Rheumatologische Erkrankungen und Schlaf – Schlafmedizinische Aspekte der Diagnostik und Therapie – Eine literaturbasierte Übersicht

Zusammenfassung

Ziel des auf einer PubMed-Recherche basierenden Übersichtsartikels ist es, die Schlafphysiologie und die pathophysiologischen Zusammenhänge von rheumatologischen Erkrankungen und primären sowie sekundären Schlafstörungen darzustellen. Dabei werden die somnologische Diagnostik und Therapie als ergänzende Verfahren in die rheumatologische Behandlungsstrategie eingebunden.

Epidemiologie 70 % aller Rheumapatienten berichten über einen verkürzten, oberflächlichen und wenig erholsamen Schlaf. Zudem treten bei über 20 % der Erkrankungen primäre Schlafstörungen, z. B. das Schlafapnoe- und Restless Legs Syndrom, auf.

Pathogenese Primäre und sekundäre Schlafstörungen können rheumaassoziierte Symptome wie Tagesschläfrigkeit, Fatigue und Depressivität, aber auch die Schmerzintensität und Krankheitsaktivität verstärken. Umgekehrt verschlechtern Schmerzintensität und inflammatorische Marker die Schlafqualität regelhaft. Bei rheumatischen Erkrankungen können neben einer Adipositas auch krankheitsspezifische skelettale Faktoren für ein Obstruktives Schlafapnoesyndrom (OSAS) prädisponieren. Das rheumatologisch komorbide auftretende Restless Legs Syndrom (RLS) mindert die Schlafqualität durch eine sensorisch bedingte Schlafstörung, sowie schlaffragmentierende periodische Beinbewegungen.

Messverfahren Die somnologische Diagnostik umfasst introspektive Fragebögen und objektive Tests zu Reaktionsvermögen und Vigilanz. Komorbide auftretende Schlafbezogene Atmungs- und Bewegungsstörungen werden im Sinne eines apparativen und polygrafischen Screenings identifiziert. Mittels Polysomnografie im Schlaflabor erfolgt die spezifische Diagnosestellung und Therapieeinleitung sowie deren Kontrolle.

Therapie Primäre und sekundäre Schlafstörungen bei RA-Erkrankungen werden verhaltenstherapeutisch, medikamentös (Insomnie und RLS) und apparativ (OSAS) behandelt. Eine suffiziente Diagnostik und Behandlung von Schlafstörungen bei rheumatologischen Erkrankungen beinhaltet eine koordinierte und interdisziplinäre Zusammenarbeit der einzelnen medizinischen Fachgebiete.

Abstract

This PubMed-based review discusses primary and secondary sleep disorders associated with rheumatological diseases. It presents the pathophysiological interaction of sleep-related diseases and rheumatological disorders and summarises clinical symptoms, diagnostic investigation and therapies from a somnological perspective.

Epidemiology 70 % of patients suffering from rheumatological diseases report poor sleep quality, numerous awakenings at night and non-restorative sleep. More than 20 % of these patients are found to have primary sleep disorders such as obstructive sleep apnoea (OSA) and the restless legs syndrome (RLS).

Pathogenesis Primary and secondary sleep disorders may increase symptoms associated with rheumatological diseases, e. g. excessive daytime sleepiness, fatigue, depression, pain intensity, and disease activity. Vice versa, pain intensity and inflammatory markers worsen sleep quality. In patients with rheumatic diseases, obesity as well as disease-related skeletal characteristics may be predisposing factors for obstructive sleep apnoea. The restless legs syndrome, which frequently occurs in rheumatological diseases, lowers sleep quality due to a sensory stimulus and periodic leg movements causing sleep fragmentation.

Diagnostic investigation Somnological diagnostic investigation consists of sleep-related questionnaires and scales. Objective tests are used to measure reaction time and vigilance. Sleep-related breathing and movement disorders can be identified with screening devices and polygrafic monitoring. A final polysomnografic sleep study is necessary to make the diagnosis and to initiate a specific treatment and follow-up examinations.

