Sleep Problems in Patients with Psoriatic Arthritis: a systematic literature review and meta-analysis

Abstract

The aim of this systematic review and meta-analysis is to summarize evidence regarding the relationship between psoriatic arthritis (PsA) and sleep problems. We identified 36 eligible studies (26 cross-sectional, 7 cohort and 3 interventional) in PubMed and EMBASE. The prevalence of self-reported sleep problems in patients with PsA ranged from 30–85%. Meta-analysis of six studies that used the Pittsburgh Sleep Quality Index (PSQI) revealed a prevalence of poor sleep quality for patients with PsA of 72.9% [95%CI 63–81.8; I²:78%], statistically higher than in healthy controls (HC) (26.9% [11.7–45.4; I²: 81%]) but not significantly different than patients with psoriasis (PsO) (59.8% [46.9–72.1; I²: 51%]). Sleep disturbance was ranked in the top 4 health-related quality of life domains affected by PsA. One study suggested a bidirectional relationship between PsA and obstructive sleep apnea. Predictors of sleep problems included anxiety, pain, erythrocyte sedimentation rate, depression, fatigue, physical function, and tender/swollen joint count. TNF-inhibitors, guselkumab, and filgotinib (a JAK-inhibitor) were associated with improved sleep outcomes. Objective sleep measures (i.e., actigraphy and polysomnography) have not been used in PsA studies, and evidence on the validity of patient-reported sleep measures in PsA is lacking. In summary, poor sleep quality is prevalent in patients with PsA. Future studies should validate self-reported sleep measures in PsA, explore how sleep quality relates to PsA disease activity and symptoms using both objective and subjective sleep measures, assess the efficacy of strategies to manage sleep problems, and the effects of such management on symptoms and disease signs in patients with PsA.

Introduction

Psoriatic arthritis (PsA) is a complex inflammatory disease that manifests as peripheral arthritis, dactylitis, enthesitis, and/or spondylitis.¹ PsA is diagnosed in approximately 30% of patients with skin psoriasis (PsO)² and is associated with other systemic inflammatory diseases, including inflammatory bowel disease, cardiovascular disease, and type II diabetes.³

PsA has also been associated with sleep problems, including short sleep duration, poor sleep quality, and sleep disorders. Sleep is vital for proper physiologic and psychologic functioning.^4–6 Sleep problems are associated with chronic physical and mental health problems including cardiovascular disease, type II diabetes, obesity, and depression. Multiple studies have also shown diminished quality of life in patients who suffer from sleep problems.^7,8 Sleep problems, therefore, may present a potential additional source of risk - and of intervention - for patients with PsA who are already at risk for such comorbidities.

A growing body of literature has investigated the relationship between psoriatic disease and sleep. The aim of this systematic review is to synthesize available evidence regarding the (i) prevalence and incidence of sleep problems in patients with PsA; (ii) prevalence and incidence of PsA in patients with sleep problems; (iii) factors associated with sleep problems in patients with PsA; (iv) use of validated versus unvalidated sleep outcome measures in patients with PsA; (v) beliefs about sleep in patients with PsA; and (vi) effect of PsA therapies on sleep problems in patients with PsA.

Methodology

This review was conducted in accordance with the PRISMA guideline for systematic reviews.⁹

Inclusion criteria

We included studies that were full-text original articles in English featuring older adolescents and adults (≥16 years) in which any of the following conditions were met: (i) sleep problems were evaluated as an outcome in patients with PsA, (ii) the incidence or prevalence of PsA was evaluated in patients with sleep disorders; (iii) the quality (i.e., measurement properties) of sleep measures was evaluated in PsA; and (iv) beliefs about sleep were elicited by patients with PsA. Sub-analysis of sleep problems for the PsA population was required for studies including other populations (e.g., psoriasis, ankylosing spondylitis).

Exclusion criteria

We excluded any non-English language studies, review articles, research letters, opinion letters, notes, abstracts, and animal studies.

Literature Search

PubMed and Embase databases were searched on January 5, 2023. The PICOS criteria, Emtree, and MeSH were used to create a thorough search strategy (Supplementary Table 2). Search results were uploaded to Covidence and reviewed first by title and abstract followed by full-text review. Studies were chosen for inclusion by three independent reviewers: CG, MW, and LPC.

Data Extraction

Data extraction was performed by each independent reviewer with subsequent discussion about any disagreements. Data were organized per study aim (i) prevalence and incidence of sleep problems in patients with PsA; (ii) prevalence and incidence of PsA in patients with sleep problems; (iii) factors associated with sleep problems in patients with PsA; (iv) use of validated versus unvalidated sleep outcome measures in patients with PsA; (v) beliefs about sleep in patients with PsA; and (vi) effect of PsA therapies on sleep problems in patients with PsA.

For the purpose of this work, we agreed that an outcome measure would be considered as “validated” if any of the following measurement properties was assessed in a validation study for any population: content validity, construct validity, structural validity, reliability, and responsiveness. If none of these measurement properties was assessed in any population, the instrument was deemed as “unvalidated”.

Quality Evaluation

Two independent reviewers (LPC, MW) evaluated the quality of the data using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields developed by Kmet et al.¹⁰ This quality assessment tool was selected given the heterogeneity of study designs included in the review. Studies were classified as of high quality (>8 out of 10), good quality (6–8 out of 10), moderate quality (4–6 out of 10), and poor quality (<4).¹¹

Statistical analysis

Proportional meta-analyses were implemented to evaluate the pooled prevalence of poor sleep quality as determined by the Pittsburgh Sleep Quality Index (PSQI)¹². Heterogeneity between studies was evaluated with I² statistics and considered present if I² was greater than 50% (p<0.1).¹³ The random-effect model was applied given that the I² statistics indicated high heterogeneity. Additional meta-analyses with single means and standard deviations were incorporated to examine pooled PSQI parameters (i.e., subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction). Individual meta-analysis was performed on patients with PsA, patients with PsO, and healthy controls (HC) if at least two studies were available.¹⁴ The assessment of publication bias was not considered relevant during the proportional meta-analyses,¹⁵ and not relevant during the meta-analyses with single means due to low number of included studies. The statistical analysis was conducted using statistical software R with additional packages meta.

Results

In all, 810 references were retrieved; duplicates were removed resulting in 567 unique references for screening (Figure 1). After screening the title and/or abstract, 152 articles remained for full-text assessment. There were 116 full-text studies excluded. A total of 36 articles were included (Table 1).

