Flares in rheumatoid arthritis: do patient-reported swollen and tender joints match clinical and ultrasonography findings?

Association of COVID-19 Vaccinations With Flares of Systemic Rheumatic Disease: A Case-Crossover Study

OBJECTIVE

We aimed to determine the association of COVID-19 vaccination with flares of systemic rheumatic disease (SRD).

METHODS

Adults with systemic rheumatic disease (SRD) in a single-center COVID-19 Rheumatology Registry were invited to enroll in a study of flares. COVID-19 vaccine information from March 5, 2021, to September 6, 2022, was obtained from chart review and self-report. Participants self-reported periods of SRD flare and periods without SRD flare. "Hazard periods" were defined as the time before a self-report of flare and "control periods" as the time before a self-report of no flare. The association between flare and COVID-19 vaccination was evaluated during hazard and control periods through univariate conditional logistic regression stratified by participant, using lookback windows of 2, 7, and 14 days.

RESULTS

A total of 434 participants (mean ± SD age 59 ± 13 years, 84.1% female, 81.8% White, 64.5% with inflammatory arthritis, and 27.0% with connective tissue diseases) contributed to both the hazard and control periods and were included in analysis. A total of 1,316 COVID-19 vaccinations were identified (58.5% Pfizer-BioNTech, 39.5% Moderna, and 1.4% Johnson & Johnson); 96.1% of participants received at least one dose and 93.1% at least two doses. There was no association between COVID-19 vaccination and flares in the subsequent 2, 7, or 14 days (odds ratio [OR] 1.46, 95% confidence interval [CI] 0.86-2.46; OR 1.09, 95% CI 0.76-1.55; and OR 0.85, 95% CI 0.64-1.13, respectively). Analyses stratified on sex, age, SRD subtype, and vaccine manufacturer similarly showed no association between vaccination and flare.

CONCLUSION

COVID-19 vaccination was not associated with flares in this cohort of participants with SRD. These data are reassuring and can inform shared decision-making on COVID-19 immunization.

E-learning and practical performance in musculoskeletal ultrasound: a multicentre randomized study

OBJECTIVES

To examine the effect of pre-course e-learning on residents' practical performance in musculoskeletal ultrasound (MSUS).

METHODS

This was a multicentre, randomized controlled study following the Consolidated Standards of Reporting Trials (CONSORT) statement. Residents with no or little MSUS experience were randomized to either an e-learning group or a traditional group. One week before a 2-day face-to-face MSUS course, the e-learning group received access to an interactive platform consisting of online lectures, assignments, and practical instruction videos aligned with the content of the course. The traditional group only received standard pre-course information (program, venue, and time). All participants performed a pre- and post-course practical MSUS examination and were assessed by two individual raters, blinded to the group allocation, using the validated Objective Structured Assessment of Ultrasound Skills (OSAUS) tool.

RESULTS

Twenty-eight participants completed the study. There were no statistically significant differences in the pre- or post-course practical MSUS performance between the e-learning group and the traditional group; the mean pre-course OSAUS score (s.d.) in the -learning group was 5.4 (3.7) compared with 5.2 (2.4) in the traditional group (P = 0.8), whereas the post-course OSAUS score in the e-learning group was 11.1 (2.8) compared with 10.9 (2.4) in the traditional group (P = 0.8). There was a significant difference between the mean pre- and post-course scores (5.74 points, P < 0.001). The OSAUS assessment tool demonstrated good inter-rater reliability (intra-class correlation = 0.84).

CONCLUSION

We found no significant impact of pre-course e-learning on novices' acquisition of practical MSUS skills. Hands-on training is of the utmost importance and improves MSUS performance significantly. The OSAUS assessment tool is an applicable tool with high interrater reliability.

TRIAL REGISTRATION

https://clinicaltrials.gov/ NCT04959162.