Treatment Sleep disorders associated with rheumatological diseases may be treated with behavioural and drug therapies. Drug therapy is commonly used in the management of insomnia and RLS. Most cases of OSAS can be treated with CPAP or UPS devices. Interdisciplinary cooperation in the fields of somnology and rheumatology may improve treatment in RA patients.

Schlüsselwörter

Rheumatologie - Schlafstörungen - Schlafapnoe - RLS - Insomnie

Key words

rheumatology - sleep disorders - sleep apnoea - RLS - insomnia

• Literatur

• 1 Roizenblatt S, Moldofsky H, Benedito-Silva AA. et al. Alpha sleep characteristics in fibromyalgia. Arthritis Rheum 2001; 44: 222-230
• 2 Moldofsky H. Sleep and pain. Sleep Med Rev 2001; 5: 387-398
• 3 Carskadon MA, Dement WC. Monitoring and staging human sleep. In: Kryger MH, Roth T, Dement WC. (Eds.) Principles and practice of sleep medicine. 5th edition. 2011. St. Louis: Elsevier Saunders; 16-26
• 4 Rasch B, Büchel C, Gais S. et al. Odor cues during slow-wave sleep prompt declarative memory consolidation. Science 2007; 315: 1426-1429
• 5 Spiegel K, Leproult R, Van Cauter E. Impact of sleep debt on metabolic and endocrine function. Lancet 1999; 354: 1435-1439
• 6 Kapsimalis F, Richardson G, Opp MR. et al. Cytokines and normal sleep. Curr Opin Pulm Med 2005; 11: 481-484
• 7 Xie L, Kang H, Xu Q. et al. Sleep drives metabolic clearance from the adult brain. Science 2013; 342: 373-377
• 8 Cajochen C. Schlafregulation. Somnologie 2009; 13: 64-71
• 9 Melamed S, Oksenberg A. Excessive daytime sleepiness and risk of occupational injuries in non-shift daytime workers. Sleep 2002; 23: 315-322
• 10 Dinges DF, Pack F, Williams K. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance during a week of sleep restricted to 4–5 hours per night. Sleep 1997; 20: 267-277
• 11 Carskadon MA, Dement WC, Mitler MM. et al. Guidelines for the multiple sleep latency test (MSLT). A standard measure of sleepiness. Sleep 1986; 9: 519-524
• 12 Wilhelm B, Körner A, Heldmeier K. Normwerte des pupillographischen Schläfrigkeitstests für Frauen und Männer zwischen 20 bis 60 Jahren. Somnologie 2001; 5: 115-120
• 13 Mitler MM, Doghramji K, Shapiro C. The maintenance of wakefulness test: normative data by age. J Psychosom Res 2000; 49: 363-365
• 14 Ang DC, Choi H, Kroenke K. et. al. Comorbid depression is an independent risk factor for mortality in patients with rheumatoid arthritis. J Rheumatol 2005; 32: 1013-1019
• 15 Topp CW, Østergaard SD, SØndergaard S. The WHO-5 Well-Being Index: A Systematic Review of the Literature. Psychother Psychosom 2015; 84: 167-176
• 16 Pincus T, Swearingen C, Wolfe F. Toward a multidimensional health assessment questionnaire (MDHAQ). Arthritis Rheum 1999; 42: 2220-2230
• 17 Wells G, Becker JC, Teng J. et al. Validation of the 28-joint Disease Activity Score (DAS28) and European League Against Rheumatism response criteria based on C-reactive protein against disease progression in patients with rheumatoid arthritis, and comparison with the DAS28 based on erythrocyte sedimentation rate. Ann Rheum Dis 2009; 68: 954-960
• 18 Kushida CA, Littner MR, Morgenthaler T. et al. Practice parameters for the indications for polysomnography and related procedures: An update for 2005. Sleep 2005; 28: 487-521
