Rheumatoid Arthritis and Sleep Apnea

There’s nothing unusual about having trouble sleeping. As many as 30 percent of Americans report problems falling or staying asleep. But the chances of having sleep problems are significantly greater among those with rheumatoid arthritis (RA), an autoimmune disease that causes widespread inflammation that leads to stiffness, swelling, and joint pain. Nearly 57 percent of people with RA in one recent study reported experiencing insomnia.

Part of the problem can be blamed on the discomfort associated with RA. Chronic pain is one of the main reasons people have problems getting a good’s night sleep.

However, if you have RA and can’t seem to catch enough Zzz’s, your insomnia may be a symptom of an underlying sleep disorder known as obstructive sleep apnea (OSA). In one 2016 study published in the journal BMJ Open, the incidence rate of sleep apnea was 75 percent greater in people with RA than in those without the disease.

The Link Between Rheumatoid Arthritis and Obstructive Sleep Apnea

With OSA, a person’s airway becomes partially or completely obstructed during sleep, which interrupts their breathing for 10 to 30 seconds at a time and deprives them of oxygen until they wake up and start breathing again. These short stops in breathing can happen up to 400 times every night. Even if the periods of not breathing don’t fully wake you up, the micro-interruptions in breathing can disturb your sleep.

“If someone poked you with a stick every 10 minutes while you were asleep, you’d feel pretty tired even if you slept eight hours,” says Nitun Verma, MD, a sleep doctor in San Francisco and a spokesperson for the American Academy of Sleep Medicine.

Researchers aren’t sure why people with RA have a higher risk of OSA. Here are some possible explanations.

Structural Differences of the Head, Neck, and Spine

The increased sleep apnea risk in people with rheumatoid arthritis could be the result of structural abnormalities of the head, neck, and spine that are common in people with RA, such as:

  • Underdeveloped lower jaw
  • Reduction of the size of the upper airway due to the degeneration of the temporomandibular joints (TMJ)
  • Narrowing of the spaces between cervical vertebrae that can cause compression on the brain stem and affect the severity of sleep apnea

A recent study confirmed a close association between TMJ abnormality (TMJA) and OSA. People with moderate-to-severe sleep apnea had a higher level of TMJA, and conversely, people with RA and TMJA tend to have more severe sleep apnea.


Inflammation in rheumatoid arthritis likely also plays a role. RA increases certain proinflammatory cytokines, such as tumor necrosis factor (TNF), and these intercellular signaling proteins are involved in the process of normal sleep regulation.

According to Regina M. Taylor-Gievre, MD, who researches inflammatory arthritis and sleep disorders at the University of Saskatchewan in Canada, higher TNF levels have also been reported in sleep apnea. So, as she explained in a review article published in the International Journal of Clinical Rheumatology, in someone who has RA, it could be that this increase in TNF levels may increase susceptibility to OSA.


Obesity seems to be another common connection between sleep apnea and rheumatoid arthritis. Half of people with sleep apnea are overweight and two-thirds of people with RA are overweight or obese. While not everyone with RA who is overweight has OSA, carrying extra weight does increase the chance of having the disorder. That’s because weight gain can cause fat to accumulate in the neck area, which obstructs breathing and leads to OSA. Having OSA can also contribute to gaining weight, and people with severe OSA have a greater chance of gaining more weight compared to those with less severe OSA, according to the National Sleep Foundation.

But the obesity connection is more complex than that, and it, too, involves inflammation. Because fat cells release cytokines, having more fat cells brings more inflammation, which can also contribute to rheumatoid arthritis.

Obesity has been linked with an increased risk for developing RA, as well as with making it harder to control and treat the disease. However, according to Dr. Taylor-Gievre, there’s also speculation about the role of fatty tissue in promoting inflammatory processes like RA directly — meaning it’s possible that increased cytokines from excess fat may actually lead to the development of sleep apnea and/or rheumatoid arthritis.

Increased Cardiovascular Risk for Sleep Apnea and Rheumatoid Arthritis

Whatever the link, it’s important — potentially even lifesaving — to learn if you have sleep apnea. Both sleep apnea and rheumatoid arthritis are associated with increased risks of cardiovascular disease (CVD), including heart attack and stroke. OSA is even associated with sudden death.

OSA is more prevalent in men, but researchers suspect it may be disproportionately underrecognized in women, who are three times more likely to have rheumatoid arthritis than men. It can be difficult to know you have OSA. Many people have it without even realizing it.

Fatigue: A Sneaky Symptom of RA and Sleep Apnea

The most common signs of sleep apnea are loud, persistent snoring (which may be noticed only by your sleep partner) and excessive sleepiness during the day. When fatigue is one of the most common symptoms of RA (high inflammation levels can wear you out), it can be easy to miss the possibility that an RA patient’s fatigue may also be due to sleep apnea. But the medical community is becoming hip to the connection.

“When RA patients are overly tired all the time, we may suggest they get a sleep study [a test for sleep apnea] because of the high prevalence of sleep apnea,” says Vinicius Domingues, MD, a rheumatologist in Daytona Beach, Florida, and medical advisor for CreakyJoints.

How Sleep Apnea Is Diagnosed and Treated

A definitive diagnosis of sleep apnea can be made only with a sleep study (polysomnography), a non-invasive exam that records what happens in your brain and body while you sleep. Sleep studies are conducted during a visit to a sleep lab, usually overnight, or a home test performed with special equipment.

If you’re diagnosed with OSA, chances are you’ll be advised by your doctor to use a continuous positive airway pressure (CPAP) machine to treat it. CPAP helps eliminate the pauses in breathing caused by OSA by delivering a stream of pressurized air. Once you’re able to breathe freely, you’re able to sleep through the night without waking up.

For people with RA, whose sleep disturbances lead to increased flare-ups, as well as depression, pain severity, and trouble performing normal daily functions, that will hopefully provide relief they only dream about.

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