Update on recent developments in imaging of inflammation in osteoarthritis: a narrative review

Synovitis is an important component of the osteoarthritis (OA) disease process, particularly regarding the "inflammatory phenotype" of OA. Imaging plays an important role in the assessment of synovitis in OA with MRI and ultrasound being the most deployed imaging modalities. Contrast-enhanced (CE) MRI, particularly dynamic CEMRI (DCEMRI) is the ideal method for synovitis assessment, but for several reasons CEMRI is not commonly performed for OA imaging in general. Effusion-synovitis and Hoffa-synovitis are commonly used as surrogate markers of synovitis on non-contrast-enhanced (NCE) MRI and have been used in many epidemiological observational studies of knee OA. Several semiquantitative MRI scoring systems are available for the evaluation of synovitis in knee OA. Synovitis can be a target tissue for disease-modifying OA drug (DMOAD) clinical trials. Both MRI and ultrasound may be used to determine the eligibility and assess the therapeutic efficacy of DMOAD approaches. Ultrasound is mostly used for evaluation of synovitis in hand OA, while MRI is typically used for larger joints, namely knees and hips. The role of other modalities such as CT (including dual-energy CT) and nuclear medicine imaging (such as positron-emission tomography (PET) and its hybrid imaging) is limited in the context of synovitis assessment in OA. Despite research efforts to develop NCEMRI-based synovitis evaluation methods, these typically underestimate the severity of synovitis compared to CEMRI, and thus more research is needed before we can rely only on NCEMRI.

Flare during tapering of biological DMARDs in patients with rheumatoid arthritis in routine care: characteristics and predictors

OBJECTIVE

To identify predictors of flare in a 2-year follow-up study of patients with rheumatoid arthritis (RA) in sustained clinical remission tapering towards withdrawal of biological disease-modifying anti-rheumatic drugs (bDMARDs).

METHODS

Sustained clinical remission was defined as Disease Activity Score for 28 joints (DAS28)-C reactive protein (CRP) ≤2.6 without radiographic progression for >1 year. bDMARDs were tapered according to a mandatory clinical guideline to two-thirds of standard dose at baseline, half of dose at week 16 and discontinuation at week 32. Prospective assessments for 2 years included clinical evaluation, conventional radiography, ultrasound and MRI for signs of inflammation and bone changes. Flare was defined as DAS28-CRP ≥2.6 with ∆DAS28-CRP ≥1.2 from baseline. Baseline predictors of flare were assessed by logistic regression analyses.

RESULTS

Of 142 included patients, 121 (85%) flared during follow-up of which 86% regained remission within 24 weeks after flare. Patients that flared were more often rheumatoid factor positive, had tried more bDMARDs and had higher baseline ultrasound synovitis sum scores than those not flaring. For patients on standard dose, predictors of flare within 16 weeks after reduction to two-thirds of standard dose were baseline MRI-osteitis (OR 1.16; 95% CI 1.03 to 1.33; p=0.014), gender (female) (OR 6.71; 95% CI 1.68 to 46.12; p=0.005) and disease duration (OR 1.06; 95% CI 1.01 to 1.11; p=0.020). Baseline predictors for flare within 2 years were ultrasound grey scale synovitis sum score (OR 1.19; 95% CI 1.02 to 1.44; p=0.020) and number of previous bDMARDs (OR 4.07; 95% CI 1.35 to 24.72; p=0.007).

CONCLUSION

The majority of real-world patients with RA tapering bDMARDs flared during tapering, with the majority regaining remission after stepwise dose increase. Demographic and imaging parameters (MR-osteitis/ultrasound greyscale synovitis) were independent predictors of immediate flare and flare overall and may be of importance for clinical decision-making in patients eligible for tapering.

