Why I, as a rheumatologist, am happy to make the diagnosis of obstructive sleep apnea
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* Brian F. Mandell

  
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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.

*   Copyright © 2023 The Cleveland Clinic Foundation. All Rights Reserved.

## References

1.  Aboussouan LS, Bhat A, Coy T, Kominsky A. Treatments for obstructive sleep apnea: CPAP and beyond. Cleve Clin J Med 2023; 90(12):755–765. doi:10.3949/ccjm.90a.23032
    
    [Abstract/FREE Full Text](http://www.ccjm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiY2Nqb20iO3M6NToicmVzaWQiO3M6OToiOTAvMTIvNzU1IjtzOjQ6ImF0b20iO3M6MjE6Ii9jY2pvbS85MC8xMi83MTIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  Eshak N, Vutthikraivit W, Beltagy A, Pixley J. Obstructive sleep apnea in fibromyalgia patients: a meta-analysis [abstract]. Arthritis Rheumatol 2020; 72:(suppl 10). [https://acrabstracts.org/abstract/obstructive-sleep-apnea-in-fibromyalgia-patients-a-meta-analysis/](https://acrabstracts.org/abstract/obstructive-sleep-apnea-in-fibromyalgia-patients-a-meta-analysis/). Accessed November 13, 2023.
    
    

3.  Vantine F, Ettlin D, Meira-E-Cruz M. Resolution of fibromyalgia by controlling obstructive sleep apnea with a mandibular advancement device. Sleep Sci 2021; 14(3):291–295. doi:10.5935/1984-0063.20200077
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.5935/1984-0063.20200077&link_type=DOI) 

4.  Ishida K, Kato M, Kato Y, et al. Appropriate use of nasal continuous positive airway pressure decreases elevated C-reactive protein in patients with obstructive sleep apnea. Chest 2009; 136(1):125–129. doi:10.1378/chest.08-1431
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1378/chest.08-1431&link_type=DOI) 
    
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    [Web of Science](http://www.ccjm.org/lookup/external-ref?access_num=000267779000019&link_type=ISI) 

5.  Blagojevic-Bucknall M, Mallen C, Muller S, et al. The risk of gout among patients with sleep apnea: a matched cohort study. Arthritis Rheumatol 2019; 71(1):154–160. doi:10.1002/art.40662
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1002/art.40662&link_type=DOI) 

6.  Gu X, Tang D, Xuan Y, Shen Y, Lu LQ. Association between obstructive sleep apnea symptoms and gout in US population, a cross-sectional study. Sci Rep 2023; 13(1):10192. doi:10.1038/s41598-023-36755-4
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1038/s41598-023-36755-4&link_type=DOI) 

7.  Zeng Z, Jin T, Ni J, et al. Assessing the causal associations of obstructive sleep apnea with serum uric acid levels and gout: a bidirectional two-sample Mendelian randomization study. Semin Arthritis Rheum 2022; 57:152095. doi:10.1016/j.semarthrit.2022.152095
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1016/j.semarthrit.2022.152095&link_type=DOI) 

8.  Parmaksız E, Parmaksız ET. The effect of CPAP treatment on uric acid levels in obstructive sleep apnea syndrome. Sleep Vigilance 2021; 5:85–88. doi:10.1007/s41782-021-00130-y
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1007/s41782-021-00130-y&link_type=DOI)

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