Pain at night

Sleep problems in rheumatoid arthritis over 12 years from diagnosis: results from the Swedish EIRA study

Objective

Most studies of rheumatoid arthritis (RA) and sleep have focused on established RA. We here investigate sleep quality and sleep duration in patients with newly diagnosed RA and during 1–12 years after diagnosis.

Methods

Data were collected on sleep 1–12 years after diagnosis from patients diagnosed 1998–2018 in the Swedish study Epidemiological Investigation of RA. Six sleep domains (sleep problems, non-restorative sleep, insomnia, insufficient sleep, sleep quality perceived as poor and sleep considered a health problem); a global sleep score and time spent in bed were estimated. Using logistic regression, ORs were calculated for each sleep outcome by disease duration. We explored whether pain (low (Visual Analogue Scale=0–20 mm, reference), intermediate=21–70, high=71–100) or functional impairment (Health Assessment Questionnaire>1.0) was associated with problems.

Results

We had sleep data on 4131 observations (n=3265 individuals). Problems with ≥1 sleep domain (global sleep score) was reported in 1578 observations (38%) and increased with disease duration (OR 1.04, 95% CI 1.02 to 1.07). Median time in bed was 8 hours (Q1-Q3: 7.5–9.0). High-grade pain increased the likelihood of sleep problems ~3–9 fold, and increased functional impairment ~4–8 fold.

Conclusion

In this cohort of newly diagnosed patients with RA with access to the current treatment from diagnosis, we did not find any major problems with sleep, and existing sleep problems related mainly to pain and reduced function. Treatment of sleep problems in RA should be guided towards treating the underlying problem causing the sleep disturbance.

Intravenous versus oral paracetamol in a UK ambulance service: a case control study

OBJECTIVES

To determine the effectiveness of intravenous versus oral paracetamol (acetaminophen) in the management of acute pain in the out-of-hospital setting.

METHODS

We extracted ambulance electronic patient care records for all patients who received 1 g intravenous paracetamol throughout January 2019, and case matched these by sex and age with consecutive patients who received 1 g oral paracetamol over the same time period. Eligible for inclusion were all patients aged ≥ 18 who received 1 g paracetamol for acute pain and who were transported to the emergency department (ED). The primary outcome was the mean reduction in pain score using the numeric rating scale (NRS), with a reduction of 2 or more accepted as clinically significant.

RESULTS

80 care records were eligible for analysis; 40 patients received intravenous and 40 patients received oral paracetamol. The mean age of both groups was 54 years (± 3 years) and 67.5% (n = 54) were female. Patients receiving intravenous paracetamol had a clinically significant mean (SD) improved pain score compared to those receiving oral paracetamol, 2.02 (1.64) versus 0.75 (1.76), respectively [p = 0.0013]. 13/40 (32.5%) patients who received intravenous paracetamol saw an improved pain score of ≥ 2 compared to 8/40 (20%) who received oral paracetamol. No patients received additional analgesia or reported any adverse symptoms. Abdominal pain, infection and trauma were the most common causes of pain in both groups.

CONCLUSION

Our study suggests that intravenous paracetamol is more effective than oral paracetamol when managing acute pain in the out-of-hospital setting. Our findings support further investigation of the role of paracetamol in paramedic practice using more robust methods.

Sleep Disorders are a Prevalent and Serious Comorbidity in Dry Eye

Purpose

Sleep is an essential life habit and closely associated with lifespan, diabetes, hypertension, and mental health. Sleep disorders are a prominent, but overlooked problem in patients with dry eye disease (DED), characterized by a poor sleep index, short sleep duration, long sleep latency, and poor subjective sleep. DED and sleep disorders are more prevalent in women than men. Moreover, sleep quality in DED is worse than in other eye diseases, including glaucoma, retinal diseases, cataract, and allergic and chronic conjunctivitis.

Methods

We reviewed the literature for studies investigating sleep and health, eyes and sleep, and DED and sleep, in terms of systemic and eye health, especially in women.

Results

Two studies reported that approximately half of patients with DED suffer from poor sleep. The severity of mood disorders, including anxiety and depression, is correlated strongly with sleep disorders in DED, and the symptoms and signs of DED, especially pain, also are correlated with sleep quality. Sleep disorders are documented in primary Sjögren's syndrome and an association with sleep apnea and depression is suggested. Primary Sjögren's syndrome includes arthritis and other rheumatic disease causing pain and fatigue; however, how sicca contributes to sleep disorders is not known.