High-frequency ultrasound in patients with seronegative rheumatoid arthritis

This study aimed to investigate the value of high-frequency ultrasound (HFUS) in differentiation of the seronegative rheumatoid arthritis (SNRA) and osteoarthritis (OA) and in the diagnosis of SNRA. 83 patients diagnosed with SNRA (SNRA group) and 40 diagnosed with OA (OA group) who received HFUS were retrospectively analyzed. The grayscale (GS) scores, power Doppler (PD) scores, and bone erosion (BE)scores were recorded, and added up to calculate the total scores of US variables. The correlations of the total scores of US variables with the 28-joint disease activity score (DAS28), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were analyzed. The diagnostic efficacy of the total scores of US variables for SNRA was assessed. In the SNRA group, the detection rate of abnormal US findings in the joints and tendons by GS and PD as well as BE was higher than those in the OA group. There were significant differences between the two groups in GS scores and PD scores of joints and tendons, and BE scores of joints (P < 0.05). In the SNRA group, the total scores of most US variables were positively correlated with CRP, ESR, and DAS28 (P < 0.05), while such correlations were not observed in the OA group (P > 0.05). Among different US variables, the diagnostic value of total PD scores of the joints was the highest for SNRA. HFUS could be used to differentiate SNRA from OA and make a diagnosis of SNRA based on joint and tendon synovial sheath assessment.

Evaluation of tenosynovitis in patients with seronegative rheumatoid arthritis using microvascular flow imaging

OBJECTIVES

The purpose of this research was investigate the potential use of MVFI (microvascular flow imaging) in the assessment of tenosynovitis in cases with SNRA (seronegative rheumatoid arthritis).

METHODS

Fifty-six SNRA cases and 20 HCs (healthy controls) were enrolled, and all of them were subjected to ultrasonographic examination of the compartments I-VI of the extensor tendons of the wrist, flexor carpi radialis and flexor tendons of the five digits. Each tendon synovial sheath was semi-quantitatively scored by GS (gray-scale) ultrasound, PD (power Doppler) ultrasound, and MVFI. The PD and MVFI scores for each tendon synovial sheath were added up for each patient to get the total scores. GS scores, PD scores, and MVFI scores of tendon synovial sheaths were compared between the two groups. The correlations of total PD scores and total MVFI scores with DAS28 (disease activity scores in 28 joints), ESR (erythrocyte sedimentation rate), and CRP (C-reactive protein) were analyzed.

RESULTS

(1) In the HC group (480 tendons), GS revealed abnormalities in 29 (6.04%) tendon synovial sheaths. The GS score was 1.03 ± 0.18 with the predominance of GS grade 1 (96.55%). In the SNRA group (1,344 tendons), GS detected abnormalities in 418 tendon synovial sheaths (31.10%). The GS score was 1.97 ± 0.53 with the predominance of GS grade 2 (71.77%). There were significant differences in the GS examination rate and grade for tenosynovitis between the two groups (P < 0.05). (2) In the SNRA group, involvement of the extensor carpi ulnaris in the 6^th dorsal compartment was the most common among all extensor tendons; the flexor tendon of the third digit was the most commonly affected among all flexor tendons. (3) In the HC group, the MVFI and PD scores were 0 for tendon synovial sheaths upon GS examination. In the SNRA group, the blood flow display rate of abnormal tendon synovial sheaths indicated by GS was 83.49% and 64.59% upon MVFI and PD, respectively. The results of the two imaging techniques were significantly different (P < 0.05). The blood flow grade of abnormal tendon synovial sheaths indicated by GS was significantly different between MVFI and PD (P < 0.05), which was higher upon MVFI than PD. (4) The total MVFI score and the total PD score in the SNRA group were correlated positively with CRP, ESR and DAS28 (P < 0.05).

CONCLUSION

MVFI is a more sensitive way in detection of blood flow in the tendon synovial sheaths of SNRA cases, which may be used in clinic to evaluate disease activity and tenosynovitis in SNRA cases.

Identification of poor prognostic joint locations in an early rheumatoid arthritis cohort at risk of rapidly progressing disease: a post-hoc analysis of the Phase III AGREE study

Background

Rheumatoid arthritis (RA) is a heterogeneous disease with established poor prognostic factors such as seropositivity, joint damage, and high disease activity at an early, treatment-naïve stage of disease. However, few studies have examined if specific joint locations are correlated with these factors in such a population. This analysis explored the potential correlation of individual swollen and erosive joints with other disease characteristics at baseline and with remission rates in a post-hoc analysis of the Phase III randomized AGREE study.

