Sleep · One page to start with
If back pain wakes you in the second half of the night and eases once you get up and move, tell your rheumatology team. Night pain that improves on getting up is one of the five features used to identify inflammatory back pain. It can mean your disease is active, and the guideline says new or worsening fatigue should prompt a check of disease activity and a look at whether treatment needs changing. That is a conversation, not a mattress.
Insomnia affects roughly 60 per cent of people with rheumatoid arthritis, against 10 to 30 per cent of everyone else. Fatigue in inflammatory disease involves biological, psychological, and social factors interacting; it is not a matter of willpower or discipline.
The dark room, the fixed bedtime, less caffeine: sensible, but on its own it does not treat long-term insomnia. The American Academy of Sleep Medicine gives sleep hygiene used on its own a conditional recommendation against, for lack of efficacy, and gives multicomponent CBT-I a strong recommendation. Relying on the tips alone can delay the treatment that works while insomnia carries on. If you tried the tips and they did not work, that is the expected result, not your failure.
Cognitive behavioural therapy for insomnia is a structured, time-limited programme that changes the habits and thinking keeping insomnia going. In a trial in rheumatoid arthritis, six weeks of it improved insomnia, sleep quality, fatigue, mood, pain, and the overall impact of RA on daily life, still measurable six months later.
Be clear about what it does not do: in that trial it did not change disease activity, physical function, or laboratory-measured sleep. It treats your sleep, fatigue, and mood, not your arthritis. Those are worth treating.
Ask your team: "Can I get CBT-I, in person or online?"
The sleep-medicine guideline puts them in an order: CBT-I first; CBT-I plus a medicine second; a medicine on its own last. Medicines are mainly for people who cannot do CBT-I, who still have symptoms after a fair trial of it, or as a temporary addition.
Worth knowing: that guideline gives conditional recommendations against trazodone, diphenhydramine, melatonin, tryptophan, and valerian, on insufficient evidence. Diphenhydramine is the antihistamine in most over-the-counter sleep aids. Melatonin is on the same list. Bring whatever you are taking, including anything off a pharmacy shelf, to your appointment.
Sleep apnoea. In that RA trial, 40 per cent of participants had it on testing, and were referred. If you snore, wake unrefreshed, or someone has seen you stop breathing, say so, especially if you are exhausted while your arthritis is well controlled.
Steroids. If you take prednisone, ask about timing. Sleep disturbance is one of the effects patients rate as most bothersome.
Movement. Tailored physical activity is one of only four things the fatigue guideline recommends, and it carries its strongest grade. The effect on fatigue was largest in spondyloarthritis.
Describe the pattern, not just the tiredness: when you wake, whether you get back to sleep, whether moving helps or not. Then ask the four questions: Is my disease active? Can I get CBT-I? Should I be checked for sleep apnoea? Is my steroid timing right?