Sleep Apnea and Rheumatoid Arthritis

How They're Linked—and How Treating One Could Help the Other

People with rheumatoid arthritis (RA) are especially likely to have a sleep disorder called obstructive sleep apnea (OSA) in which breathing is interrupted by an intrusion in the back of the throat that shuts off the airway. This may be due to several factors, including joint abnormalities and immune-system features associated with both conditions.

Fatigue is recognized as a huge problem for those living with rheumatoid arthritis. Identifying and treating OSA (and other sleep disorders) may help alleviate that symptom and make people with RA more functional. Beyond that, though, a proper diagnosis and treatment regimen for OSA could help you stay healthier and live longer.

How They're Linked

According to study results published in BMJ Open, the rate of OSA in people with RA was 75% higher than in people without RA. There are a number of possible reasons why.

Physiological Abnormalities

Certain physiological differences that can occur due to RA appear to contribute to a higher risk of OSA:

  • Micrognathia and TMJ involvement: In micrognathia, the lower jaw is abnormally small. In RA, it can be due in part to the destruction of the temporomandibular joint (TMJ). The end result is intrusion into the upper airway, which contributes to sleep apnea.
  • Cervical spine issues: Your cervical vertebrae are in your neck. In RA, misalignment of the higher cervical vertebrae and other abnormalities in the area can narrow the upper airway, compress the brainstem, and affect the severity of OSA.
  • Cricoarytenoid joint involvement: The cricoarytenoid joints sit in the back wall of your larynx (voice box). They open, close, and tighten your vocal cords when you speak and breathe, and RA can impair their function.

The Immune System

Several known immune-system irregularities are involved in RA, and many of them are also involved with OSA, which points to a possible physiological link between the two diseases.

Both RA and OSA are linked to elevated levels of numerous substances in the immune system:

In RA, these are related to immune-system dysfunction and inflammation. In OSA, some interleukins and TNF-alpha have been found to be involved with the non-rapid-eye-movement (non-REM) phases of sleep.

Additionally, research suggests that higher levels of pro-inflammatory cytokines and TNF-alpha are associated with more severe OSA. This may explain why people with RA who are treated with TNF blockers find that they're less fatigued.

Research into these areas is in its early stages, so no one can say for certain what the impact is right now, but these findings make a case for common underlying physiology that could help explain the relationship between the two diseases.

Impact of OSA on RA

Sleep apnea brings about a number of symptoms, including:

  • Chronic loud snoring
  • Choking or gasping for air during sleep
  • Frequent wakings (your rouses you to get you to breathe again)
  • Insomnia
  • Excessive daytime sleepiness
  • Mood changes, such as depression
  • Irritability
  • Headache upon waking
  • Problems with concentration

It's easy to see, then, why people with OSA struggle with daytime tiredness. But fatigue is very common with RA too; the disease can require you to exert more energy to go about your day due to physical limitations.

Having OSA along with RA means this symptom—and those related to it—is only compounded in terms of its severity and impact on your daily life.

Complications

Rheumatoid arthritis and sleep apnea may significantly contribute to increased health problems and death in people who have both conditions.

The BMJ Open article suggested that the known association between cardiovascular disease and rheumatoid arthritis may, in part, be due to sleep apnea. This is likely because OSA is associated with inflammation, coagulation (blood clotting), and endothelial dysfunction (a problem with the inner lining of the small arteries that can lead to myriad problems and imbalances in blood and tissues).

Other serious health issues that can result from sleep apnea include:

  • High blood pressure
  • Diabetes
  • Stroke
  • Erectile dysfunction
  • Sudden death

The symptoms and risks of OSA on top of RA can make life significantly more difficult and, in the worst-case scenario, considerably shorter.

Treatment and Management

If you have any symptoms of OSA, bring it up with your doctor and see about getting a referral to a sleep specialist or sleep study (polysomnography).

OSA is typically managed with use of a continuous positive airway pressure (CPAP) machine. The machine is attached to a hose and mask that you wear over your nose (and sometimes mouth) while you sleep, and it pressurizes your airway to keep it open.

Other ways to manage OSA include:

  • Body position during sleep, such as not lying on your back
  • Weight loss
  • Devices that thrust your lower jaw forward so it doesn't reduce the airway

If jaw deformity from RA and TMJ are associated with the sleep apnea, jaw surgery may be performed if CPAP isn't successful. If abnormalities of the cervical spine are compressing the airway, surgical fusion of neck vertabrae sometimes helps correct the abnormality and improve OSA.

A Word From Verywell

If you have RA and feel fatigued a lot, don't just dismiss it as a symptom of the disease. An estimated 22-million Americans have sleep apnea, but much of it is believed to be undiagnosed. Talk to your doctor, go through the diagnostic process, and, if you have OSA, give the treatment a chance. The risks of OSA are too serious to be ignored.

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  1. Shen TC, Hang LW, Liang SJ, et al. Risk of obstructive sleep apnoea in patients with rheumatoid arthritis: a nationwide population-based retrospective cohort studyBMJ Open. 2016;6(11):e013151. Published 2016 Nov 28. doi:10.1136/bmjopen-2016-013151

  2. Taylor-Gjevre RM, Nair BV, Gjevre JA. Obstructive sleep apnoea in relation to rheumatic diseaseRheumatology (Oxford). 2013;52(1):15–21. doi:10.1093/rheumatology/kes210

  3. Ataka H, Tanno T, Miyashita T, Isono S, Yamazaki M. Occipitocervical fusion has potential to improve sleep apnea in patients with rheumatoid arthritis and upper cervical lesionsSpine (Phila Pa 1976). 2010;35(19):E971–E975. doi:10.1097/BRS.0b013e3181c691df

  4. American Sleep Apnea Association. Information for clinicians.

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