Identify RA Flare Patterns to Improve Patient Outcomes

Rheumatoid arthritis (RA) is a disease of ups and downs. One day, your joints feel pretty good. The next, swelling and pain ratchet up and you can barely get out of bed. These symptom episodes — called flares — can be unpredictable and debilitating. Because symptoms differ from person to person, doctors have had trouble agreeing on a standard definition to guide them in treating flares. New RA research hopes to develop tools to help doctors and patients bridge these gaps in understanding. Understanding Flares Through Research For the last decade, Clifton O. Bingham III, MD, has been working to make life easier for RA patients who experience flares, and the doctors who treat them. He’s led an international initiative from a group called OMERACT (Outcome Measures in Rheumatology) that aims to better understand and identify RA flares. RA patients from around the world were studied through focus groups, interviews and surveys to understand from the patient’s perspective what flare meant to them and what was involved when they experienced a flare. “The concepts that came from this were that flares were a common part of the RA experience, even when the condition was otherwise well controlled,” says Bingham, who is director of the Johns Hopkins Arthritis Center and director of research for its Division of Rheumatology. Flare Types and Triggers Flares come in two varieties, according to Bingham: Predictable flares have a known trigger. For example, you decide to clean your house from top to bottom one day, overdo it and end up with swollen, stiff joints the next day. Overexertion, poor sleep, stress or an infection like the flu can all set off RA symptoms. With a predictable flare you’ll temporarily feel worse, but your symptoms will resolve in time. Unpredictable flares have more uncertainty associated with them. These flares cause patients to feel worse, but did not have a trigger that was causing symptoms to get worse. These flares might not get better on their own. When self-care measures like rest and anti-inflammatory medicines aren’t enough, your symptoms could ultimately drive you to see your doctor. Repeated or consistent flares may need a medication adjustment or other change in treatment to help you find relief. Defining a Flare When it comes to defining flares, doctors and patients often don’t agree, and even individual patients have differing definitions. In focus groups, patients have described their flare symptoms in subjective terms. One said the pain “…doesn’t let up. It just is unrelenting.” Another complained of stiffness so severe that, “I feel I am stuck together with superglue.” Though pain, stiffness and fatigue are common flare themes, duration, severity and frequency can vary widely from person to person. Even though a flare can feel debilitating to you, your doctor’s assessment might not reveal your symptoms as significant. “The doctor is focusing on whether there are more swollen joints, and whether the lab tests have changed, and will use that information to determine if you’re worse,” Bingham says. To create more alignment between patient experiences and doctor evaluations, Bingham’s group has focused not only on flare symptoms, but also on their consequences. In other words, is your flare severe enough to make you repeatedly stay home from work and miss social engagements? The OMERACT group is developing a questionnaire to help patients better evaluate their symptoms and determine when to see their doctor, and to help doctors more accurately assess their patients’ symptom severity. “One of our goals is to help patients communicate the experience of worsening with their doctors,” Bingham says. Finding Relief for RA Flares