Identifying Flare Using the Flare Assessment in Rheumatoid Arthritis (FLARE) Questionnaire

Color enhanced X-ray of hands afflicted with rheumatoid arthritis
The efficacy and safety of subcutaneous tocilizumab in patients with active rheumatoid arthritis was evaluated.

The Flare Assessment in Rheumatoid Arthritis (FLARE-RA) and disease activity score 28 with erythrocyte sedimentation rate (DAS28ESR) assessments differ and a FLARE-RA cut-off of 2.3 has been proposed below which is considered without flare, according to study data published in Rheumatology.

FLARE-RA is a self-administered questionnaire that was developed to help identify patients who had flare in the interval between 2 rheumatology consultations. To establish a threshold for the FLARE-RA score to identify RA flare, researchers evaluated the efficacy and safety of subcutaneous tocilizumab in 139 patients with active RA. Disease activity was assessed with the DAS28ESR at baseline and at weeks 2, 4, 12, and 24, and the FLARE-RA questionnaire was administered at weeks 12 and 24. Patient satisfaction, assessed at baseline and at week 24 with the Patient Acceptable Symptom State (PASS) was used as a surrogate marker of no flare.

A correlation was sought between the FLARE-RA score at weeks 12 and 24 and the area under the receiver operating characteristic (ROC) curve (AUC) for monthly DAS28ESR testing. The optimal FLARE-RA cut-off below which patient satisfaction reached the PASS was explored with an ROC curve. The researchers found that the correlation between the FLARE-RA score and DAS28ESR AUC was moderate at all times, and that the optimal cut-off for the FLARE-RA score to identify absence of flare was 2.3 with an AUC of 0.81. They also identified a cut-off of 3.8 for the general symptom subscale and 1.8 for the arthritis subscale when deciding on disease management.

Limitations to the study include the observation that most patients included in the study had chronic disease, and their progression may be different from that of patients with recently diagnosed RA.

The study authors concluded, “We have identified a cut-off of 2.3 for the FLARE-RA score to help physicians detect a patient ‘in flare’ versus ‘not in flare’ over the past 3 months or since the last visit with the physician, particularly when the recognition of flare is uncertain.”

Disclosure: This research was supported by Roche-Chugai pharmaceuticals. Please see the original reference for a full list of disclosures.


Aouad K, Gaudin P, Vittecoq O, et al. Cut-off value to identify a flare using the Flare Assessment in Rheumatoid Arthritis (FLARE-RA) questionnaire: analysis of the TOSCA study. Rheumatology. Published online March 31, 2021. doi: