We all agree that mornings with RA is not easy. Stiffness, pain,  and suffering that feels like it lasts forever. I have learned to manage morning pain well.  I usually wake up about five or six to use the rest room. At that time, I take  pain medication  and I go back to sleep. When I wake up around eight,  the edge has been taken off my discomfort. I  have coffee and read the New York Times for an hour. And then I am good to go.

Some of us with rheumatoid arthritis (RA) experience increased pain at night.

 When I am in a flare, I have a hard time sleeping.  My body feels worn and ragged. Knuckles, wrists, shoulders, feet, ankles, pelvic girdle, spine. And even my elbows. Nighttime pain is different. It feels heavy. It feels overwhelming. It feels endless. It just seems too much. Research has shown that people who experience nocturnal pain have an increased number of swollen, painful joints. They are sicker.

The body repairs itself during the quiet of night.

For normal bodies the inflammatory system works to heal wounds and ward off infection at night. This is efficient as the system is not competing with digestion and muscle activity for calories as it would during the day.  

• First the brain triggers the production of melatonin and prolactin as day turns into night.
• In turn melatonin and prolactin stimulate the production of inflammatory cytokines such as tumor necrosis factor, TNF,  and interleukin 6.  In a normal body these cytokines do their part in nighttime repair of the body.
• And then  in the wee hours of the morning,  the normal body produces cortisol.  Cortisol  suppresses these increased cytokines and their inflammatory actions. The body returns to its normal levels of inflammatory cytokines.  
• A normal person wakes up in the morning refreshed and totally unaware of the nighttime activity.

Those who have RA have an overactive inflammatory system. Their inflammatory cytokines are already elevated.

• So, when melatonin and prolactin stimulate the production of inflammatory cytokines during their routine nighttime body repair, they are adding to an already increased level of inflammation.
• But then for those with RA, the normal nighttime cortisol  production  does not increase to control  the additional nighttime inflammatory cytokines and resulting inflammation.
• Consequently, the nighttime cytokine elevation  does not return to its daytime levels. Inflammation continues.  Pain and stiffness continues into the morning.

Understanding why you might have more nighttime pain doesn’t relieve it. It does give us an understanding of what is happening to us. It gives us a chance to work around our situation. Take extra care. Warm shower. Favorite lotion. Warm herbal tea. Hot chocolate. Good book. Favorite movie. Heated mattress pad.   I am on low dose Medrol in addition to Orencia. I split the dose. I take half in the morning and the other half during the evening.  

RA is part of who we are and will always be. Understanding what we have to work with will help us have more satisfying lives.