Figure 1.

PRISMA Flow Diagram.

Table 1.

Characteristics of included studies.

Author, year	Study Aim	Study Design	Sample Size, n	Sex, n [M/F]	Age, years [Mean (SD)]	Sleep measure	Summary of main sleep-related results
Studies measuring sleep with an unvalidated sleep PROM
Callis Duffin 200917	Determine what clinical features of PsO predict sleep interference	Cross-Sectional	140 PsA 280 PsO	198/222 (PsA and PsO patients)	28.9 (16.4) (PsA and PsO patients)	Sleep interference question	Prevalence of “sleep interference” in the entire sample: 49.5% PsA was the most significant predictor of sleep interference Itching and physical pain or soreness were also independently associated with sleep interference
Haugeberg, Hoff 202023	Explore the occurrence of sleep disturbances, fatigue, and anxiety/depression in PsA	Cross-Sectional	137 PsA	68/69	52.3 (10)	Sleep difficulty question (NRS)	Prevalence of sleep disturbance (sleep difficulty NRS>5): 38% Sleep difficulty NRS mean (SD): 3.5 (2.9) Pain, fatigue, and higher MHAQ were independently associated with sleep disturbance NRS sleep disturbance score presented strong correlations with fatigue, pain, and MHAQ and moderate correlation with anxiety/depression
Haugeberg, Michelsen 202025	Explore the impact of the various disease manifestations and disease consequences on HRQoL in PsA patients treated with biologics	Cross-Sectional	131 PSA	66/65	51.9 (10.1)	Sleep disturbance question (NRS)	NRS sleep difficulty mean (SD): 3.34 (2.94) Impaired HRQOL was independently associated with sleep disturbance
Haugeberg 202124	Explore associations between sleep disturbance, fatigue, pain, anxiety, depression, general health status, and satisfaction with life before and after a diagnosis of PsA	Cross-Sectional	160 PsA 36,347 HC	66/94 PsA 16001/20346 HC	44.1 (10.5) PsA 47.0 (13.4) HC	Sleep difficulty question (NRS)	Prevalence of sleep disturbances in individuals who developed PsA compared to those without PsA was increased only after a diagnosis of PsA (Adjusted OR 2.03 [95% CI 1.35–3.06]) Prevalence of sleep disturbances in PsA: 30%, in HC: 15.3%
Smith 201934	Understand the nature of sleep disturbance in patients with PsA	Cross-Sectional	1530 PsA 1588 PsO	960/2153 (whole sample)	NR	Sleep difficulty question	Prevalence of “sleep difficulty” in the entire sample: 58.4% Prevalence of short sleep duration in the entire sample (<7h): 38.8% Sleep difficulty was independently associated with PsA, female gender, obese body mass index (BMI>30), OSA, PsO severity of moderate or severe, and smoking
Wendler 202248	Assess long-term effectiveness, impact on quality of life, and safety of ustekinumab treatment for PsA	Cohort	129 PsA	NR	NR	Sleep quality (100-mm VAS) - question and anchors not described	Absolute change from baseline to week 4: 3.3; week 28: 4.9; week 52: 6.2; week 76: 1.4; week 100: 6.5; week 124: 7.1; week 160: 9.5.
Studies measuring sleep with a sleep question embedded in a psoriatic disease PROM
Azarfar 202116	Determine the prevalence and correlation of anxiety, depression, sleep disturbance, fibromyalgia, and obesity in rheumatic patients	Cross-Sectional	22 PsA 27 SLE 116 RA 20 SS 31 >1 diagnosis	NR	NR	RAPID3 (“good night sleep” question)	Prevalence of “sleep disturbance” in PsA: 71.4%, RA: 78.6%, SS: 85.7%, SLE: 60.9%, and >1 diagnosis 77.8%
Desthieux 201719	Assess patient-physician discordance in PsA and patient-reported domains of health associated with discordance	Cross-Sectional	460 PsA	223/237	50.6 (12.9)	PsAID (“sleep disturbance” question)	PsAID sleep disturbance mean (SD) 3.4 (3.3) Sleep was not independently associated with discordance between PGA and PhGA
Palominos 202031	Analyze determinants of impaired sleep in patients with PsA	Cross-Sectional	396 PsA	194/202	51.9 (12.6)	PsAID (“sleep disturbance” question)	PsAID sleep disturbance median (25th–75th IQR): 2 (0–6) Prevalence of “sleep impairment”: 39.6% Sleep impact among the 14 countries and continent was comparable (p>0.05) Sleep disturbance was independently associated with anxiety and pain
Puyraimond-Zemmour 201732	Explore the link between a PASS and patient-perceived impact in RA and PsA	Cross-Sectional	446 PsA 531 RA	224/221 PsA 117/414 RA	50.6 (12.6) PsA 55.8 (13.3) RA	PsAID (“sleep disturbance” question)	PsAID sleep disturbance mean (SD): 3.3 (3.2) Mean (SD) of those in PASS: 2.4 (2.7) Mean (SD) of those NOT in PASS: 4.8 (3.4) Cohen’s d (95% CI): 0.82 (0.66–1.00) - relevant if >0.5. Pain and coping were independently associated with being in PASS. Fatigue, coping functional capacity and sleep disturbance were not associated with PASS status. Sleep disturbance cutoff points for PASS: 2 (Sensitivity/specificity: 0.77/0.50)
Pincus 199946	Develop components of a MHAQ through the addition of new items in the patient friendly HAQ format	Cohort	18 PsA 162 RA 114 FM 63 OA 34 SLE 20 Vasculitis 16 Scleroderma 261 Other	NR	50.2	MDHAQ (“good night sleep” question)	“Good night sleep” mean: 2.17; lower compared to FM (2.8), SLE (2.33)
Orbai 202049	Examine the effects of filgotinib on HRQoL in active PsA	RCT	131 PsA	NR	NR	PsAID (“sleep disturbance” question)	PsAID sleep disturbance mean (SD) Filgotinib (n=65): −1.9 (2.4) PsAID sleep disturbance mean (SD) Placebo (n=66): −1.0 (2.9) Treatment difference: −1.28 (−2.10, −0.46), p=0.0025
Studies measuring sleep with a sleep PROM validated in other populations
Cano-García 202118	Describe sleep disorders and positive psychological factors in patients with AxSp and PsA	Cross-Sectional	149 PsA 152 AxSp	53/96 PsA 102/50 AxSp	48.4 (10.1) PsA 49.4 (10.4) AxSp	OSQ	OSQ median (IQR): 3.0 (2.0–4.0) Insomnia was independently associated with depression and emotional recovery Patients with AxSp more frequently had insomnia than patients with PsA; p=0.014 Patients with PsA had higher values for pain intensity (p=0.001) and pain interference (p<0.001) than patients with AxSp OSQ insomnia score presented moderate correlation with depression
Duruoz, Baklacioglu 201820	Evaluate the static and dynamic balances in PsA and investigate their relationship with clinical and functional parameters	Cross-Sectional	50 PsA 50 HC	10/40 PsA 10/40 HC	45.02 (12.81) PsA 45.12 (10.56) HC	PSQI	Prevalence of “sleep disorders”: 76% Prevalence of fatigue: 88% PSQI mean (SD): 8.2 (4.11) There was no correlation between the balance tests and depression, sleep disorders, fatigue, foot deformities, foot function, fear of falling, or BMI
Gezer 201721	Determine the effects of PsA on sleep quality, quality of life and psychological state	Cross-Sectional	41 PsA 38 HC	16/25 PsA 13/25 HC	41.36 (12.60) PsA 38.02 (9.79) HC	PSQI	Prevalence of “poor sleep quality” in PsA: 85.4%, HC: 28.9%; p < 0.001 PSQI mean (SD): 9.70 (3.90) All PSQI scores were significantly higher in patients with PsA compared to HC, (p<0.05) PSQI score presented moderate correlations with anxiety, generalized pain, PsAQoL scores, enthesitis, CRP, ESR, and age Sleep disturbance was independently associated with ESR
Krajewska-Wlodarczyk 201828	Assess and measure occurrence of sleep disorders in patients with PsA and PsO	Cross-Sectional	62 PsA 52 PsO 41 HC	29/33 PsA 25/27 PsO 20/21 HC	47.8 (8.9) PsA 42.4 (12.4) PsO 42.4 (11.6) HC	PSQI	PSQI mean (SD) PsA: 9.32 (5.02); PsO: 7.11 (4.31); HC: 4.05 (2.91) Prevalence of “poor sleep quality” in PsA 67.7%; PsO: 57.7%; HC: 14.6%; p<0.001 Methotrexate treatment was not related to sleep problems Anti-TNF antibodies had a beneficial effect on sleep problems in PsA and PsO Sleep quality was independently associated with pain, tender joint count, CRP, age, and duration of PsO. PSQI sleep quality presented moderate correlations with age, pain severity, tender joints, HAQ, fatigue, and duration of skin disease and weak correlation with CRP
Orbai 202250	Assess the effects of treatment on general health outcomes in patients with PsA	RCT	381 PsA	186/195	48.4 (11.4)	PROMIS Sleep Disturbance	Sleep disturbance baseline scores were higher than the US population norm (50), but within 1/2 SD (5 points) of the norm: Mean (SD) sleep disturbance score: 52 (6.9) for guselkumab Q4W, 52.3 (6.8) for guselkumab Q8W, and 51.8 (7.3) for placebo Guselkumab Q4W and Q8W improved sleep scores by week 24, and improvement was even more pronounced by week 52.
Sandikci 201933	Determine the prevalence of RLS in PsA patients and investigate a relationship between sleep and quality of life impairments of RLS in PSA patients	Cross-Sectional	50 PsA 50 PsO 50 HC	17/33 PsA 22/28 PsO 16/34 HC	44.7 (12.0) PsA 40.4 (13.9) PsO 42.6 (12.6) HC	RLS Study Group Criteria / PSQI / ESS/ ISI	Prevalence of RLS in PsA: 64% compared to PsO: 20%; p<0.001 and HC: 14%; p<0.001 PSQI median (min-max) in PsA: 5.0 (0–17), PsO: 4.0 (0–17), HC: 2.5 (0–16); p<0.001 ISI median (min-max) in PsA: 4 (0–23), in PsO: 5 (0–28), HC: 2.5 (0–23); p<0.05 ESS was similar across PsO, PsA, and HC RLS was independently associated with PSQI, FSS, SF-36 PF, and BDI RLS score presented moderate correlations with PSQI and SF-36 PCS and weak correlations with ISI and SF-36 MCS
