Management of Rheumatoid Arthritis Relapse
When RA relapses, immediately intensify DMARD therapy by reassessing disease activity with composite measures and adjusting treatment within 1-3 months if the target of remission or low disease activity is not re-achieved. 1
Immediate Assessment and Monitoring
- Measure disease activity using validated composite measures (DAS28, SDAI, or CDAI) to objectively quantify the relapse severity 1
- Increase monitoring frequency to every 1-3 months during active disease until the treatment target is re-established 1
- Evaluate for radiographic progression if joint damage appears to be advancing despite previous low disease activity, as any increase in disease activity can reignite the destructive process 1
Treatment Intensification Strategy
If Currently on Methotrexate Monotherapy:
- Add short-term systemic glucocorticoids (prednisone 7.5-10 mg daily) for rapid symptom control while DMARD adjustments take effect 2
- Optimize methotrexate dosing to 20-25 mg weekly if not already at this level 3, 4
- Add a biologic DMARD (TNF inhibitor such as adalimumab, etanercept, infliximab, certolizumab, or golimumab) combined with methotrexate if the treatment target is not achieved within 3 months and poor prognostic factors are present 3
If Already on Combination Therapy:
- Switch to a different biologic DMARD or add/switch to a JAK inhibitor (tofacitinib) if currently on a TNF inhibitor with inadequate response 5
- Do not substitute unproven therapies like low-dose naltrexone for evidence-based DMARD therapy, as delaying DMARDs leads to irreversible joint damage 2
Critical Treatment Principles
- Maintain the treatment target continuously throughout the disease course—only sustained remission halts joint damage, and any disease activity increase can restart destruction 1
- Adjust therapy if no improvement occurs within 3 months or if the target (remission or low disease activity) is not reached within 6 months 1
- Avoid stopping or reducing DMARDs prematurely, as stopping synthetic DMARDs in remission leads to twice as many flare-ups and difficulty re-inducing remission 1
Common Pitfalls to Avoid
- Do not delay treatment adjustments based on patient reluctance or cost concerns—irreversible joint damage accumulates during periods of active disease 6
- Do not rely solely on patient-reported symptoms without objective disease activity measures, as comorbidities like fibromyalgia can confound assessment 1, 2
- Do not use NSAIDs alone for disease control—they provide only symptomatic relief and do not prevent joint destruction 2
- Taper glucocorticoids as rapidly as clinically feasible once disease control is re-established to minimize long-term adverse effects 3, 7
Addressing Non-Inflammatory Pain
- Investigate non-inflammatory causes such as fibromyalgia, osteoarthritis, or central pain amplification if pain persists despite achieving low disease activity 2
- Address comorbid depression and anxiety with appropriate pharmacologic and non-pharmacologic approaches rather than escalating immunosuppression 2