What is the recommended management for an adult with established rheumatoid arthritis experiencing an acute flare with increased joint pain, swelling, stiffness, and functional limitation?

Treatment for an Acute RA Flare-Up

For an adult with established rheumatoid arthritis experiencing an acute flare, initiate NSAIDs at the minimum effective dose for symptomatic relief while simultaneously administering intra-articular glucocorticoid injections for involved joints, and if disease activity remains high after assessment, escalate DMARD therapy within 3 months. 1, 2

Immediate Symptomatic Management

First-Line Therapy

• NSAIDs are the recommended initial therapy for symptomatic relief of joint pain, swelling, and stiffness during an acute flare 1
• Use NSAIDs at the minimum effective dose for the shortest time possible to minimize cardiovascular, renal, and gastrointestinal adverse effects 1
• Naproxen has demonstrated efficacy in reducing joint swelling, morning stiffness, and disease activity in rheumatoid arthritis patients, with onset of pain relief beginning within 1 hour 3
• Continuing NSAID monotherapy beyond 2 months in patients with active arthritis is inappropriate and represents a critical pitfall to avoid 1

Glucocorticoid Therapy

• Intra-articular glucocorticoid injections should be administered for relief of local inflammatory symptoms, particularly effective for oligoarticular involvement 1, 2
• Triamcinolone hexacetonide injections can provide clinical improvement for at least 4 months 1
• Systemic glucocorticoids may be used as temporary adjunctive treatment to reduce pain and swelling, but must be limited to the lowest effective dose for the shortest duration (less than 6 months) to avoid cumulative side effects including cataracts, osteoporosis, fractures, and cardiovascular disease 4, 1

Critical Diagnostic Consideration

Before treating as a simple RA flare, you must rule out septic arthritis, especially in monoarticular presentations. 2

• If a single joint is disproportionately affected, perform arthrocentesis immediately to exclude infection 2
• Systemic signs like fever can indicate possible septic arthritis, which requires immediate IV antibiotics and orthopedic consultation 2
• Established RA increases the risk of septic arthritis, making this distinction critical 2

Disease Activity Assessment and Treatment Escalation

Structured Monitoring

• Disease activity must be measured and documented at 1-3 month intervals during active disease using composite measures that include tender and swollen joint counts, patient and physician global assessments, ESR, and CRP 4, 1
• The treat-to-target strategy requires adjusting drug therapy at least every 3 months until the desired treatment target is reached 4

Treatment Target

• The primary treatment target should be clinical remission, defined as the absence of signs and symptoms of significant inflammatory disease activity 4
• For patients with long-standing disease where remission may not be achievable, low disease activity is an acceptable alternative therapeutic goal 4

DMARD Escalation Strategy

• For patients with high disease activity and poor prognostic features during a flare, consider initiating or escalating methotrexate therapy without delay 1
• Following initial glucocorticoid joint injections, methotrexate should be considered for patients with high disease activity 1
• If methotrexate alone is not effective in controlling disease activity, rapidly escalate treatment with biologic DMARDs or targeted synthetic DMARDs 5, 6
• Treatment decisions must be made jointly between patient and rheumatologist 4

Common Pitfalls to Avoid

• Failing to assess cardiovascular, renal, and gastrointestinal risks before prescribing NSAIDs is a frequent error 1
• Relying solely on NSAID therapy beyond 2 months without DMARD escalation leads to progressive joint damage 1
• Using long-term corticosteroids (beyond 1-2 years) where risks outweigh benefits 4
• Misinterpreting high disease activity scores in patients with concurrent fibromyalgia or central pain amplification—investigate disproportionate tender joint counts relative to swollen joints and inflammatory markers before escalating immunosuppressive therapy 4
• Delaying treatment adjustments beyond 3-6 months when the treatment target is not achieved 4

Adjunctive Non-Pharmacological Interventions

• Dynamic exercises and occupational therapy should be considered as adjuncts to drug treatment during and after flare management 1