Conclusions

Possible explanations for sleep disorders in DED may be depression, pain, and eye exposure at night. Reciprocal effects may be expected and consultation-liaison psychiatry is recommended for the management of sleep disorders in DED. Topical medication and lid heating also may be advantageous for sleep quality in DED.

Prevalence and factors associated with disturbed sleep in patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis: a systematic review

This review explores the prevalence and factors associated with disturbed sleep for patients with ankylosing spondylitis and non-radiographic axial spondyloarthritis in order to clarify consistent findings in this otherwise disparate research field. The association of physical, demographic and psychological factors correlating with poor sleep was explored, and the effectiveness of interventions assessed. Ten electronic databases were searched: AMED, CINAHL, Embase, Medline, PsycINFO, PubMed, Scopus, Web of Science, OpenGrey and BASE. Following application of inclusion and exclusion criteria, 29 articles were critically assessed on the basis of methodology, experimental design, ethics and quality of sleep data, leading to the selection of 15 studies for final review. Poor sleep was reported in 35-90% of patients with axial spondyloarthritis and is more prevalent within this clinical population compared to healthy control subjects. Disturbed sleep is an important aspect of disease for patients and reflects the severity of disease activity, pain, fatigue and functional disability. However, the direction of this relationship is undetermined. Associations with age, gender, years spent in education, quality of life and depression have also been demonstrated. Anti-TNF medication is effective in reducing poor sleep, and exercise has also produced beneficial results. Future research into poor sleep should take account of its multifactorial nature. There is also a current lack of research investigating non-pharmacological interventions or combination therapies. A standardised, validated measurement of poor sleep, appropriate for regular patient screening, would be a useful first step for future research.

Timing of Administration: For Commonly-Prescribed Medicines in Australia

Chronotherapy involves the administration of medication in coordination with the body's circadian rhythms to maximise therapeutic effectiveness and minimise/avoid adverse effects. The aim of this study is to investigate the "time of administration" recommendations on chronotherapy for commonly-prescribed medicines in Australia. This study also aimed to explore the quality of information on the timing of administration presented in drug information sources, such as consumer medicine information (CMI) and approved product information (PI). Databases were searched for original research studies reporting on the impact of "time of administration" of the 30 most commonly-prescribed medicines in Australia for 2014. Further, time of administration recommendations from drug information sources were compared to the evidence from chronotherapy trials. Our search revealed 27 research studies, matching the inclusion and exclusion criteria. In 56% (n = 15) of the research studies, the therapeutic effect of the medicine varied with the time of administration, i.e., supported chronotherapy. For some medicines (e.g., simvastatin), circadian-based optimal administration time was evident in the information sources. Overall, dedicated studies on the timing of administration of medicines are sparse, and more studies are required. As it stands, information provision to consumers and health professionals about the optimal "time" to take medications lags behind emerging evidence.

Chronotherapy in practice: the perspective of the community pharmacist

BACKGROUND

Optimising the time of drug administration in alignment with circadian rhythms to enhance the clinical effect or minimise/avoid adverse effects is referred to as chronotherapy. Pharmacists have a key role in providing medicine related information, including counselling about the optimal time for medication administration. Where applicable, the principles of chronotherapy should underlie this aspect of medication counselling. Despite significant developments in the science of chronotherapy for specific pharmacological treatments, the perspective of pharmacists about their understanding and application of these principles in practice has not been explored.

OBJECTIVE

To explore community pharmacist's viewpoints about and experience with the application of chronotherapy principles in practice.

SETTING

Community pharmacies within metropolitan Sydney in New South Wales, Australia.

METHODS

Semi-structured, face to face interviews with a convenience sample of community pharmacists were conducted. All interviews were audio-recorded, transcribed verbatim and thematically analyzed using a 'grounded theory' approach, given the novelty of this area. Main outcome measure Community pharmacists' awareness, current practice and future practice support requirements about the principles of chronotherapy.

RESULTS

Twenty-five semi-structured interviews were conducted. Most participants reported encountering cases where clinical decision making about suggesting appropriate times of drug administration to patients was needed. Their approach was mainly pragmatic rather than based on theoretical principles of circadian variation in drug disposition or on current or emerging evidence; thus there was an evidence practice chasm in some cases. However, most participants believed they have an important role to play in counselling patients about optimal administration times and were willing to enact such roles or acquire skills/competence in this area.

CONCLUSION

Community pharmacists contribute to the safe and effective use of medications in providing the patients with information on optimal timing of drug administration during counselling. Further education, practical training and access to information may help pharmacists in translating principles of chronotherapy into the practice.