Skougaard 202238	Determine the prevalence of sleep disturbances in PsA, PsO, and HC and explore associations between PSQI and PROMs/treatment	Cross-sectional	109 PsA 20 PsO 20 HC	44/65 PsA 10/10 PsO 10/10 HC	53.9 PsA 52 PsO 51.3 HC	PSQI	Prevalence of “poor sleep quality” in PsA 66.1%, PsO 45% p<0.001; HC 15% p<0.001 PSQI median (IQR) in PsA: 7.0 (5–11), PsO: 4.0 (2–8), HC: 4 (2.8–5); p<0.001 Univariate analysis, PSQI score in PsA was associated with DAS28-CRP, tender joint count, VAS global, VAS pain, PsAID fatigue, HAQ and Pain detect questionnaire. Multivariate analysis, PSQI score in PsA was associated with tender joint count, VAS global, VAS pain. TNF- and IL-17 inhibitors did not influence the change in PSQI scores over time.
Ulutatar 202035	Examine the presence of neuropathic pain in PsA and its relationship with functional parameters	Cross-Sectional	50 PsA	18/32	Median (IQR)=50.5 (17)	PSQI	PSQI median (IQR): 10 (7) in patients with NP, and 4 (9) patients without NP; p=0.002 PDQ score presented moderate correlation with PSQI
Ulutatar 202136	Evaluate the relationship of fibromyalgia with enthesopathy, sleep, fatigue, and quality of life in PsA	Cross-Sectional	50 PsA	19/31	50 (10.3)	PSQI	Prevalence of “poor sleep quality”: 54% PSQI mean (SD) among patients with FMS: 8.5 (4.5); patients without FMS: 2.8 (3.1); p<0.0005 FIQ score presented strong correlation with PSQI
Wong 201737	Determine the prevalence and quality of sleep-in patients with PsA and those with PsO to compare findings to controls	Cross-Sectional	113 PsA 62 PsO 52 HC	62/51 PsA 25/37 PsO 15/37 HC	57.4 (11.58) PsA 56.9 (14.2) PsO 42.2 (13.6) HC	PSQI	Prevalence of “poor sleep quality” in PsA: 84%, PsO: 69%, and HC: 50% PSQI mean (SD): 9.24 (3.54) in PsA, in PsO: 7.18 (2.9) and in HC: 5.67 (2.12); (all p<0.001) All PSQI parameters were significantly higher in patients with PsA compared to HC EQ5D Anxiety, EQ5D final and FACIT-Fatigue were associated with worse PSQI in patients with PsO and PsA (p<0.05) TSJC are independently associated with worsePSQI in patients with PsA (p<0.01)
Tektonidou 202047	Evaluate the effect of adalimumab on work productivity measures, overall activity impairment, and sleep quality in patients with active moderate to severe RA, PsA, or AS	Cohort	166 PsA 184 RA 150 AS	73/93 PsA 99/51 RA 39/145 AS	Median (IQR)= 51.0 (41.0–60.8) PsA 60.0 (50.8–69.0) RA 45.0 (34.3–56.0) AS	MOS-SS	Adalimumab significantly lowered the MOS-SS SPI after 24-month treatment: MOS-SS median (IQR) baseline: 42.2 (29.2−57.5) MOS-SS median (IQR) after 24 month: 13.3 (4.4−20.8) MOS-SS median (IQR) change: −29.4 (−43.3 to −11.4), statistically significant p<0.001 High correlation between change in MOS-SS and PGA and PhGA
Strober 201251	Assess the extent of sleep impairment, the effect of adalimumab on sleep, patient-reported outcomes, and correlations between changes in these outcomes and sleep quality	Non-RCT	71 PsA 81 PsO	NR	47.6 (13.7) (whole sample)	MOS-SS	Among all patients, adalimumab showed improvement in sleep quality by 15% from baseline SPI-I mean (SD) baseline: 34.3 (24.3) SPI-I mean (SD) change by month 16: 4.9 SPI-II mean (SD) baseline: 35.1 (17.4) SPI-II mean (SD) change by month 16: 5.2 PsA was significantly (p<0.05) associated with sleep adequacy MOS-SS score was independently associated with PASI, DLQI, depression, PsA, and WPAI
Studies evaluating sleep beliefs in PsA
Hu 201026	Piloted a novel application of WTP as a Patient Reported Outcome to measure the relative impact of PsA in 8 domains of HRQoLmk	Cross-Sectional	59 PsA	56/44	30% <45 years, 70% ≥ 45 years	Domain evaluated: “Ability to Sleep”	60% of participants believed that sleep disturbances were affected by PsA 60% of participants ranked sleep disturbances in the top 4 domains affected by PsA 59% of participants were WTP for a cure in this domain WTP Median Amount in US$ (25th quartile, 75th quartile): 10,000 (5000, 50,000)
Kotulska 201827	Evaluate various aspects of satisfaction and dissatisfaction of Polish patients treated with biologics	Cross-Sectional	117 PsA 606 RA 427 AS 62 JIA	297/52 PsA 121/485 RA 297/130 AS 15/47 JIA	18–29: 183 (15.2) 30–39: 255 (21) 40–49: 239 (19.7) 50–59: 332 (27.4) (whole sample)	Question: effect of biologics on sleep quality	28.2% participants with PsA believed that biologics had a ‘very beneficial’ effect on sleep quality 38.5% participants with PsA believed that biologics had a ‘beneficial’ effect on sleep quality
Ogdie 202030	Characterize and develop a conceptual model to represent the patient experience of PsA	Cross-Sectional	19 PsA	6/13	<60: 7 60–70: 6 >70: 6	Factor impacting PsA: Sleep disturbance	>80% of PsA participants mentioned sleep disturbance as a salient impact
Ogdie 202239	Evaluate patients’ experiences regarding the burden of PsA symptoms and disease impacts, and patients’ preferences for treatment	Cross-Sectional	332 PsA	66/266	53.9 (11.4)		Of a list of 9 candidate disease impacts, sleep quality was reported by 92% of participants, being the second most frequently reported disease impact following difficulties performing physical activities. The top 3 disease impacts that were important to improve included: 1. ability to perform physical activities (10/10.), 2. Ability to function independently (7/10), and 3. Sleep quality (6/10). Improvement in sleep quality was of greater importance to bDMARD-naive respondents than to bDMARD-experienced respondents (P<0.05)
Nowell 202145	Understand which patient-reported outcomes patients with rheumatic and musculoskeletal disease are considered most important to track for disease management	Cohort	34 PsA 67 RA 56 FM 87 OA 6 SLE 18 AS 34 OP	16/124 (whole sample)	55.1 (9.3) (whole sample)	Sleep measure ranked: PROMIS Sleep Disturbance	PROMIS mean (SD): 21.0 (24.4) Patients with PsA ranked the PROMIS sleep disturbance as the 4th most important PROM to track disease management
Tsang 202240	Assess the correlation between cannabis use and psoriatic disease severity, health-related quality of life, pain, psychosocial outcomes, and cytokine levels in patients with PsO and PsA.	Cross-Sectional	100 PsA 51 PsO	80/71 (whole sample)	55.75 (13.4) (whole sample)	Perceived benefit of cannabis on sleep	63% patients believed that use of cannabis helped them sleep better
Claims-based studies using ICD codes
Cohen 201542	Evaluate association between OSA and snoring and incidence of PsO and PsA	Cohort	71,108 No OSA 490 OSA	All females	61.2 (6.8) No OSA 61 (6.8) OSA	OSA ICD code	Women with OSA had a significantly increased risk of PsO, but not PsA RR of PsA among women with OSA
Egeberg 201643	Investigate the potential bidirectional association between PsO and OSA	Cohort	6,348 PsA 53,290 Mild PsO 6,885 Severe PsO 5,393,040 No PsO/PsA	2774/3574 PsA 25,868/27,422 Mild PsO 3473/3412 PsA Severe PsO 2,659,620/2,733,420 No PsO/PsA	40.4 (13.8) PsA 44.8 (16.7) Mild PsO 43.2 (15.7) Severe PsO 40.8 (19.7) No PsO/PsA	OSA ICD code	PsO and PsA were associated with increased risk of OSA, and OSA was associated with increased risk of PsO and PsA
Studies evaluating measurement properties or interpretability of patient-reported sleep measures in PsA
Duruoz, Erdem 201841	Investigate the validity and reliability of the Turkish version of JSS in PsA	Cross-Sectional	56 PsA	12/44	42.71 (11.79)	JSS	JSS mean (SD): 8.08 (5.35) Cronbach’s alpha: 0.862. JSS score presented weak correlations with duration of disease and duration of joint symptoms
Guler 202022	Validate the Turkish version of the PsAID	Cross-Sectional	80 PsA	20/60	50.2 (9.9)	PsAID (“sleep disturbance” question)	PsAID sleep disturbance median (IQR): 4.0 (1.75–7.0) PsAID sleep disturbance presented moderate to strong correlations with other PSAID items
Morante 202129	Address the clinimetric properties of the instrument ASAS-HI in patients with PsA	Cross-Sectional	90 PsA	52/38	Median (IQR): 53 (45–65)	ASAS-HI (‘I sleep badly at night’ question)	PsAID sleep disturbance mean (SD): 2.8 (2.3) Item “I sleep badly at night’ was independently associated with PsA disease activity (DAPSA) Item “I sleep badly at night’ was independently associated with the PSAID
Kwok 201044	Determine the MID for the HAQ-DI, pain, fatigue, sleep, and global VAS in patients with PsA using a patient-reported overall health status anchor	Cohort	200 PsA	83/117	51.05 (14.08)	Sleep (VAS)	Sleep VAS mean (SD) baseline: 37.99 (32.93) Sleep VAS mean (SD) follow up: 38.83 (32.32) Sleep VAS mean (SD) change: 0.75 (27.19) Sleep VAS MID estimate for “better” sleep: −10.97 (27.94; −21.35, −0.60) Sleep VAS MID estimate for “worse” sleep: 13.81 (27.32; 5.88, 21.75)

