Evaluation of sleep quality in patients with ankylosing
spondylitis and efﬁcacy of anti-TNF-a therapy on sleep
problems: A polisomnographic study
and Fatma Aytul CAKCI
Department of Physical Medicine and Rehabilitation, Karabuk University Faculty of Medicine, Karabuk,
Departments of Physical
Medicine and Rehabilitation, and
Respiratory Medicine and Sleep Clinic, Diskapi Education and Research Hospital, Ankara, Turkey
Introduction: This study was conducted to investigate the relationship between sleep quality (SQ) and disease
activity (DA) in patients with ankylosing spondylitis (AS) and to evaluate the response to anti-tumor necrosis
factor a (anti-TNF-a) therapy on sleep disorders.
Materials and Methods: A total of 34 patients who met the modiﬁed New York classiﬁcation criteria for AS were
included in this prospective study. Patients were divided into two groups as follows: Group I (n = 15) with high
DA and receiving anti-TNF-a therapy, and Group II (n = 19) in remission. DA was assessed by the Bath AS Dis-
ease Activity Index. Pittsburgh Sleep Quality Index (PSQI) and polysomnography (PSG) were used to determine
disorders and patterns of sleep, respectively, in both groups at baseline as well as at the third month of anti-
TNF-a therapy in Group I.
Results: Baseline evaluation revealed impaired SQ in 57.9% of all patients. PSG demonstrated obstructive sleep
apnea syndrome, snoring and periodic leg movements in 73.7%, 74.4% and 26.3% of patients, respectively.
Prior to anti-TNF-a therapy, PSQI and snoring score were signiﬁcantly higher in Group I (P = 0.0001,
P = 0.012, respectively). Although there was a signiﬁcant reduction in PSQI scores in Group I (P = 0.005) at the
third month of anti-TNF-a therapy, no change was observed in PSG parameters (P > 0.05).
Conclusion: Sleep disorders increase in AS, particularly in patients with high DA. Anti-TNF-a therapy has
improved SQ without any improvement in PSG. Therefore, it may be concluded that PSG parameters might be
more associated with disease pathogenesis rather than DA in patients with AS.
Key words: ankylosing spondylitis, sleep quality, sleep disorders, anti-TNF-a treatment.
Ankylosing spondylitis (AS) is a chronic, systemic,
inﬂammatory disease predominantly affecting the
axial skeleton and thoracic cage, leading to wide-
spread muscle-joint pain, and dysfunction.
main etiology is not yet clear; however, macrophage
and T cell inﬁltration, and expression of proinﬂam-
matory cytokines such as tumor necrosis factor alpha
(TNF-a) have been implicated in disease pathogene-
The current optimal treatment consists of combi-
nation of pharmacological and non-pharmacological
therapies. Anti-TNF-a therapy must be considered in
patients whose disease is refractory to conventional
New York criteria for AS suggest that
patients with a Bath AS Disease Activity Index
Correspondence: Dr Gulsah Karatas, Department of Physical
Medicine and Rehabilitation, Faculty of Medicine, Karabuk
University, Karabuk, Turkey. Email: firstname.lastname@example.org
© 2017 Asia Paciﬁc League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd
International Journal of Rheumatic Diseases 2018; 21: 1263–1269