• 19 Ohayon MM, Carskadon MA, Guilleminault C. et al. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals. Developing normative sleep values across the human lifespan. Sleep 2004; 27: 1255-1273
• 20 Bonnet MH, Arand DL. EEG arousal norms by age. J Clin Sleep Med 2007; 3: 271-274
• 21 Stepanski EJ. The effect of sleep fragmentation on daytime function. Sleep 2002; 25: 268-276
• 22 Guilleminault C, Lopes MC, Hagen CC. et al. The cyclic alternating pattern demonstrates increased sleep instability and correlates with fatigue and sleepiness in adults with upper airway resistance syndrome. Sleep 2007; 30: 641-647
• 23 National Sleep Foundation. 2003 Sleep in America Poll.
• 24 Diskussion der Ergebnisse u. a. in: Abad VC, Sarinas P, Guilleminault C. Sleep and rheumatologic disorders. Sleep Med Rev 2008; 12: 211-228
• 25 Wells GA, Li T, Kirwan JR. Assessing quality of sleep in patients with rheumatoid arthritis. J Rheumatol 2009; 36: 2077-2086
• 26 Sariyildiz MA, Batmaz I, Bozkurt M. et al. Sleep quality in rheumatoid arthritis: Relationship between the disease severity, depression,functional status and the quality of life. J Clin Med Res 2014; 6: 44-52
• 27 Ulus Y, Akyol Y, Tander B. et al. Sleep quality in fibromyalgia and rheumatoid arthritis: associations with pain, fatigue, depression and disease activity. Clin Exp Rheumatol 2011; 29 (Suppl. 61) 92-96
• 28 Ranzolin A, Brenol JCT, Bredemeier M. et al. Association of concomitant Fibromyalgia with worse disease activity score in 28 joints, health assessment questionnaires, and short form 36 Scores in patients with rheumatoid arthritis. Arthritis Rheum 2009; 61: 794-800
• 29 Wolfe K, Michaud K. Severe rheumatoid arthritis (RA), worse outcomes, comorbid illness, and sociodemographic disadvantage characterize RA patients with fibromyalgia. J Rheumatol 2004; 31: 695-700
• 30 Bloom BJ, Owens JA, McGuinn M. et al. Sleep and its relationship to pain, dysfunction, and disease activity in juvenile rheumatoid arthritis. J Rheumatol 2002; 29: 169-173
• 31 Tishler M, Barak Y, Paran D. et al. Sleep disturbances, fibromyalgia and primary Sjögren’s syndrome. Clin Exp Rheumatolo 1997; 15: 71-74
• 32 Hultgren S, Broman JE, Gudbjoornsson B. et al. Sleep disturbances in outpatients with ankylosing spondylitis: a questionnaire study with gender implications. Scand J Rheumatol 2000; 29: 365-369
• 33 Duffin KC, Wong B, Horn EJ. et al. Psoriatic arthritis is a strong predictor of sleep interference in patients with psoriasis. J Am Acad Dermatol 2009; 60: 604-608
• 34 Valencia-Flores M, Resendiz M, Castano VA. et al. Objective and subjective sleep disturbances in patients with systemic lupus erythematosus. Arthritis Rheum 1999; 42: 2189-2193
• 35 Prado GF, Allen RP, Trevisani VM. et al. Sleep disruption in systemic sclerosis (scleroderma) patients; clinical and polysomnographic findings. Sleep Med 2002; 3: 341-345
• 36 Hamuryudan V, Mat C, Saip S. et al. Thalidomide in the treatment of the mucocutaneous lesions of the Behçet syndrome. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 1998; 128: 443-450
• 37 Wilcox S, Brenes GA, Levine D. et al. Factors related to sleep disturbances in older adults experiencing knee pain or knee pain with radiographic evidence of knee osteoarthritis. J Am Geriatr Soc 2000; 48: 1241-1251