AS, ankylosing spondylitis; ASAS-HI, Assessment of SpondyloArthritis international Society-Health Index; AxSp, axial spondyloarthritis; BDI, Beck Depression Inventory; BMI, body mass index; CI, confidence interval; CRP, C-reactive protein; DAPSA, Disease Activity in Psoriatic Arthritis; DLQI, Dermatology Life Quality Index; EQ5D, European Quality of Life-5 Dimensions; ESR, erythrocyte sedimentation rate; ESS, Epworth sleepiness scale; FACIT-Fatigue, Functional Assessment of Chronic Illness Therapy-Fatigue; FIQ, Fibromyalgia Impact Questionnaire; FM, fibromyalgia; FSS, fatigue severity scale; HAQ-DI, health assessment questionnaire disability index; HC, healthy controls; ICD, international classification of diseases; IQR, interquartile range; ISI, insomnia severity index; JIA, juvenile idiopathic arthritis; JSS, Jenkins Sleep Scale; MAF, Multidimensional Assessment of Fatigue; MDHAQ, Multidimensional Health Assessment Questionnaire; MHAQ, modified health assessment questionnaire; MID, minimal important difference; MOS-SS, Medical Outcomes Study Sleep Scale; NP, neuropathic pain; NR, not reported; NRS, numeric rating scale; OA, osteoarthritis; OP, osteoporosis; OR, odds ratio; OSA, obstructive sleep apnea; OSQ, Oviedo Sleep Questionnaire; PASI, psoriasis area and severity index; PASS, patient acceptable symptom state; PDQ, pain DETECT questionnaire; PGA, patient global assessment; PhGA, physician global assessment; PROM, patient-reported outcome measure; PROMIS, patient-reported outcomes measurement information system; PsA, psoriatic arthritis; PsO, psoriasis; PsAID, Psoriatic Arthritis Impact of Disease; PSQI, Pittsburgh Sleep Quality Index; QoL, quality of life; RA, rheumatoid arthritis; RAPID3, Routine Assessment of Patient Index Data 3; RCT, randomized controlled trial; RLS, restless legs syndrome; RR, relative risk; SF-36 MCS, Short Form-36 Mental Health Component Score; SF-36 PCS, Short-Form 36 Physical Component Score; SLE, systemic lupus erythematosus; SPI, sleep problem index; TJC, tender joint count; TNF, tumor necrosis factor; TSJC, tender and swollen joint count; WPAI, Work Productivity and Activity Impairment; WTP, willingness-to-pay; VAS, visual analogue scale