Methods

Methotrexate (MTX)-naïve, erosive, RF- and/or ACPA-positive early RA patients (N = 509) were retrospectively evaluated. Baseline joint swelling was analyzed for large and small joints. Baseline erosions were analyzed for wrist, MCP1–5, IP1, PIP2–5 and MTP1–5. Remission rates were assessed after 6 months of treatment with abatacept (ABA) + MTX (N = 256) or MTX (N = 253). The following statistical tests were used: Chi-Square or Fisher’s exact test (categorical variables); Student’s t-test or Wilcoxon rank-sum test (continuous variables); continuity-corrected Chi-square test (efficacy remission endpoints).

Results

Baseline swelling was most frequent in wrist (91.9%) and MCP2 joint (89.1%), while baseline erosion was most frequent in MTP5 joint (43.5%). Swollen shoulder was significantly correlated (p < 0.0001) with swelling of almost all other large or medium joints. Baseline swelling in the knee, temporomandibular joint (TMJ), wrist and elbow was highly correlated (p < 0.001) with higher tender and swollen joint counts, higher DAS28(CRP) and higher SDAI and CDAI. Baseline swelling was not correlated with erosion per joint, except for MCP2. The largest difference in mean Boolean remission rates at 6 months was in patients with baseline swollen wrist favoring ABA + MTX (14.0% vs 4.4%; p < 0.001).

Conclusions

Swelling in the large and medium joints (knee, TMJ, elbow and wrist) was highly correlated with severe disease activity while MCP2 swelling seemed to be correlated with joint damage. The correlation of joint locations at an early, treatment-naïve stage with poor prognostic factors, higher disease activity and joint damage, could establish a rapidly progressing anatomical pattern in early RA.

Trial registration: ClinicalTrials.gov NCT00122382, registered July 2005.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00252-4.

Application of Automated Hand Ultrasound Scanning and a Simplified Three-Joint Scoring System for Assessment of Rheumatoid Arthritis Activity

Ultrasound can be used to objectively diagnose and evaluate disease activity in patients with rheumatoid arthritis (RA). We aimed to determine the value of a new automated hand ultrasound (AHUS) scanning device and a simplified 3-joint ultrasound scoring system (US3) in detecting synovitis in RA. We compared AHUS and traditional ultrasound (US) scanning in detecting synovial hyperplasia (SH), joint effusion, bone erosion and power Doppler (PD) synovitis in 49 patients. In addition, we compared the value of US3 (in which 3 proximal interphalangeal [PIP] and/or metacarpophalangeal [MCP] joints with the highest scores for swelling and tenderness were evaluated) with the 22-joint ultrasound scoring system (US22) in 26 patients. Almost perfect κ coefficients (0.86-0.937) were obtained between AHUS and traditional US in detecting SH, joint effusion, bone erosion and PD synovitis (p < 0.001). The intra-class correlation coefficient (ICC) between AHUS and traditional US was 0.955-0.995. Of the US3 findings in AHUS, SH synovitis and PD synovitis were positively correlated with DAS28-CRP (adjusted R² = 0.421, p < 0.0001; adjusted R² = 0.365, p < 0.0001). US3 was highly correlated with US22 in detecting SH and PD synovitis (R = 0.792, p < 0.01; R = 0.948, p < 0.01). Compared with US22, a more significant correlation was identified between US3 scores and most clinical and laboratory values. In conclusion, AHUS performed comparably to traditional US in detecting synovitis in RA, and US3 was highly consistent with US22 in assessing synovitis and was positively correlated with RA disease activity.

Effect of Training on Patient Self-Assessment of Joint Counts in Rheumatoid Arthritis: A Systematic Review

Objective

Patient self‐assessed joint counts, if accurate and reliable, could potentially serve as a useful clinical assessment tool in rheumatoid arthritis (RA). This systematic review examines the effect of patient training on the inter‐rater reliability of joint counts between patients and clinicians.