Timing is important in medication administration: a timely review of chronotherapy research

BACKGROUND

Chronotherapy involves altering the timing of medication administration to improve the overall control of a disease and to minimise treatment side-effects, and is an emerging concept in the field of therapeutics.

AIM

The aim of this review is to conduct an in-depth analysis of the recent literature in order to identify and evaluate the evidence base for drug chronotherapy.

METHOD

A literature search was conducted in three databases (Medline, Embase, International Pharmaceutical Abstracts) using the search terms "Chronotherapy", "Chronopharmacology", "Chronopharmacokinetics", "Chronopharmacodynamics", "Chronoefficacy", "Chronoformulation", "Morning and Evening", "Morning and Bedtime" and their combinations. The selection criteria for the inclusion of articles in the review included currency (years 2008-Aug 2011), publication in English language, studies done in Humans and non-review articles that pertained to 'drug' therapy.

RESULTS

Our search revealed a total of 192 journal articles, of which 41 articles were selected for review. The specific hypothesis for the effectiveness of chronotherapy that was tested in these 41 studies was chronoeffectiveness (n = 34), followed by chronopharmacokinetics (n = 5), chronomodulation (n = 3) and chronopharmacodynamics (n = 2). The findings from two-thirds (n = 27) of the reviewed studies, support the notion of chronotherapy.

CONCLUSION

The review presents the scope of chronotherapy in drug utilization. We believe that the knowledge of chronotherapy is growing and the current research for chronotherapy is promisingly in the conceptualization or early experimental phase. Going forward, chronotherapy studies should also explore genetic, gender and age related differences. Preliminary screening of new drugs for chronotherapeutic potential may be a way of enhancing quality use of medicines.

Indomethacin or amylobarbitone sodium for sleep in rheumatoid arthritis, with some observations on the use of sequential analysis

1 A double blind crossover trial in patients with rheumatoid arthritis showed that indomethacin given at night was superior to a hypnotic in providing sleep and relieving morning stiffness. 2 In a second trial, the combination of a hypnotic with indomethacin was not superior to indomethacin alone as judged by patients' preference, but further analysis suggested that the combination improved sleep without affecting morning stiffness. 3 It is argued that the use of a small closed sequential design produced too small a sample in the first trial. In the second trial, the sample was relatively large but the result was inconclusive; measurement of the response in terms of preference alone obscured the effect of treatment on one aspect of the symptomatology studied.

More Night Than Day — Circadian Rhythms in Polymyalgia Rheumatica and Ankylosing Spondylitis

The circadian rhythm of symptoms in patients with chronic inflammatory diseases is well known. Circadian rhythms could be used to identify targets for time-adapted antiinflammatory therapies, which are administered prior to the flare of cytokine synthesis and inflammatory activity. In recent years, the diurnal variations in rheumatoid arthritis have been described precisely for pain, stiffness, and functional disability, as well as the underlying cyclic variations in hormone levels and cytokine concentrations. This review summarizes the current knowledge on circadian rhythms in other rheumatic diseases, focusing on polymyalgia rheumatica and ankylosing spondylitis.

Sleep Disruptions Mediate the Relationship Between Early Postoperative Pain and Later Functioning Following Total Knee Replacement Surgery

Despite relatively standardized surgical procedures, patients undergoing total knee replacement (TKR) surgery differ dramatically in the speed of their recovery. Previous research has suggested a relationship between the experience of pain and sleep disruptions among patients with chronic pain or those undergoing surgery, such that more severe pain is associated with more frequent awakenings throughout the night. This study examined sleep disruptions 1 month following surgery as a mediator of the relationship between pain 1 month following surgery and functional limitations 3 months following surgery. A total of 110 patients scheduled to undergo unilateral TKR were examined at three time points: 2-3 weeks prior to surgery, 1 month following surgery, and 3 months following surgery. After controlling for presurgical levels of pain, sleep disruptions, and functional limitations, sleep disruptions 1 month following surgery partially mediated the relationship between pain 1 month following surgery and functional limitations 3 months following surgery. The present findings underscore the importance of adequate sleep during postsurgical recovery and suggest that interventions targeting sleep disruptions may improve the speed and quality of patients' recovery from TKR and other surgical procedures.

How pain and analgesics disturb sleep

OBJECTIVE

Clinical experiences as well as specific investigations show that pain and sleep disturbances are closely correlated. The aims of this review are first to describe sleep disturbances related to painful medical diseases and analgesics and secondly to propose management possibilities for these sleep disturbances.

METHOD

The viewpoints presented were based mainly on objective rest activity and sleep studies using actigraphy and polysomnography.