Study Design and Quality Evaluation

We identified (i) 33 observational studies, including 26 cross-sectional studies^16–41, 7 cohort studies^42–48, and (ii) 3 interventional studies, including 2 RCT^49,50 and 1 non-RCT⁵¹. Supplementary Table 3 includes the quality evaluation for studies. Most studies were of high quality (i.e., low risk of bias). Common limitations of these studies included absence of sample size calculations and limited methods to adjust for confounders. Two qualitative studies^26,45 had moderate risk of bias due to limitations in sampling strategy, verification of study results, and data collection methods.

Prevalence and incidence of sleep problems in patients with PsA

Sleep problems were defined in different ways across studies, using a variety of measures. Based on these multiple definitions, the prevalence of sleep problems in patients with PsA ranged from 30 to 85% (Table 1 and Supplementary Table 4). Meta-analysis of the prevalence of poor sleep quality across 6 studies^{20,21,28,36–38} that used the PSQI¹² revealed a prevalence of poor sleep quality for patients with PsA of 72.9% [95%CI 63–81.8; I²:78%], statistically higher than in healthy controls (HC) (26.9% [11.7–45.4; I²: 81%])^28,37,38 but not significantly different than patients with psoriasis (PsO) (59.8% [46.9–72.1; I²: 51%])^21,28,37,38 Figure 2 and Supplementary Table 5).

Figure 2.

Meta-analysis of the prevalence of ‘poor sleep quality’ as measured by the Pittsburgh Sleep Quality Index (PSQI) in patients with psoriatic arthritis, patients with psoriasis, and healthy controls.

Meta-analysis of the prevalence of ‘poor sleep quality’ as measured by the Pittsburgh Sleep Quality Index (PSQI) in patients with psoriatic arthritis, patients with psoriasis, and healthy controls.

Regarding discrete sleep disorders, as defined by the International Classification of Sleep Disorders, one study reported that the prevalence of restless legs syndrome (RLS) in patients with PsA was 64%; significantly higher compared to patients with PsO (20%) and HC (14%).³³ Insomnia was more frequent in patients with axial spondylarthritis (AxSp) than patients with PsA (PsA insomnia score [Median (IQR): 26.0 (18.0–30.7)] vs. AxSp [Median (IQR): 22.0 (15.2–28.7)], p=0.014); prevalence estimates, however, were not reported¹⁸ (Table 1 and Supplementary Table 4).