Methods

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines. A search was performed in PubMed, Embase, Cochrane Library, and CINAHL for articles that incorporated patient training and measured the reliability of patient self‐assessed joint counts in RA. Articles were included if they reported on the inter‐rater reliability between patient and clinician joint counts in both trained and untrained patients with RA. Data were extracted on characteristics of patients, structure and components of the training interventions, joint count reliability of patients with and without training, and patient feedback on training interventions. The relevant data were summarized and described.

Results

Multiple training methods have been studied (n = 5), including in‐person sessions run by rheumatologists and instructional videos on the joint examination. Overall, training improved the reliability of patient self–joint counts, with more marked improvement in reliability of swollen joint counts than tender joint counts. Patients had positive feedback when surveyed on their experiences with training.

Conclusion

Various training modalities (in‐person and video‐based) may be effective at improving reliability of patient self–joint counts. More research is needed on this topic, with potential areas for future research including 1) comparison between the efficacy of different modalities of training, and 2) impact of patient factors (education level and disease severity) on the efficacy of training.

Rheumatoid Arthritis Relapse and Remission - Advancing Our Predictive Capability Using Modern Imaging

Clinical remission has become an achievable target for the majority of patients with rheumatoid arthritis, but subclinical inflammation as assessed by ultrasound and magnetic resonance imaging (MRI) has been demonstrated to be frequent in patients in clinical remission. Subclinical synovitis has been shown to be linked to both subsequent structural damage progression and a risk of flare, demonstrating that subclinical synovitis represents incomplete suppression of inflammation and questions whether it is appropriate only to use clinical composite scores as treatment target in clinical practice. Maintaining a state of remission has proven important as sustained clinical remission impacts long-term outcome regarding joint damage progression, physical function and quality of life. Treating subclinical inflammation has been attempted and has led to more frequent strict clinical remission and better physical function, but also to more adverse events. Thus, an overall benefit of incorporating imaging goals in treat-to-target strategies has not been documented. However, in patients in clinical remission on biological disease-modifying anti-rheumatic drugs, both ultrasound and MRI may aid in the clinical decision regarding whether drug tapering or even discontinuation should be attempted.

Assessment of a dried blood spot C-reactive protein method to identify disease flares in rheumatoid arthritis patients

Rheumatoid arthritis (RA) is characterised by painful, stiff and swollen joints. RA features sporadic 'flares' or inflammatory episodes-mostly occurring outside clinics-where symptoms worsen and plasma C-reactive protein (CRP) becomes elevated. Poor control of inflammation results in higher rates of irreversible joint damage, increased disability, and poorer quality of life. Flares need to be accurately identified and managed. A method comparison study was designed to assess agreement between CRP values obtained by dried blood spot (DBS) versus conventional venepuncture sampling. The ability of a weekly DBS sampling and CRP test regime to detect flare outside the clinic was also assessed. Matched venepuncture and finger lancet DBS samples were collected from n = 100 RA patients with active disease at baseline and 6 weeks (NCT02809547). A subset of n = 30 RA patients submitted weekly DBS samples over the study period. Patient demographics, including self-reported flares were recorded. DBS sample CRP measurements were made by enzyme-linked immunosorbent assay, and venepuncture samples by a reference immunoturbometric assay. Data was compared between sample types by Bland-Altman and weighted Deming regression analyses. Flare detection sensitivity and specificity were compared between 'minimal' baseline and 6 week sample CRP data and the 'continuous' weekly CRP data. Baseline DBS ELISA assay CRP measures yielded a mean positive bias of 2.693 ± 8.640 (95% limits of agreement - 14.24 to 19.63%), when compared to reference assay data. Deming regression revealed good agreement between the DBS ELISA method and reference assay data, with baseline data slope of 0.978 and intercept -0.153. The specificity of 'continuous' area under the curve (AUC) CRP data (72.7%) to identify flares, was greater than 'minimal' AUC CRP data (54.5%). This study indicates reasonable agreement between DBS and the reference method, especially at low to mid-range CRP values. Importantly, longitudinal CRP measurement in RA patients helps to clearly identify flare and thus could assist in remote monitoring strategies and may facilitate timely therapeutic intervention.Trial registration: The Remote Arthritis Disease Activity MonitoR (RADAR) study was registered on 22/06/2016 at ClinicalTrials.gov Identifier: NCT02809547. https://clinicaltrials.gov/ct2/show/NCT02809547 .