• 38 Turner GA, Lower EE, Corser BC. et al. Sleep apnea in sarcoidosis. Sarcoidosis Vac Diffuse Lung Dis 1997; 14: 61-64
• 39 Modolfsky H, Lue FA, Smythe HA. Alpha EEG and morning symptoms in rheumatoid arthritis. J Rheumatol 1983; 10: 373-380
• 40 Mahowald MW, Mahowald ML, Bundlie SR. et al. Sleep fragmentation in rheumatoid arthritis. Arthritis Rheum 1989; 32: 974-983
• 41 Drewes AM, Svendsen L, Taagholt SJ. et al. Sleep in rheumatoid arthritis: A comparison with healthy subjects and studies of sleep/wake interactions. Br J Rheumatol 1998; 37: 71-81
• 42 Rizzi M, Sarzi-Puttini P, Atenzi F. et al. Cyclic alternating pattern: a new marker for sleep alteration in patients with fibromyalgia?. J Rheumatol 2004; 31: 1193-1199
• 43 Vgontzas AN, Zpumakis E, Bixler EO. et al. Adverse effects of modest sleep restriction on sleepiness, performance, and inflammatory cytokines. J Clin Endocrinol Metab 2004; 89: 2119-2126
• 44 García-García F, Drucker-Colín R. Sleep Disorders. In: Pandi-Perumal SR, Verster JC, Lader M. et al. (Eds.) Sleep disorders. Diagnosis and Therapeutics. CRC Press; 2008
• 45 Ranjbaran Z, Keefer L, Farhadi A. et al. Impact of sleep disturbances in inflammatory bowel disease. J Gastroenterol Hepatol 2007; 22: 1748-1753
• 46 Ciriaco M, Ventrice P, Russo G. et al. Corticosteroid-related central nervous system side effects. J Pharmacol Pharmacother 2013; 4: 94-98
• 47 Morin C, Fardet L. Systemic glucocorticoid therapy. Risk factors for reported adverse events and beliefs about the drug. A cross-sectional online survey of 820 patients. Clin Rheumatol 2015; 34: 2119-2126
• 48 Murphy PJ, Badia P, Myers BL. et al. Nonsteroidal anti-inflammatory drugs affect normal sleep patterns in humans. Physiol Behav 1994; 55: 1063-1066
• 49 Surrall K, Smith JA, Bird H. et al. Effect of ibuprofen and indomethacin on human plasma melatonin. J Pharm Pharmacol 1987; 39: 840-843
• 50 Gossec L, Danré A, Combe B. et al. Improvement in patient-reported outcomes after rituximab in rheumatoid arthritis patients: An open-label assessment of 175 patients. Joint Bone Spine 2015; 82: 451-454
• 51 Strand V, Kremer JM, Gruben D. et al. Tofacitinib in combination with conventional disease-modifying antirheumatic drugs in patients with active rheumatoid arthritis: Patient-reported outcomes from a phase III randomized controlled trial. Arthritis Care Res (Hoboken) 2017; 69: 592-598
• 52 Ruperto N, Lovell DJ, Li T. Abatacept improves health-related quality of life, pain, sleep quality and daily participation in subjects with juvenile idipathic arthritis. Arthritis Care Res (Hoboken) 2010; 62: 1542-1551
• 53 Salih AM, Gray RE, Mills KR. et al. A clinical, serological and neurophysiological study of restless legs syndrome in rheumtoid arthritis. Br J Rheumatol 1994; 33: 60-63
• 54 Taylor-Gjevre RM, Gjevre JA, Skomro R. et al. Restless legs syndrome in a rheumatoid arthritis patient cohort. J Clin Rheumatol 2009; 15: 12-15
• 55 Allen RP, Picchietti DL, Garcia-Borreguero D. Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria – history, rationale, description, and significance. Sleep Med 2014; 15: 860-873