Using data from the Danish National Patient Register, Egeberg et al. reported an incidence rate ratio (IRR) of 1.75 (95% CI 1.35–2.26) for sleep apnea (ICD-10 G473) in patients with PsA, after adjusting for age, sex, smoking, alcohol, comorbidities, and socioeconomic status⁴³ (Table 1 and Supplementary Table 6).

Prevalence and incidence of PsA in patients with sleep apnea

Egeberg et al. identified a high incidence of PsA in patients with sleep apnea (IRR of PsA in sleep apnea treated with continuous positive airway pressure (CPAP): 1.94 (95% CI 1.34–2.79 and without CPAP: 5.59 (95% CI 3.74–8.37), showing a significant bidirectional association in adjusted models.⁴³ Cohen et al. further reported that patients with obstructive sleep apnea (OSA) had an increased risk of developing PsA (Table 1 and Supplementary Table 6).⁴² No studies determining the prevalence and incidence of PsA in other sleep disorders (e.g., insomnia, RLS) were found.

Factors associated with sleep problems in patients with PsA

Overall, we found moderate-to-strong (0.3 ≤ r < 0.7) correlations between sleep problems and pain, fatigue, physical function, emotional distress, tender joint counts, enthesitis, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), patient age, and number of tender joints (Supplementary Table 7). In studies in which the sample consisted of patients with psoriasis and PsA, PsA was identified as an independent predictor of sleep problems.^17,34,51 Other factors independently associated with sleep problems in this population were itch, physical pain or soreness, female sex, obesity, OSA, moderate and severe psoriasis severity, smoking, poor dermatologic quality of life, and work productivity impairment (Supplementary Table 8).

In studies in which the sample consisted of patients with PsA (with or without psoriasis),^{18,21,23,28,31,37,38} pain was the most frequently identified factor independently associated with sleep problems, followed by actively inflamed or tender joints. Other factors independently associated with sleep problems included depression, anxiety, emotional recovery, physical function, itch, ESR, CRP, age, and duration of psoriasis (Supplementary Table 8).

Sleep problems were identified as a predictor of fatigue⁵² [i.e., a sustained, overwhelming sense of exhaustion associated with decreased capacity for physical and mental work that is different from sleepiness (i.e., propensity to sleep⁵³]. Sleep problems were also identified as a predictor of poor health-related quality of life [as measured by the 15-Dimensional Questionnaire], and active PsA [as measured by the Disease Activity in Psoriatic Arthritis (DAPSA) score]²⁹ (Supplementary Table 8).

Use of validated sleep PROMs in patients with PsA

Twenty-four studies (67%) utilized a patient-reported outcome measure (PROM) to assess sleep (Table 1). Six of these studies used a sleep question that had not been previously validated in any population. Six studies used a sleep question embedded in a validated psoriatic disease PROM (i.e., PsAID, RAPID3, and MDHAQ). Twelve studies used a PROM that was previously validated to measure sleep in other populations but not in PsA (i.e., Ottawa Sleep Scale, PSQI, PROMIS Sleep disturbance, Epworth Sleepiness Scale, Insomnia Severity Index, and the Medical Outcomes Sleep Scale).

We identified four studies evaluating one or more measurement properties of sleep measures in patients with PsA.^22,29,41,44 The evaluated sleep measures included the Jenkins Sleep Scale (JSS), the PsAID item “sleep disturbance”, the Assessment of SpondyloArthritis International Society Health Index (ASAS-HI) item “I sleep badly at night’, and the sleep Visual Analogue Scale (VAS, 0–100 mm; 0 mm = no/minimal symptoms, 100mm = worse symptoms) (Table 1).

Sleep problems as measured by the PSQI

Eight studies assessed sleep problems in patients with PsA with the PSQI.^{20,21,28,33,35–38} PSQI scores ranged from 5.0–10.0. Patients with PsA consistently presented with worse sleep quality than HC and patients with PsO. Patients with PsA that had neuropathic pain or fibromyalgia had worse sleep quality than patients without neuropathic pain or fibromyalgia.^35,36

Meta-analysis of the mean scores for the sleep dimensions assessed by the PSQI (i.e., PSQI parameters) across 3 studies showed that mean sleep quality, latency, disturbances, and day dysfunction were significantly higher in patients with PsA compared to HC (Supplementary Table 10 and Supplementary Figures 1–4).^21,28,37 Evaluating the overlapping confidence interval, differences between patients with PsA and PsO were considered not significant. Use of sleep medication was comparable across groups. PSQI parameters are each scored on a 0–3 scale, where a higher score reflects worse sleep. Sleep efficiency was the sleep dimension most affected (Mean (SD) 2 [1.1; 2.9]), followed by sleep latency (1.6 [1.3; 1.9]), sleep disturbance (1.6 [1.4; 1.8]), and day dysfunction (1.5 [1.1; 2]) (Supplementary Table 10).

Sleep problems as measured by the PsAID questionnaire

Four studies evaluated sleep with the ‘sleep disturbance’ item from the PsAID questionnaire.^19,31,32,49 The score ranged from 0–7, with a mean (SD) ranging from 1.9–3.4 (2.4–3.3). In Palominos et al., a score of 4 or higher was considered as having ‘sleep disturbance’ mirroring the PsAID cut-off value used to identify patients at a patient acceptable symptom state (PASS).³¹ Other studies did not clarify what cut-off value was used to define ‘sleep disturbance’. Puyraimond et al. described that a value of 2 for the ‘sleep disturbance’ item corresponded to PASS level.³² This threshold had a sensitivity of 0.77 and specificity of 0.5 (Table 1).

Studies evaluating beliefs about sleep problems in patients with PsA

Six studies explored patients’ beliefs about sleep problems in patients with PsA (Table 1).^26,27,30,45 Hu et al. described that 60% of participants believed that sleep was affected by PsA and ranked sleep disturbances in the top 4 domains affected by PsA. Additionally, they reported that 59% of participants were willing to pay for a cure in this domain [median (25^th quartile, 75^th quartile): $10,000 ($5000, $50,000)].²⁶ In Nowell et al., patients with PsA ranked the PROMIS sleep disturbance domain as the 4^th most important PROM to track disease management.⁴⁵ In one study, 78 (67%) participants believed that biologics had a ‘very beneficial’ or ‘beneficial’ effect on sleep quality,²⁷ and in another study 29 (63%) patients believed that the use of cannabis helped them sleep better.⁴⁰ More that 80% of participants further identified sleep disturbance as an important impact in patients with PsA, along with physical disability, effects on daily activities, and feelings of frustration.³⁰ In a study involving 332 participants, improving sleep quality was identified as the third most important disease impact that required improvement, ranking higher than the ability to do physical activities, participate in work, social or leisure activities, and emotional well-being.