RESULTS

Polysomnographic and actigraphic studies have described significant sleep disturbances in patients suffering from different pain disorders. These disturbances are: reduced sleep efficiency and altered sleep architecture characterized by increased wakefulness and stage 1 non-rapid eye movement sleep, associated with diminished slow wave sleep and rapid eye movement sleep. Sleep disturbances may be related to pain and to the analgesic or sedative medications administered.

CONCLUSION

If many factors, including pain, disease process per se, as well as medication, could disturb sleep, sleep disturbances may also adversely affect the natural course of the painful disease. Improving sleep quantity and quality in patients with painful disorders may break this vicious circle and as consequence enhance the patients' overall health and quality of life.

Sleep disturbance and nonmalignant chronic pain: a comprehensive review of the literature

Sleep disturbance is an important clinical complaint for individuals with nonmalignant pain conditions. This review is a broad introduction to the literature on sleep disturbance and chronic pain conditions. The article critically reviews studies of sleep disturbance in musculoskeletal pain, arthritis, headache, and fibromyalgia. Current neurobiological hypotheses regarding the pathogenesis of sleep disturbance and chronic pain, common comorbid disorders, and pharmacologic and non-pharmacologic treatments for sleep disturbance are reviewed.

Brainstem modulation of pain during sleep and waking

Moderately painful stimuli applied during sleep evoke motor and neural responses indicative of arousal, but seldom cause awakening. Different reactions occur in response to acute pain stimulation across behavioral states; pain reactions are modulated by the activity of serotonergic and non-serotonergic cells in the raphe magnus (RM). Serotonergic RM cells have state-dependent discharge and may inhibit simple motor withdrawal responses during waking. ON and OFF cells are non-serotonergic RM neurons thought to facilitate and inhibit pain, respectively. These cells display reciprocal spontaneous discharge patterns across the sleep-wake cycle, with ON cells most active during waking and OFF cells most active during sleep. We propose that they also play an important role in modulating the alertness evoked by any brief external stimulus, either noxious or innocuous. ON cells may facilitate alertness during waking and OFF cells suppress arousals during sleep. In the presence of chronic pain, both ON and OFF cell discharge appear to increase. The increase in ON cell discharge may contribute to enhancing pain sensitivity and alertness. Future research is needed to understand why sleep is so adversely affected in chronic pain patients, whereas sleep is minimally disrupted, even by acutely painful stimuli, in humans and animals without chronic pain.

Sleep disturbances in outpatients with ankylosing spondylitisa questionnaire study with gender implications

OBJECTIVE

To study the sleep pattern in ankylosing spondylitis, and to investigate gender differences in sleep, pain, and fatigue.

METHODS

Forty-three male and 27 female patients with ankylosing spondylitis completed a sleep questionnaire and the results were compared with earlier findings in 3,558 persons randomly selected from the general population.

RESULTS

Too little sleep was reported by 80.8% of the female and 50.0% of the male patients, compared to 28.8% and 21.8% respectively in the reference group (p<0.0001). The main reason was pain in the pre-sleep and sleep-periods (p<0.0001). Daytime fatigue was a major problem (p<0.0001). Higher correlation was found between pain and daytime fatigue than between sleep disturbance and daytime fatigue.

CONCLUSION

Sleep disturbance is a significant problem in ankylosing spondylitis. The disturbance is closely related to pain at bedtime and during the night. Gender differences exist in the subjective sleep disturbance, fatigue, and pain.

Nighttime sleep and daytime functioning (sleepiness and fatigue) in well-defined chronic rheumatic diseases

Wake/sleep complaints are very common in the rheumatic diseases, and include: insomnia, non-restorative sleep, frequent awakenings, daytime fatigue and excessive daytime sleepiness. Imprecise use of terminology has confused 'sleep dissatisfaction' (i.e. 'non-restorative sleep') with specific sleep disorders (i.e. 'insomnia' or 'sleep fragmentation') and 'fatigue' with 'daytime sleepiness'. This review examines current concepts from the literature of disparate disciplines pertaining to the complaint of poor sleep and daytime fatigue in patients with rheumatic disorders. The ability to monitor multiple physiologic parameters during sleep (polysomnography) has led to a greater understanding of normal and abnormal phenomena which occur during sleep, and has resulted in the identification of a variety of sleep disorders which have specific therapeutic implications. Actigraphy allows the prolonged monitoring of wake/sleep patterns, and the multiple sleep latency test permits the determination of physiologic sleepiness during the daytime. These techniques enable identification of objective sleep disorders in those whose complaint is subjective sleep dissatisfaction, and permit differentiation between the easily confused complaints of excessive daytime sleepiness and fatigue. The abnormal sleep/wake symptoms in patients with rheumatic diseases may not simply be a 'non-specific' or systemic effect of the disease. Some patients may have a specific sleep disorder (either independent from, or due to, the underlying rheumatic condition) which should be diagnosed and treated specifically. Conversely, subjective 'sleep dissatisfaction' does not necessarily imply an underlying sleep disorder. The primary intent of this review is to encourage systematic, objective study of sleep and daytime function in these common, often disabling conditions.

