What is the best course of action for a patient with a pre-existing diagnosis of arthritis, such as rheumatoid arthritis (RA) or osteoarthritis (OA), who is experiencing a flare-up?

Management of Arthritis Flare-Up

For a patient experiencing an arthritis flare-up, immediately initiate short-term low-dose glucocorticoids (prednisone 5-10 mg daily) as bridge therapy while simultaneously escalating or optimizing DMARD therapy, as this approach provides rapid symptom relief while preventing the joint damage and functional deterioration that occurs during untreated flares. 1, 2, 3

Immediate Assessment and Risk Stratification

Clinical Evaluation:

• Perform a 28-joint count examination assessing proximal interphalangeal joints, metacarpophalangeal joints, wrists, elbows, shoulders, and knees for tenderness and swelling 4
• Document morning stiffness duration (>30 minutes suggests inflammatory arthritis) and assess functional ability using the Health Assessment Questionnaire 1, 4
• Calculate disease activity using SDAI (tender joint count + swollen joint count + patient global + evaluator global + CRP in mg/dL), with targets of remission ≤3.3 or low disease activity ≤11 4, 2

Laboratory Testing:

• Measure CRP and ESR immediately, as elevated inflammatory markers during a flare predict radiographic progression and functional deterioration 4, 2, 3
• Obtain complete blood count with differential and comprehensive metabolic panel to assess for treatment-related complications 1, 2

Treatment Algorithm

First-Line Pharmacologic Management

Glucocorticoid Bridge Therapy:

• Initiate prednisone 5-10 mg daily for temporary relief (maximum 6 months) while awaiting DMARD effect 1, 2, 5
• For localized joint inflammation, use intra-articular glucocorticoid injections to provide immediate pain relief 1, 2
• Critical caveat: In patients with diabetes mellitus, monitor for hyperglycemia risk; if surgery is planned, avoid intraarticular injections within 3 months due to increased infection risk 1

NSAID Therapy:

• Use NSAIDs at the minimum effective dose for the shortest time possible after evaluating gastrointestinal, renal, and cardiovascular status 1, 2
• Important limitation: NSAIDs provide symptomatic relief only and do not prevent radiographic progression during flares 1, 6

DMARD Optimization (Essential for Preventing Long-Term Damage)

For Rheumatoid Arthritis:

• If not already on methotrexate, initiate at 15 mg weekly with plan to escalate to 20-25 mg weekly 1, 7, 2
• If already on methotrexate with inadequate response, escalate dose or add biologic DMARD (TNF inhibitor) within 3 months 7, 4
• Evidence supporting aggressive treatment: Flares are associated with concurrent radiographic progression (odds ratio 1.7) and cumulative joint damage, with a dose-response effect where more flares lead to worse long-term outcomes 3

For Osteoarthritis with Inflammatory Component:

• Patients with acute OA flare or superimposed inflammatory arthropathy (gout, calcium pyrophosphate deposition disease) may benefit from glucocorticoid injection 1
• However, delaying definitive treatment (such as arthroplasty in severe cases) for glucocorticoid injections provides only temporary benefit 1

Monitoring and Follow-Up

Short-Term Monitoring:

• Reassess disease activity every 4-6 weeks using SDAI or CDAI until remission or low disease activity is achieved 4, 2
• Repeat CRP and ESR at each visit to monitor treatment response 4, 2

Long-Term Surveillance:

• Obtain repeat hand, wrist, and foot X-rays at 6 and 12 months to monitor for radiographic progression 4
• Document functional status using Health Assessment Questionnaire, as flares cause mean deterioration of 0.25 points during the episode 3

Non-Pharmacologic Adjunctive Interventions

• Refer to occupational therapy for joint protection education, assistive devices, and splinting 4, 2
• Prescribe dynamic exercise programs incorporating aerobic exercise and progressive resistance training, with adequate rest during poorly controlled inflammation 1, 4, 2
• Provide smoking cessation counseling, as smoking is a modifiable predictor of adverse outcomes 7, 4

Critical Pitfalls to Avoid

Do not delay DMARD intensification while using only symptomatic therapy (NSAIDs or glucocorticoids alone). This approach allows disease progression, as flares are associated with irreversible joint damage even when symptoms are temporarily controlled 2, 3. The evidence demonstrates that the more flares a patient experiences, the higher the disability at 10 years and the more radiographic progression occurs (p=0.005) 3.

Do not dismiss the flare based on normal or mildly elevated inflammatory markers. Acute phase reactants can be normal even in active inflammatory disease, and clinical synovitis takes priority over laboratory values in treatment decisions 4.

Do not use prolonged glucocorticoid monotherapy without concurrent DMARD optimization. While prednisone is FDA-approved for short-term adjunctive therapy in rheumatoid arthritis flares 5, prolonged use without disease-modifying therapy leads to cumulative side effects without altering disease course 2.