Effect of PsA therapies on sleep problems in patients with PsA

Three studies, including 1 non-RCT⁵¹, 1 cohort⁴⁷, and 1 cross-sectional study²⁸, showed TNF-inhibitors improved sleep problems in patients with PsA as measured by the PSQI and the MOS-SS. One cohort study showed improvement in sleep quality (VAS) with ustekinumab but changes were not statistically significant, whereas a RCT reported improved sleep with guselkumab⁵⁰. Another RCT showed significant improvement in the PsAID ‘sleep disturbance’ item following treatment with filgotinib, a JAK-inhibitor⁴⁹. In a cohort study including initiators of TNF- and IL17 inhibitors, the proportion of patients who had poor sleep quality at baseline dropped from 71.9% to 47.4% (p= 0.01) by month 4. However, mixed-effect models found that initiating either of those therapies did not influence changes in PSQI scores³⁸. (Table 2).

Table 2.

Effect of therapies on sleep problems.

Author, year	Study Aim	Study Design	Sample Size, n	Sex, n [M/F]	Age, years [Mean (SD)]	Sleep measure	Summary of main sleep-related results
Studies measuring sleep with a sleep question embedded in a psoriatic disease measure
Orbai 202049	Examine the effects of filgotinib on HRQoL in active PsA	RCT	131 PsA	NR	NR	PsAID (“sleep disturbanc e” question)	PsAID sleep disturbance mean (SD) Filgotinib (n=65): −1.9 (2.4) PsAID sleep disturbance mean (SD) Placebo (n=66): −1.0 (2.9) Treatment difference: −1.28 (−2.10, −0.46), p=0.0025
Studies measuring sleep with a sleep PROM validated in other populations
Krajewska-Wlodarczyk 201828	Assess and measure occurrence of sleep disorders in patients with PsA and PsO	Cross-Sectional	62 PsA 52 PsO 41 HC	29/33 PsA 25/27 PsO 20/21 HC	47.8 (8.9) PsA 42.4 (12.4) PsO 42.4 (11.6) HC	PSQI	Methotrexate treatment was not related to sleep problems Anti-TNF antibodies had a beneficial effect on sleep problems in PsA (p<0.001) and PsO (p=0.032)
Orbai 202250	Assess the effects of guselkumab on general health outcomes in patients with PsA	RCT	381 PsA	186/195	48.4 (11.4)	PROMIS Sleep Disturbanc e	Guselkumab Q4W and Q8W improved sleep scores by week 24, and improvement was even more pronounced by week 52. Least-squares mean (95% CI) changes in T-scores from baseline – Week 24: GUS Q4W− 2.5 (− 3.5, − 1.4); GUS Q8W− 3.5 (− 4.6, − 2.4); p ≤ 0.01; Placebo − 1.2 (− 2.3, − 0.1) Least-squares mean (95% CI) changes in T-scores from baseline - Week 52: GUS Q4W − 3.7 (− 4.7, − 2.7); GUS Q8W − 3.9 (− 5.0, − 2.9); Placebo − 2.8 (− 3.8, − 1.7) Proportion of patients achieving ≥ 5-point improvements in T-scores from baseline to Week 24: GUS Q4W 33%, GUS Q8W 37% (p < 0.01); Placebo 21% Proportion of patients achieving ≥ 5-point improvements in T-scores from baseline to Week 52: GUS Q4W 38%, GUS Q8W 43%, Placebo 33%
Tektonidou 202047	Evaluate the effect of adalimumab on work productivity measures, overall activity impairment, and sleep quality in patients with active moderate to severe RA, PsA, or AS	Cohort	166 PsA 184 RA 150 AS	73/93 PsA 99/51 RA 39/145 AS	Median (IQR)= 51.0 (41.0–60.8) PsA 60.0 (50.8–69.0) RA 45.0 (34.3–56.0) AS	MOS-SS	Adalimumab significantly lowered the MOS-SS SPI after 24-month treatment: MOS-SS median (IQR) baseline: 42.2 (29.2−57.5) MOS-SS median (IQR) at month 24: 13.3 (4.4−20.8) MOS-SS median (IQR) change: −29.4 (−43.3 to −11.4), statistically significant p<0.001 High correlation between change in MOS-SS and PGA and PhGA
Skougaard 202238	Determine the prevalence of sleep disturbances in PsA, PsO, and HC and explore associations between PSQI and PROMs/treatment	Cohort	109 PsA 20 PsO 20 HC	44/65 PsA 10/10 PsO 10/10 HC	53.9 PsA 52 PsO 51.3 HC	PSQI	TNF- and IL-17 inhibitors did not influence the change in PSQI scores over a 4-month period. TNF-α inhibitor initiators: PSQI Mean change −1.1 ± 6.3 (95% CI −13.6 to 11.4, p = 0.668) IL-17 inhibitor initiators: PSQI Mean change −1.9 ± 6.2 (95% CI −14.4 to 10.6, p = 0.406)
Strober 201251	Assess the extent of sleep impairment, the effect of adalimumab on sleep, patient-reported outcomes, and correlations between changes in these outcomes and sleep quality	Non-RCT	71 PsA 81 PsO	NR	47.6 (13.7) (whole sample)	MOS-SS	Among all patients, adalimumab showed improvement in sleep quality by 15% from baseline SPI-I mean (SD) baseline: 34.3 (24.3) SPI-I mean (SD) change by month 16: 4.9 SPI-II mean (SD) baseline: 35.1 (17.4) SPI-II mean (SD) change by month 16: 5.2 PsA was significantly (p<0.05) associated with sleep adequacy
Wendler 202248	Assess the long-term effectiveness, impact on quality of life, and safety of ustekinumab treatment for PsA	Cohort	129 PsA	NR	NR	Sleep quality (100-mm VAS)-question and anchors not described	Absolute change from baseline to week 4: 3.3; week 28: 4.9; week 52: 6.2; week 76: 1.4; week 100: 6.5; week 124: 7.1; week 160: 9.5.

