Dr. Woodworth, working under UCLA Medical School rheumatologist Daniel Furst, MD, and 300 other rheumatology researchers in various countries are conducting focus groups of RA patients to develop ways to measure flares. Their hope is that the final measurement questionnaire tool will be approved at the OMERACT global meeting in 2014.

At a series of focus groups held in five countries, these researchers asked people with RA to talk about their flares, and have developed a pilot questionnaire that may one day be used by rheumatologists to measure flares. Questions focus on a description of flare symptoms, self-management strategies and rating the impact of flare symptoms on daily activities. 

After gathering more than 1,000 questionnaires, Dr. Woodworth has noticed that stiffness is one of the most common problems people with RA develop during flares. “It’s hard to measure stiffness by duration, because it’s highly variable. But having patients report the severity of their stiffness on a 10-point scale is really useful,” she says. Patients don’t just report classic morning stiffness during flares. They also experience stiffness at other times of day and after sitting or strenuous activity.

What Triggers Flares?

Molnar-Kimber, who left her university research position in 2002 to focus on independent research on RA flares, also has been querying people with RA about their flare experiences through a web-based questionnaire. She has gathered more than 500 responses looking at the potential triggers of RA flares and how they may impact the person’s joints and function, and has published her findings in peer-reviewed journals. 

Common triggers seem to be sensitivity to particular foods, falls or physical traumas, exposure to environmental toxins like cigarette smoke or industrial pollution, and infections, she says.

Categorizing Flares

Currently, RA flares are broken into four categories based on duration and impact, Dr. Woodworth says. Mild flares may last a week or less, and be successfully treated with over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, and basic self-management strategies like ice or rest. 

Moderate flares may last longer, and require an opiate analgesic and activity restriction for up to two weeks. Severe flares are disabling, requiring time off from work and highly restricting activities, plus the need to take an opiate or corticosteroids to alleviate it. 

The most devastating RA flare is what Dr. Woodworth calls “life-interrupting.” This type of flare doesn’t resolve with standard treatment and may requiring the rheumatologist to reconsider the entire disease-management approach for that patient. “Nowadays, we are lucky to have lots of treatments to work with in RA. Nevertheless, during flares, joint damage can occur, and disability.”

Learning About Flares from People With RA

Dr. Woodworth says the questionnaires indicate a shift from looking at lab test results to actually gathering data from RA patients who are, after all, the greatest source of knowledge about flare causes and impacts.

“We are developing a deeper appreciation for flares, what precipitates it and what can manage it better,” Dr. Woodworth says. 

She’d like to see the approved tool posted online, so patients may self-test and learn when a flare’s severity requires a call to their rheumatologist, or when they can self-manage it successfully. “This is a tool for patients. It’s intended to facilitate communication in a more timely fashion and help patients better understand their flares.”