuous positive airway pressure machine, or CPAP machine. However, some people don't tolerate the device well, reporting that it interferes even more with their sleep.

For these people, a better option might be an oral appliance similar to a sports mouth guard or orthodontic retainer. These devices snap in place over the upper and lower teeth, thrusting the lower jaw and tongue slightly forward, preventing throat muscles and tissues from collapsing back into the upper airway.

In some cases, surgery may be able to correct anatomic problems that contribute to OSA.

Maureen Donohue is a freelance Health reporter at U.S. News. A medical writer, editor and journalist since 1991, Maureen has written for both physicians and consumers covering a wide a variety of medical topics. Maureen's work has been published in several prestigious, peer-reviewed medical journals as well as on consumer-based websites. She has been a writer for the Stanford School of Medicine, Healthline Media, the International Medical News Group, the UC Davis Cancer Center, the Arizona Heart Institute, MedExperts International and the Sutter Institute for Medical Research. You can connect with Maureen on LinkedIn or email her at emelldee@icloud.com.