Patients with rheumatoid arthritis (RA) periodically experience surges in inflammatory activity known as flares. During a flare, the level of fatigue and joint symptoms such as pain, swelling, and stiffness temporarily increase.1 Flares are unpredictable and often debilitating. The lack of a standard definition for disease flare and the inconsistent terminology used by physicians and patients to describe flares further complicates efforts to recognize and manage them.
Over the past several years, Caroline Flurey, PhD, senior lecturer in -public health, University of the West of England, Bristol, United Kingdom, and other researchers affiliated with the Outcome Measures in Rheumatology (OMERACT) initiative, have worked to establish a consensus definition of an RA flare that incorporates the patient perspective and to create a reliable tool for measuring flare severity.1-3
“The OMERACT RA Flare Group found that patients with RA use different criteria — or domains — to identify a flare and that patients and providers differ in the domains they consider central to a flare,” Dr Flurey explained in an interview with Rheumatology Advisor.
“Because of how important it is for healthcare providers to understand what each individual patient means by [a] flare, the OMERACT Flare Group developed the RA Flare Core Domain Set,” she said.
An international group of researchers, clinicians, and patients established the OMERACT RA Flare Group in 2006. Since then, the group has worked diligently to define what constitutes a flare, understand how a flare affects patients and treatment decisions, and develop a reliable instrument for measuring RA flares.3
The definition of flare the OMERACT group agreed upon is an “episode of increased RA disease activity accompanied by worsening symptoms, functional impacts, and clinical indicators of sufficient magnitude and duration to place individuals at greater risk of joint damage and poorer outcomes when left untreated.”3
The group also identified 9 domains that more than 70% of patients and healthcare providers who participated in the workshops agreed were core contributors to an RA flare: pain, physical function, tender joints, swollen joints, patient global score from the American College of Rheumatology (ARC) RA core set, fatigue, stiffness, participation, and self-management.4
A key strength of the OMERACT RA Flare Core Domain Set is that it goes beyond physical symptoms to include measures such as the patient’s ability to participate in activities and to self-manage a flare. As Dr Flurey explained, RA is a constant backdrop to patients’ lives and they practice many strategies to manage its symptoms. At the start of a flare, however, RA shifts into the foreground.1
“My research has found patients will try everything they can think of to manage their symptoms before they seek medical help. The tipping point for recognizing a flare is when they can no longer control their symptoms on their own,” she said.
The Disease Activity Score (DAS) 28 is frequently used in trials and in practice to identify flares, but a distinct disadvantage of the DAS28 is that it does not measure fatigue. “Although physicians did not rate fatigue very highly as a critical domain, fatigue emerged as a key symptom in patients’ definition[s] of flare, and many patients considered fatigue more important than flare,” Flurey said..