FlareRA


	Treatment regimens in RA can be complex. In the event of a flare a careful review of medications is imperative. Common scenarios include reduction or cessation of long term low dose prednisone or DMARDS. There can be a delay between cessation of DMARDs and flare, particularly for leflunomide, which has an extremely long half-life. Assessment should include tender joint count (TJC), swollen joint count (SJC), Pain VAS, Patient global (VAS) and HAQ-DI. From these a composite measure such as the DAS 28 can be formulated (see section on assessing disease activity). The change in DAS28 from previous measures is just as important as the absolute number. For most patients with RA the treatment goal is therapeutic remission, or complete control of signs and symptoms of RA whilst on DMARDs. This equates to a DAS 28 of <2.6. For some patients with longstanding RA, co-morbidities or contraindications to multiple DMARDs an alternative acceptable target is low disease activity. As such, any objective increase in disease activity usually requires treatment. Options include 1. Synovitis in a single joint can be treated with a local glucocorticoid injection. This avoids the need for additional systemic therapy if the synovitis resolves. Always consider the possibility of septic arthritis, fracture or crystal arthritis in a patient presenting with a monoarticular flare. Diagnostic joint aspirate and X-ray can be considered, depending on the abruptness of onset, severity and course of the flare. 2. Flares involving multiple joints can be treated with systemic glucocorticoids. Oral Prednisone, tapering over weeks is often used. The starting dose varies according to the number of joints involved and the severity. For moderate RA (DAS 28 3.2-5.1) a starting dose of 20 mg is often sufficient, weaning down by 5mg each week for four weeks. For more severe flares, starting doses of 40-60mg may be needed. Other options include intramuscular Methylprednisolone (DepoMedrol) or Triamcinolone acetate (Kenacort) 80-120 mg. 3. Severe flares, with severe synovitis usually with systemic or extra-articular features, i.v. methylprednisolone 1g daily for three days may be given in hospital, under supervision of a rheumatologist. As well as treating inflammation, consideration should be given to supportive management include optimising analgesia and adequate rest. In patients where the flare indicates moderately active disease (DAS28 > 3.2) in addition to the immediate treatment of the flare, most rheumatologists will consider adjusting DMARD therapy. The individual choices of DMARDs will depend on disease activity, co-morbidities and patient tolerance of DMARDs but most rheumatologists now use combination, additive therapy. Rheumatologists should be reviewing RA patients with a flare that has not settled within a month with treatment as above. The data supports a variety of approaches but commonly used approaches include: 1. Optimising dosage of MTX. Target of 25mg weekly with change to subcutaneous dosing if inadequate response. 2. Addition of SSZ +/- HCQ (known as “Triple Therapy) 3. Addition of LEF 4. Consideration of Biological Therapy. Usually TNF inhibitor (Adalimumab or Etanercept) or rituximab if contraindications to TNF inhibitor. This information is given to support GPs in the ongoing management of people with active RA. The rheumatologist should be considered responsible for management decisions regarding changes in DMARD therapy. Next Page