What are the treatment options for a rheumatoid arthritis flare-up?

From the Guidelines

Treatment for a rheumatoid arthritis flare-up should be aimed at reaching a target of sustained remission or low disease activity, and therapy should be adjusted if the target has not been reached by 6 months, as recommended by the 2019 EULAR update 1.

Key Treatment Options

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can reduce pain and inflammation.
• Corticosteroids such as prednisone provide rapid relief for severe flares.
• Disease-modifying antirheumatic drugs (DMARDs) like methotrexate or hydroxychloroquine may need adjustment during flares.

Non-Medication Approaches

• Rest the affected joints while maintaining gentle movement to prevent stiffness.
• Apply cold packs to reduce inflammation or heat for muscle relaxation.
• Stay hydrated and maintain a balanced anti-inflammatory diet.

Importance of Monitoring and Adjustment

• Monitoring should be frequent in active disease, and therapy 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, as per the 2019 EULAR update 1.
• The patient should be appropriately informed about the treatment target and the strategy planned to reach this target under the supervision of the rheumatologist, as recommended by the 2010 international task force 1.

Additional Considerations

• The choice of treatment should consider co-morbidities, patient factors, and drug-related risks, as noted in the 2010 international task force recommendations 1.
• Non-pharmacological interventions, such as dynamic exercises and occupational therapy, should be considered as adjuncts to drug treatment, as suggested by the 2017 EULAR update 1.

From the FDA Drug Label

The benefits of alternate day therapy should not encourage the indiscriminate use of steroids. In the event of an acute flare-up of the disease process, it may be necessary to return to a full suppressive daily divided corticoid dose for control. Once control is again established alternate day therapy may be re-instituted Although many of the undesirable features of corticosteroid therapy can be minimized by alternate day therapy, as in any therapeutic situation, the physician must carefully weigh the benefit-risk ratio for each patient in whom corticoid therapy is being considered.

The treatment options for a rheumatoid arthritis flare-up include:

• Returning to a full suppressive daily divided corticoid dose for control, such as prednisone 2
• Using alternate day therapy, which may help minimize undesirable features of corticosteroid therapy
• Adding or increasing other symptomatic therapy as needed to control symptoms It is essential to individualize and tailor the therapy to each patient, and the physician must carefully weigh the benefit-risk ratio for each patient.

From the Research

Treatment Options for Rheumatoid Arthritis Flare-Up

• The treatment goals for rheumatoid arthritis (RA) are to reduce pain and stop or slow further damage, as there is no cure for the disease 3.
• Methotrexate (MTX) is considered the preferred disease-modifying anti-rheumatic drug (DMARD) for the treatment of RA, but combining MTX with other DMARDs can provide additional benefits 4, 5, 6.
• Combination therapy with MTX + sulfasalazine + hydroxychloroquine (triple therapy) or MTX + biologic DMARDs or tofacitinib were found to be similarly effective in controlling disease activity and generally well tolerated in MTX-naïve patients or after an inadequate response to MTX 5, 6.
• In patients with an inadequate response to MTX, several treatments were statistically significantly superior to oral MTX for ACR50 response, including triple therapy, MTX + hydroxychloroquine, MTX + leflunomide, MTX + intramuscular gold, MTX + most biologics, and MTX + tofacitinib 5, 6.
• Methotrexate + some biologic DMARDs were superior to MTX in preventing joint damage in MTX-naïve patients, but the magnitude of these effects was small over one year 5.

Comparison of Treatment Options

• A network meta-analysis found that most novel DMARDs, when used in combination with MTX, demonstrated comparable ACR responses, with the exception of anakinra plus MTX, which was less efficacious 7.
• Tocilizumab monotherapy was found to have higher ACR responses than anti-tumor necrosis factor agents (aTNF) or tofacitinib, and ACR responses with tocilizumab plus MTX were similar to those with tocilizumab monotherapy 7.
• The estimated probability of ACR50 response was similar between triple therapy, biologics, and tofacitinib, ranging from 56-67%, compared to 41% with MTX alone 5, 6.

Safety and Tolerability

• Triple therapy had statistically fewer withdrawals due to adverse events than MTX plus infliximab 5, 6.
• Methotrexate + abatacept had a statistically lower rate of withdrawals due to adverse events than several treatments 5, 6.
• Methotrexate + some biologic DMARDs had a higher rate of withdrawals due to adverse events than MTX alone 5.