AS, ankylosing spondylitis; HC, healthy controls; HRQoL, health-related quality of life; IQR, interquartile range; MOS-SS, Medical Outcomes Study Sleep Scale; NR, not reported; PGA, patient global assessment; PhGA, physician global assessment; PsA, psoriatic arthritis; PsAID, Psoriatic Arthritis Impact of Disease; PsO, psoriasis; PSQI, Pittsburgh Sleep Quality Index; RA, rheumatoid arthritis; RCT, randomized control trial; SPI, sleep problem index; TNF, tumor necrosis factor

Discussion

In this systematic review, we found that 30 to 85% of patients with PsA reported sleep problems. The difference in the rates of sleep problems across studies may respond partly to the different sleep problems evaluated and the instruments used to measure them. The sleep problems evaluated included ‘sleep disturbance’, ‘sleep interference’, ‘sleep difficulty’, ‘sleep impairment’, ‘sleep disorders’, and ‘poor sleep quality’. Even among studies measuring the same sleep problem, different measurement instruments were used. For example, ‘sleep disturbance’ was measured with an unvalidated Numeric Rating Scale (NRS) question, with the ‘sleep disturbance’ question from the PsAID and with the ‘sleep disturbance’ sub-score from the PSQI. The lack of a common terminology and common measurement instrument for a given sleep problem across studies hinders comparison of results.

Despite the variability in sleep problems evaluated and sleep measures used among studies, we identified 6 studies reporting on the prevalence of ‘poor sleep quality’ as measured by the PSQI.^{20,21,28,35,37,38} A meta-analysis based on these studies concluded that 73% of patients with PsA had poor sleep quality. Pooled data from 4^21,28,37,38 of these studies further showed that the prevalence of poor sleep quality in patients with PsA was significantly higher compared to HC (27%). Compared to patients with PsO, pooled data from 3^28,37,38 of these studies revealed that differences were not significant. Additionally, our meta-analysis of mean scores of PSQI parameters found that patients with PsA suffered from worse subjective sleep quality, latency, disturbances, and day dysfunction than HC, but not compared to patients with PsO. Results of these meta-analyses, however, are limited by the large heterogeneity identified and the small number of studies included.⁵⁴ Differences in patient demographics and disease severity, the presence of comorbidities including sleep disorders, and medication status may account for the variability of results among studies.

In this review, only self-reported sleep measures were used; objective sleep measures (i.e., actigraphy or polysomnography) and sleep diaries were not used in PsA. Henry et al. described similar findings in their review for patients with PsO.⁵⁵ Although they identified a few studies that utilized polysomnography in patients with PsO, actigraphy and sleep diaries were not applied. Both subjective and objective sleep measures are required to identify and assess sleep problems,⁵⁶ especially for targeting interventions. Future studies in psoriatic disease should include both type of sleep assessments.

The JSS was the only sleep PROM whose measurement properties were formally assessed in a validation study. However, we did not find studies reporting results for the JSS in patients with PsA.⁴¹ In this validation study, investigators explored the internal consistency and construct validity of the JSS, but its content validity in PsA has not been explored. The PSQI is the most widely used sleep PROM in clinical and non-clinical populations. It was developed for patients with depression and later validated in several other disorders.⁵⁷ Yet, the PSQI has not been validated in patients with PsA. Furthermore, even in other populations, its dimensionality (i.e., factor structure) warrants further investigation.⁵⁸ Given that patients with psoriatic disease were not involved in the development of these instruments and that such instruments do not quantify symptoms that may cause sleep problems in these patients such as pruritus, skin pain, joint pain, and stiffness, evaluation of the content validity and other measurement properties of sleep PROMs in PsA is warranted. To address the potential lack of comprehensiveness of these measures in psoriatic disease, a set of psoriatic disease-specific sleep measures - the “PsO Sleepy Q” and the “PsA-Sleepy-Q” - are currently being validated.⁵⁹

This review identified several predictors of sleep problems in patients with PsA including anxiety, pain, ESR, emotional recovery, depression, fatigue, physical function, and tender or swollen joint count (TSJC). Yet, the directionality of the association between sleep and these predictors has not been established. Longitudinal studies including both PROMs and actigraphy are needed to explore whether the symptoms and/or signs of PsA (e.g., joint pain or TSJC) hold a bidirectional relationship with sleep problems as suggested in qualitative studies.^59,60

Finally, we found that TNF-inhibitors, guselkumab, and filgotinib were associated with improved sleep outcomes. However, these assessments presented certain limitations. First, only 2^49,50 of 6^28,47,49,51 studies consisted of an RCT. Second, sleep was not the primary outcome in any of these 4 studies. Therefore, power calculations were not based on sleep outcomes. Third, sleep PROMs used had not been validated in PsA and objective sleep measures were not used as previously noted. Properly powered clinical trials exploring the efficacy of (i) psoriatic disease interventions and (ii) sleep-directed interventions (e.g., cognitive behavioral therapy for insomnia) to treat sleep outcomes in PsA are required.

Limitations:

Our search was restricted to two databases, PubMed and Embase, and inclusion criteria were restricted to data from individuals 16 years and older, studies evaluating sleep in patients with PsA (or at least sub-analysis for the PsA population was required), and studies in English. Therefore, it is possible that studies outside of these parameters with information relevant to our study aims were not included.

Conclusion

Sleep problems are common in patients with PsA, and patients consider sleep problems as having an important impact on PsA. The prevalence of poor sleep quality was significantly higher in patients with PsA compared to HC, but not compared to those with PsO. Our results rely on a small number of heterogenous studies. Sleep apnea holds a bidirectional relationship with PsA in adjusted models, but data about the association between PsA and other sleep disorders is lacking. The PSQI and the PsAID item ‘sleep disturbance’ were the most widely used sleep PROMs across studies, though evidence supporting their validity is needed. Longitudinal studies combining daily measurement of PsA signs and symptoms, and subjective (i.e., validated sleep PROMs and sleep diaries) and objective sleep measures (e.g., actigraphy) are needed to further understand how sleep quality relates to PsA disease activity and symptoms. Finally, while a few studies support the beneficial effect of biologics and JAK inhibitors for PsA on sleep problems, further RCT evaluating the efficacy of diverse therapies to manage and improve sleep in PsA are needed.