Q&A: Psoriatic arthritis and its impact on sleep

From healio.com

Key takeaways:

• Rheumatologists and primary care physicians play a crucial role in addressing sleep problems among patients with psoriatic arthritis.
• 73% of patients with psoriatic arthritis report poor sleep quality.

Healio spoke with Lourdes Perez-Chada, MD, MMSc, an instructor in dermatology and assistant director for Master of Medical Sciences in Clinical Investigation at Harvard Medical School, about how patients with psoriatic arthritis are impacted by sleep issues, and how rheumatologists and primary care physicians can address this issue.

Lourdes Perez-Chada

Healio: How common is it for patients with PsA to experience sleep problems? Examples of these problems?

Perez-Chada: Sleep problems in patients with PsA are very common. The most reported sleep problem is poor sleep quality. In a recent meta-analysis conducted by our study group, we found that 73% of patients with PsA report poor sleep quality as measured by a validated tool called the Pittsburgh Sleep Quality Index. Sleep quality is only one of the dimensions of “sleep health.” There are other dimensions of sleep health that could be affected in these patients including daytime alertness, sleep timing, duration, efficiency, and regularity. However, there is limited data about these other sleep health dimensions. With regards to discrete sleep disorders, a Danish cohort study showed that patients with PsA have a higher risk of developing obstructive sleep apnoea (OSA), and vice versa. However, data on the prevalence of OSA remains limited.

Healio: How many of those patients receive treatment for these sleep problems? Examples of treatment?

Perez-Chada: That is a great question, though further research is needed to answer it. The type of possible sleep therapies depends on the nature of the sleep problem. For example, if a patient suffers from chronic insomnia, cognitive behavioural therapy for insomnia (CBT-I) is considered the gold standard therapy. Instead, if a patient suffers from obstructive sleep apnoea, possible therapies might include Continuous Positive Airway Pressure (CPAP), oral appliances or even surgery.

Healio: Does the severity of the PsA symptoms have a direct impact on sleep? And vice versa, how can lack of sleep impact PsA symptoms?

Perez-Chada: In our qualitative study involving patients with PsA, we aimed to gain insight into their sleep experiences. Our findings revealed a possible bidirectional connection between PsA symptoms and sleep. Patients frequently expressed difficulties in either initiating or maintaining sleep due to musculoskeletal pain and itching associated with PsA. Additionally, they mentioned that their musculoskeletal pain hindered their ability to find a comfortable sleeping position. Interestingly, patients also reported that inadequate sleep exacerbated their musculoskeletal pain and itching sensations.

However, it is important to note that these observations were derived from qualitative data, and quantitative studies have yet to confirm these relationships. To address this gap, we have initiated a longitudinal study where we collect daily data on PsA symptoms and sleep patterns. This study is being funded by a pilot research grant received from the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA). By utilizing both subjective measures, such as sleep questionnaires and diaries, and objective measures, such as actigraphy, we aim to quantify these associations. This comprehensive approach will provide a more robust understanding of the interplay between PsA symptoms and sleep quality.

Healio: If patients with PsA don’t get treatment for their sleep issues, could it hurt their overall PsA disease activity? In what ways?

Perez-Chada: Cross-sectional studies have shown an association between poor sleep quality and disease activity. However, longitudinal studies testing the directionality of this association have not been conducted.

Considering that PsA is characterized by underlying systemic inflammation and that inadequate sleep is associated with inflammatory dysregulation, it is possible that poor sleep health among PsA patients may exacerbate the overall inflammatory burden, consequently leading to heightened disease activity. Our study group is currently conducting a prospective study to test this hypothesis.  By revealing the potential link between poor sleep health and disease activity in PsA, we hope to pave the way for improved treatment strategies that address not only the underlying inflammation but also the sleep-related factors that may contribute to disease severity.

Healio: How do you approach the discussion of sleep with your patients with PsA?

Perez-Chada: Rheumatologists and PCPs play a crucial role in addressing sleep problems among patients with PsA. To effectively initiate discussions about sleep problems, rheumatologists/PCPs can employ several approaches:

1. Assessing sleep quality: Rheumatologists and PCPs should inquire about various aspects of sleep that could be affected, including sleep quality, difficulties with falling asleep or staying asleep, snoring, daytime sleepiness, and how sleep problems impact their patients' daily lives.
2. Providing information: Rheumatologists and PCPs should educate their patients about the connection between PsA and sleep problems. It is important to explain how pain, itching, and inflammation associated with PsA can disrupt sleep patterns, and vice versa. Patients should be informed about the significance of addressing sleep problems to enhance their overall well-being.
3. Screening for sleep disorders: Rheumatologists and PCPs can utilize validated screening tools to identify potential sleep disorders like insomnia, sleep apnoea, or restless legs syndrome. This screening process enables them to identify patients who may require further evaluation or referral to sleep specialists.
4. Medication review: Rheumatologists and PCPs should carefully review the patient's current medication regimen to identify any medications that might contribute to sleep disturbances. If feasible, adjustments to medications can be made or alternative options explored to minimize their impact on sleep.
5. Providing sleep advice: Rheumatologists and PCPs should offer guidance on maintaining a consistent sleep schedule, creating a comfortable sleep environment, practicing relaxation techniques, and avoiding factors that can disrupt sleep, such as caffeine or excessive screen time before bed. 
6. By proactively addressing sleep problems, rheumatologists and PCPs can contribute to improved disease management, enhanced quality of life, and better overall health outcomes for their patients with PsA.

https://www.healio.com/news/rheumatology/20230613/qa-psoriatic-arthritis-and-its-impact-on-sleep