Why I, as a rheumatologist, am happy to make the diagnosis of obstructive sleep apnea

In this issue of the Journal, Aboussouan and his multidisciplinary coauthors¹ review available treatment options for patients with obstructive sleep apnea (OSA) and discuss the relative benefits. The cardiovascular morbidities associated with OSA are well known. But why should a rheumatologist have special interest in this disorder? The answer lies in 2 major reasons patients are referred for a rheumatology consultation: fatigue and inflammation.

The fatigue part seems obvious. People who don’t sleep well are fatigued, although those with severe OSA, if carefully questioned, describe symptoms of sleepiness instead of or in addition to “fatigue.” Recognizing and implementing effective therapy for OSA will reduce sleepiness and, often, fatigue. While fatigue frequently accompanies inflammation and will likely not abate unless the inflammation is treated, patients with noninflammatory pain may also experience fatigue and sleep disorders. The pain-sleep relationship is complex and bidirectional. Chronic pain can disrupt effective sleep, and patients with disrupted sleep often experience pain and amplified discomfort with various forms of sensory stimulation. Fibromyalgia is the exemplar of the latter.

In addressing fibromyalgia, many of us try to correct the sleep disorder. But this is hard to accomplish. In my experience, behavioral sleep approaches have limited success in these patients, as do pharmacologic efforts to treat the sleep disturbance and pain. Interestingly, OSA seems to be prevalent in patients with fibromyalgia.² Since OSA has a reasonable chance of responding to treatment, it is worth questioning patients (and their partners) about the symptoms of this disorder and having a low threshold to order a formal sleep study. I have seen benefits in reducing patient symptoms using this approach, and in rare cases, a patient may report resolution of fibromyalgia after successful remediation of their OSA.³

The link between OSA and inflammation is more biologically intriguing but still not well understood, and its clinical significance is not yet clear. Successful treatment of OSA with positive airway pressure has been shown to reduce elevated C-reactive protein levels.⁴ Patients with OSA have higher serum urate levels, and some studies have indicated they also have a higher likelihood of having gout,^5,6 though it is not certain what proportion of this increased risk is attributable to comorbidities in OSA such as obesity and diabetes.⁷ The authors of a study of 30 patients with moderate-severe OSA suggested that continuous positive airway pressure can elicit a modest reduction in the serum urate level.⁸ But there have been no large studies on a potential benefit of effective OSA therapy in the management of patients with gout.

Thus, whenever I make the diagnosis of OSA, I also have the possibility of reversing a sleep disorder that may be amplifying a patient’s pain, as well as potentially reducing their systemic inflammation.

As 2023 draws to a close, we at the Journal take this opportunity to thank our peer reviewers and authors who have devoted hours of effort to help us present practical and timely educational articles. We send our sincere wishes for a healthy and hopefully kinder and more peaceful 2024 to them—and to you, our readers.

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