• 56 Michaud M, Soucy JP, Chabli A. et al. SPECT imaging of striatal pre- and postsynaptic dopaminergic status in restless legs syndrome with periodic leg movements in sleep. J Neurol 2002; 249: 164-170
• 57 Earley CJ, Kuwabara H, Wong DF. et al. The dopamine transporter is decreased in the striatum of subjects with restless legs syndrome. Sleep 2011; 34: 341-347
• 58 Lui MM, Lam JC, Mak HK. et al. C-reactive protein is associated with obstructive sleep apnea with independent of visceral obesity. Chest 2009; 135: 950-956
• 59 Bravo Mde L, Serpero LD, Barceló A. et al. Inflammatory proteins in patients with obstructive sleep apnea with and without daytime sleepiness. Sleep Breath 2007; 11: 177-185
• 60 Strollo Jr PJ, Rogers RM. Obstructive sleep apnea. N Engl J Med 1996; 334: 99-104
• 61 Durgan DJ, Bryan RM. Cerebrovaskular consequences in obstructive sleep apnea. JAMA 2012; 1: e000091
• 62 Gottlieb DJ, Yenokyan G, Newman AB. et al. Prospective study of obstructive sleep apnea and incident of coronary heart disease and heart failure. The sleep heart health study. Circulation 2010; 122: 352-360
• 63 Redline S, Yenokyan G, Gottlieb DJ. et al. Obstructive sleep apneahypopnoa and incident stroke. The sleep heart health study. Am J Respir Crit Care Med 2010; 182: 269-277
• 64 Punjabi NM, Caffo BS, Goodwin JL. et al. Sleep disordered breathing and mortality. A prospective cohort study. PLoS Med 2009; 6: e1000132
• 65 Punjabi NM, Shahar E, Redline S. et al. Sleep-disordered breathing, glucose intolerance and insulin resistance. The sleep heart health study. Am J Epidemol 2004; 160: 521-530
• 66 Lavie P, Nahir M, Lorber M. et al. Nonsteroidal antiinflammatory drug therapy in rheumatoid arthritis patients: lack of association between clinical improvement and effects on sleep. Arthritis Rheum 1991; 34: 655-659
• 67 May KP, West SG, Baker MR. et al. Sleep apnea in male patients with the fibromyalgia syndrome. Am J Med 1993; 94: 505-508
• 68 Solak O, Fidan F, Dündar U. et al. The prevalence of obstructive sleep apnea syndrome in ankylosing spondylitis patients. Rheumatology 2009; 48: 433-435
• 69 Turner GA, Lower EE, Corser BC. Sleep apnea in sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 1997; 14: 61-64
• 70 Shoda N, Seichi A, Takeshita K. et al. Sleep apnea in rheumatoid arthritis patients with occipitocervical lesions: the prevalence and associated radiographic features. Eur Spine J 2009; 18: 905-910
• 71 Alamoudi OS. Sleep-disordered breathing in patients with acquired retrognathia secondary to rheumatoid arthritis. Med Sci Monit 2006; 12: 530-534
• 72 Shen TC, Hang LW, Liang SJ. et al. Risk of obstructive sleep apnea in patients with rheumatoid arthritis. A nationwide population-based retrospective cohort study. BMJ Open 2016; 6: e013151
• 73 Riemann D, Baum E, Cohrs S. et al. S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen – Kapitel „Insomnie bei Erwachsenen“ Update 2016. Somnologie 2017; 21: 2
• 74 S3-Leitlinie Nicht erholsamer Schlaf/Schlafstörungen – Kapitel. „Schlafbezogene Atmungsstörungen beim Erwachsenen“. Somnologie 2017; 20 (02) 97
• 75 Strollo Jr PJ, Soose RJ, Mauer JT. et al. Upper airway stimulation for obstructive sleep apnea. N Engl J Med 2014; 370: 139-149