Pain management strategies

[Ted Pimentel]

I am in the middle of my first gout flare up (that I know of). The pain seems to hit peak in the middle of the night. I am on 60mg of prednisone daily. It seems to help as the throbbing pain dissipates significantly during the day though I still walk with a considerable limp.

I’d like to get through the night without sleep getting interrupted by my throbbing foot. I’ve been taking prednisone in the morning. I assume that the peak pain is happening partially as the medicine is wearing off. I am considering:

Option 1: Taking prednisone early in the evening (they say prednisone can affect sleep but so far, i haven’t seen that to be the case)

Option 2: Take half doses – half early in the evening, half in the morning.

Option 3: Continue to take in the morning but supplement with tylenol if I wake in the middle of the night.

I briefly discussed option 3 with my doc and she was supportive but after doing some light internet reading, I don’t see any indication that tylenol is useful for gout pain. Right now I am avoiding meds that would have little utility so unless someone with real experience / data can vouch for tylenol, I am not even going to bother.

Any thoughts or other suggestions on how to get around the late night surges in pain?

[nobody]

Tylenol alone isn’t much help but if the prednisone has already done enough work, it could do the job. It’s worth trying as long as you don’t end up taking a strong dose every day.
Obviously a proper painkiller would work better but even then sleeping through the whole night may be an unrealistic goal if the prednisone isn’t effective enough.
You probably noticed elevating the joint a bit decreases the pressure.
You could also try a hot foot bath before going (back) to bed or simply a hot (or cold/hot) shower.
But at the end of the day, pain is something you deal with mentally. It’s a message telling you to take care of the inflammation. Don’t fear it or push it away and pay attention to your other bodily functions such as your heartbeat and breathing as well as the details of the pain… or whatever else works for you.
If you’ve had enough of your bodily sensations, painful sleepless nights are a good time to take a relaxing podcast break, eyes closed.

[Ted Pimentel]

Thanks for the reply.

Is there a reason that the pain is so pronounced at night? Is it the timing of the medication or is it something else? Right now (3pm), I don’t feel anything wrong with my foot at all when I am sitting down. Yet at 3am, it feels like someone took a hammer to my toe.

[nobody]

I think you should pay more attention to the inflammation and less to the pain. I can’t tell if the inflammation is serious at night based on your description.
Inflammation should be better controlled anyway, whether it be by splitting the dose (I’ve not taken that drug so I don’t know it if would work) or simply by increasing it or taking another drug.
If your foot is swelling at night, I would definitely tell a doctor this happens a certain number of hours after taking the 60mg because you don’t want serious swelling to happen, during the day or at night.

If on the other hand the foot doesn’t look very bad at night but only feels painful, it’s probably for the best if the drug is most effective when you’re active and there are other reasons than the time when you take the drug which might make the pain worse in the evening and at night.
The same “raw amount” of pain would probably bother you a lot more at night than during the day for psychological reasons but what you describe also seems somewhat consistent with my experience with mild inflammation: while I wouldn’t want to be sitting normally with serious inflammation, sitting can numb a mildly inflamed foot and you’re only going to feel the damage from sitting too long when the blood can flow properly again. You can also walk on a mildly inflamed foot but this sort of stress is going to build up as the day goes on and result in a painful evening (and night if you can’t sleep).

[Ted Pimentel]

Hmm.. I read somewhere that while sleeping, the drop in our body temp and the slight increase in blood acidity both promote uric acid crystals to form which is the part of the reason “gout attacks” happen at night (https://www.arthritis-health.com/blog/gout-attacks-strike-mostly-night).

But to your point, my foot does look and feel more swelled in the middle of the night. At this point, I don’t know how to quantify how much more or even if it is serious. Presumably, any swelling is serious but there isn’t much I can do about it until I finish my current course of prednisone (3 more days). I’ll take your advice though and bring it up with my doc.

Sorry to bombard with questions but I am doing my best to learn from other’s experiences so one more thing regarding activity during the day – in your experience / to your knowledge, does the foot swell more at night if the person is more active and gutting it out during the day? Also, icing my foot when it is more swollen a good idea?

[nobody]

Yes, I have found the night (specifically, the end of the night) to be a time when serious attacks tend to start. Ongoing symptoms are something else and I do not remember that they got worse at that time with any regularity (though that might of course happen to others).
There are still other reasons why inflammation might be worse during some parts of the night (lookup cortisol for instance). I didn’t want to provide you with a whole catalogue.

And yes, gutting it out during the day leads to worse nights in my experience. However the effect depends on the particulars. For instance I found that interfering with blood circulation for long periods (for instance by sitting normally) to be problematic while short bursts of slightly painful physical activity might actually be beneficial, perhaps because they promote blood circulation.

Finally, no: icing has failed to produce good results in my case. In fairness I didn’t give that trick much of a chance and may not have iced for long enough to get the expected benefit since letting your extremeties get cold is risky. Elevation is in my opinion a safer way to deal with swelling since you can regularly lower your foot to allow more blood to flow to it before putting it back up (as long as you don’t plan on sleeping).

[Author]

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