What is the management of Rheumatoid Arthritis (RA) flare?

From the Guidelines

Management of a rheumatoid arthritis (RA) flare should prioritize the use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and glucocorticoids (GCs) as first-line treatment, with the option to add biological (b) DMARDs or targeted synthetic (ts) DMARDs in cases of insufficient response or poor prognostic factors, as recommended by the European League Against Rheumatism (EULAR) in 2020 1. The goal of RA flare management is to quickly reduce inflammation and prevent joint damage, while also adjusting long-term therapy to prevent future flares.

• Key considerations in managing RA flares include:
  • Increasing the dose of non-steroidal anti-inflammatory drugs (NSAIDs) for short-term symptom relief
  • Using local ice application and rest to reduce pain and swelling
  • Implementing a short course of oral corticosteroids, such as prednisone, for more severe flares
  • Considering intra-articular steroid injections for single or few joint involvement
• According to the EULAR recommendations, the initial treatment for RA should include methotrexate (MTX) plus GCs, with the option to add bDMARDs or tsDMARDs if there is an insufficient response within 3 to 6 months 1.
• The American College of Rheumatology (ACR) also recommends considering the addition of low-dose glucocorticoids when starting DMARDs or in cases of DMARD failure or biologic failure, as well as using short-term glucocorticoids for RA disease flares 1.
• The most recent and highest quality study, the 2020 EULAR recommendations, should be prioritized in guiding treatment decisions for RA flares, with a focus on minimizing morbidity, mortality, and improving quality of life 1.

From the Research

Management of RA Flare

• The management of RA flare involves a treat-to-target strategy aimed at reducing disease activity by at least 50% within 3 months and achieving remission or low disease activity within 6 months, with sequential drug treatment if needed 2.
• Effective treatments include oral conventional synthetic disease-modifying antirheumatic drugs (DMARDs; eg, methotrexate), injectable biologic DMARDs, and targeted synthetic DMARDs (oral) 3.
• Methotrexate is first-line therapy and should be prescribed at an optimal dose of 25 mg weekly and in combination with glucocorticoids; 40% to 50% of patients reach remission or at least low disease activity with this regimen 2.
• If this treatment fails, sequential application of targeted therapies, such as biologic agents (eg, tumor necrosis factor [TNF] inhibitors) or Janus kinase inhibitors in combination with methotrexate, have allowed up to 75% of these patients to reach the treatment target over time 2.

Treatment Strategies

• The current approach to treatment of RA includes early and aggressive treatment with routine monitoring of outcomes to give patients the best chance of decreasing disease activity as much as possible, with low disease activity and remission being a realistic goal for many patients 4.
• Low dose prednisone should also be considered in combination with methotrexate as the best initial choice for RA treatment 4.
• Corticosteroids are disease modifying agents that enhance the effects of DMARDs with no real impact on adverse events 4.

Flare Frequency and Management

• Patients with RA experienced flares more often when noted to be in higher disease activity states than when in remission and reported changes in disease-modifying antirheumatic drugs or biologics more frequently when flares were of longer duration 5.
• Longer duration of flare was associated with changes in disease-modifying therapy 5.
• There is a need to prospectively study symptom intensity and duration of flare in relation to disease activity and consider self-management strategies in the development of a measure of flare 5.

Multidisciplinary Approach

• Good RA management requires a multidisciplinary approach due to its complexity, which is based on an incompletely elucidated pathophysiological mechanism 6.
• The clinical status of RA patients has improved in recent years due to medical advances in diagnosis and treatment, that have made it possible to reduce disease activity and prevent systemic complications 6.
• Ongoing drug development has led to obtaining molecules with improved efficacy and safety profiles, but further research is needed until RA turns into a curable pathology 6.