Original ArticleSleep disordered breathing in patients with primary Sjögren’s syndrome: A group controlled study
Introduction
Primary Sjögren’s syndrome (pSS) is a multi system autoimmune disorder characterised by lymphocytic infiltration and exocrine failure of salivary and lacrimal glands, resulting in the classical symptoms of the disease including xerostomia (dry mouth) and keratoconjuctivitis sicca (dry eyes) [1]. In addition, other extraglandular features have also been associated with the disease, including interstitial nephritis, renal tubular acidosis, peripheral neuropathy and palpable purpurae [2]. Other less common extraglandular features can occur, e.g., lymphocytic interstitial pneumonitis, cutaneous vasculitis, autonomic dysfunction, and increased risk of non-hodgkin’s lymphoma.
Patients with pSS have increased salivary and upper airway lining surface tension [3], and there is some evidence that increased surface tension forces are involved in the pathophysiology of obstructive sleep apnea (OSA) [4], [5]. OSA is a sleep-related breathing disorder characterised by repetitive airway obstruction and arousal during sleep and is an established cause of daytime hypersomnolence. Patients with pSS also report frequent sleep disturbances and excessive daytime sleepiness [6], [7]. Up to 70% of pSS patients report higher fatigue levels compared to non-pSS control subjects [1], [7]. pSS patients show more sleepiness during the day and suffer from fatigue and nap more frequently than healthy controls and rheumatoid arthritis patients [6]. Another study has demonstrated excessive daytime sleepiness in female patients with pSS, as measured by the Epworth Sleepiness Scale (ESS) [8], when compared to control patients with osteoarthritis [9]. There are a number of other possible explanations, in addition to OSA, for increased sleepiness and fatigue in pSS. For example, a recent study showed a possible overlap between fatigue and fibromyalgia in pSS [10].Other factors that may be important include mood disturbance, medication side effects, and sleep restriction. Sleep restriction in pSS could be related to awakening to drink water to relieve dry mouth, nocturia [9] or nocturnal musculoskeletal pain. In addition, patients with pSS have been shown to have an increased frequency of restless legs symptoms, which are often associated with periodic limb movements of sleep, which can cause daytime sleepiness [6].
We postulated that OSA would be more prevalent in patients with pSS compared to healthy age and weight-matched controls and that excessive daytime sleepiness and fatigue in patients with pSS could possibly be due to a disorder of sleep and be related to the severity of OSA.
Section snippets
Participants
Female patients with pSS were recruited from a cohort of rheumatology clinic patients approached consecutively from the clinic list to be a part of the study. All patients fulfilled the American-European Classification Criteria for Sjogren’s syndrome [11]. Group matching was performed on the basis of gender, age, and body mass index (BMI), resulting in the selection of eighteen non-pSS controls, who were recruited through local advertisements and friends of index cases. Controls were healthy
Baseline characteristics
A total of 46 middle-aged females were recruited to the study, 28 of whom were formally diagnosed with pSS, and 18 of whom were healthy controls. Complete data were collected from all participants, but fatigue scores are missing from six controls. The two groups were very similar in terms of their age and BMI, as per the study protocol; however, pSS patients had significantly increased daytime sleepiness, fatigue, anxiety, and depression, but not MWT scores, compared to the control group (Table
Discussion
This study is the first to systematically compare polysomnographic findings in pSS patients with those of healthy age, gender, and weight matched controls. As hypothesised, we found that pSS patients exhibited more frequent apneas and hypopneas during sleep and a higher prevalence of clinically defined obstructive sleep apnea syndrome. The mechanism for the increased sleep disordered breathing was not addressed in this study. However, we have previously reported more mouth dryness and increased
Conflict of interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2012.06.010.
Acknowledgements
Foundation Daw Park.
All the participants of our study.
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