What is the management for an acute Rheumatoid Arthritis (RA) flare?

From the Guidelines

Management of Acute Rheumatoid Arthritis Flare

The initial management for an acute Rheumatoid Arthritis (RA) flare involves increasing the dose of the current disease-modifying antirheumatic drug (DMARD) if possible, or adding a short course of oral prednisone at a dose of 10-20 mg per day for 1-2 weeks, with a gradual taper over the next 2-4 weeks 1.

Treatment Strategies

• DMARD Therapy: The treatment should be aimed at reaching a target of sustained remission or low disease activity (LDA) in every patient, with methotrexate (MTX) being a common first-line treatment option 1.
• Biologic Agents: If the patient is already on maximum tolerated DMARD therapy, consider adding a biologic agent such as methotrexate, sulfasalazine, or hydroxychloroquine, or switching to a different biologic agent if the current one is not effective 1.
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs such as ibuprofen 800-1200 mg per day or naproxen 500-1000 mg per day can also be used for symptom relief 1.

Monitoring and Adjustment

It is essential to monitor the patient's symptoms and laboratory results, and adjust the treatment plan accordingly to achieve optimal control of the disease 1. The treatment should be adjusted if there is no improvement by at most 3 months after the start of treatment or the target has not been reached by 6 months 1.

Key Considerations

• Treat-to-Target: The treatment should be aimed at reaching a target of sustained remission or LDA in every patient, with frequent monitoring and adjustment of therapy as needed 1.
• DMARD Combination Therapy: Combination therapy with csDMARDs (e.g., hydroxychloroquine, sulfasalazine, and methotrexate) may be considered for patients with high disease activity or poor prognostic factors 1.

From the FDA Drug Label

As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in: Rheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy) The management for an acute Rheumatoid Arthritis (RA) flare may include short-term administration of prednisone as an adjunctive therapy to tide the patient over the acute episode or exacerbation 2.

• The dosage is not specified in the provided drug label for the management of an acute RA flare.
• Corticosteroids, such as prednisone, may be used concomitantly with other antirheumatic agents, like hydroxychloroquine sulfate tablets, for the treatment of rheumatoid arthritis 3.

From the Research

Management of Acute Rheumatoid Arthritis (RA) Flare

• The management of an acute RA flare involves the use of glucocorticoids, disease-modifying antirheumatic drugs (DMARDs), and biologic DMARDs (bDMARDs) 4, 5, 6, 7, 8
• Glucocorticoids, such as prednisone, are effective in suppressing inflammation associated with RA and can be used in low doses to manage acute flares 4
• The use of bDMARDs, such as tumor necrosis factor (TNF) inhibitors, can be effective in reducing inflammation and halting joint damage in RA patients 5, 6
• Methotrexate, a synthetic DMARD, is often used in combination with bDMARDs to achieve clinical remission in RA patients 6, 7
• Tapering of glucocorticoids and bDMARDs can be considered in patients who have achieved stable low disease activity or remission, but should be done slowly and with close monitoring of disease activity 5, 8

Treatment Strategies

• Low-dose prednisone (≤10 mg/day) can be effective in managing acute RA flares and can be initiated early in treatment, often in combination with another DMARD 4
• bDMARD dose reduction can be considered in patients who have achieved stable low disease activity or remission, with disease-activity-guided dose optimization and fixed dose reduction being effective strategies 5
• Methotrexate can be used orally or parenterally, with dose escalation and reduction guided by patient response and tolerance 7
• Tapering of glucocorticoids to doses >2.5 mg/day may be effective in reducing the risk of flare, while tapering to doses ≤2.5 mg/day may be associated with a higher risk of flare 8

Monitoring and Adjustment

• Disease activity should be monitored closely in patients with RA, with adjustments to treatment made as needed to achieve clinical remission 5, 6, 7, 8
• Patient monitoring should be performed regularly, with frequency guided by disease activity and treatment response 7
• Treatment decisions should be made in shared decision-making with patients, taking into account individual preferences and values 5