Objective and subjective sleep disturbances in patients with rheumatoid arthritis. A reappraisal

OBJECTIVE

To assess objective and subjective evidence of sleep disturbances in patients with rheumatoid arthritis (RA) and to examine correlations between parameters of inflammatory activity and sleep pathology.

METHODS

Nineteen RA patients and 19 age-matched healthy control subjects underwent all-night polysomnography on 2 consecutive nights. RA patients were also evaluated for daytime sleepiness by mean sleep latency test and responded to a self-report questionnaire on their first night.

RESULTS

Whereas normal sleep architecture is conserved in RA, we confirmed former findings of severe sleep fragmentation and an enhanced presence of primary sleep disorders. No correlation exists between RA activity and the sleep disorders. Subjective assessment was not consistent with the objective evidence of sleep disruption, unlike the findings in patients with fibrositis.

CONCLUSION

Sleep is severely disturbed in patients with RA, regardless of the inflammatory disease activity. The specificity of the sleep disorders assessed needs confirmation, as does specific sleep therapy for these patients.

Nonsteroidal antiinflammatory drug therapy in rheumatoid arthritis patients. Lack of association between clinical improvement and effects on sleep

Thirteen patients with rheumatoid arthritis (mean +/- SD age 55.8 +/- 10.5 years) received 20 mg of tenoxicam daily for 90 days following a 3-7 day "washout" period and 4 days of placebo treatment. Clinical evaluations were conducted at the end of the washout period and at monthly intervals thereafter. All-night polysomnography was performed in a sleep laboratory during the last 2 days of placebo treatment and on days 13, 14, 89, and 90 of tenoxicam treatment. Although there was improvement in the patients' clinical condition, there were no treatment-related changes in any of the sleep parameters. Eight of the 13 patients, however, were found to have primary sleep disorders. Four had periodic leg movements during sleep, 3 had sleep apneas, and 1 had a combination of both disorders. The implications of these findings in the treatment of sleep disorders in patients with rheumatoid arthritis are discussed.

Sleep fragmentation in rheumatoid arthritis

Fatigue is commonly reported by patients with rheumatoid arthritis (RA), and it is frequently used to evaluate disease activity and response to therapy. We theorized that the feeling of fatigue in patients with RA may be a manifestation of disturbance of sleep. Sixteen patients with chronic, active RA, who were selected for early onset of fatigue (less than 6 hours after morning awakening), were extensively evaluated by formal all-night polysomnographic recording and multiple sleep latency testing (MSLT). Although no sleep deprivation was found, all patients had some type of marked disturbances of sleep, including unanticipated sleep apnea (2 patients), frequent movement of extremities (all 16 patients), and frequent arousal (all 16 patients). The alpha-delta sleep pattern was present in 13 patients, and 7 were found by MSLT to be hypersomnolent. None of the patients accurately recognized the degree of their sleep disruption. Our findings from the MSLT indicate that fatigue in patients with RA may be a manifestation of sleep fragmentation, rather than a nonspecific constitutional symptom.

Appropriate use of drugs by elderly people

The effectiveness and safety of prescribed medication theoretically depends on the patient correctly following the prescriber's instructions. However, patient compliance is often difficult to achieve. This paper discusses reasons for this in relation to elderly people, and attempts to remedy the situation are reviewed.

Pain patterns in the rheumatic disorders

Pain patterns vary greatly in the different types of arthritis, from the localized agony without mental overtones in acute gout to the diffuse disorder we call rheumatoid arthritis, where inflammation of many joints, systemic illness, anaemia, anxiety, and depression are usually all present in some degree. Each pain pattern calls for a different therapeutic approach, physical, psychological, and pharmacological. Few patients suffer as much pain and suffering over many years as do chronic arthritics. It is all the more important to instruct them in the essentials of their own treatment. A patient with an occupied and instructed mind usually suffers less than an ignorant and depressed one, fearful of her disease and its complications and of the dark uncertain future that lies ahead.