Contemporary imaging of rheumatoid arthritis: Clinical role of ultrasound and MRI

Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.

Future use of musculoskeletal ultrasonography and magnetic resonance imaging in rheumatoid arthritis

PURPOSE OF REVIEW

Musculoskeletal ultrasonography (MSUS) and magnetic resonance imaging (MRI) play important roles in diagnosis, monitoring, and prognostication of rheumatoid arthritis. This review highlights recent literature in this field and aims to provide insight into the future use in clinical practice.

RECENT FINDINGS

Recent studies concerning the use of MSUS and MRI in clinical practice show how MSUS and MRI can improve diagnosis and monitoring of rheumatoid arthritis and how they can predict both radiographic progression and clinical outcome (e.g., successful tapering of medical treatment). Moreover, novel technical developments of the two imaging modalities, such as 3D ultrasonography, ultrasound image reading with convolutional neural network, image fusion (MSUS and MRI) and whole-body MRI show promising results. Further validation of these novel techniques is required prior to implementation.

SUMMARY

MSUS and MRI will be important parts of the future management of rheumatoid arthritis patients, mostly because of their ability to detect rheumatoid arthritis changes at a very early stage and to predict the course of disease. However, the exact role in routine clinical practice is still to be defined.

Serial magnetic resonance imaging and ultrasound examinations demonstrate differential inflammatory lesion patterns in soft tissue and bone upon patient-reported flares in rheumatoid arthritis

BACKGROUND

Magnetic resonance imaging (MRI) and ultrasonography (US) are more sensitive than clinical evaluation in assessing inflammation in rheumatoid arthritis (RA). Data is scarce regarding potential link between patient-reported flares and inflammation on imaging. The aim of the study was to explore the pattern and longitudinal associations of inflammatory lesions detected by serial MRI and US in relation to patient-reported flares in patients with RA.

METHODS

Eighty RA patients with baseline DAS28CRP < 3.2 and no swollen joints were examined at baseline and followed for 1 year. Patients were requested to contact the hospital in case of patient-reported hand flare accompanied by ≥ 1 tender and swollen joint. The 29 patients who reported hand flare had four extra visits within 4 months from flare onset comprising clinical examination, patient-reported outcomes, MRI, and US of wrists and hands. MRI synovitis/tenosynovitis/bone marrow edema (BME) and US synovitis/tenosynovitis were scored. MRI and US scores at and after the flare were compared to baseline before the flare, and associations were explored by linear mixed models for repeated measurements.

RESULTS

Synovitis and tenosynovitis by MRI/US increased significantly at flare onset. Synovitis waned quickly, as did US tenosynovitis. BME showed delayed increase yet persisted, once the patient-reported flare had resolved, as did MRI tenosynovitis. In univariate models, patient-reported flares were associated with all MRI and US inflammatory markers, except for BME, which was only associated with SJC28 and long-lasting flares > 14 days. Independent associations were observed between patient-reported flares and tenosynovitis by MRI and US (p < 0.05).

CONCLUSIONS

Patient-reported flares were linked to inflammation detected by serial MRI and US. Differential patterns of inflammatory lesion evolution were observed by serial imaging with early synovial and tenosynovial inflammation, followed by delayed-onset BME.

Pain and Self-reported Swollen Joints Are Main Drivers of Patient-reported Flares in Rheumatoid Arthritis: Results from a 12-month Observational Study

OBJECTIVE

To examine prospectively self-reported flare characteristics and their longitudinal association with disease activity and patient-reported outcomes (PRO) in patients with rheumatoid arthritis (RA).

METHODS

Consecutive RA patients with 28-joint count Disease Activity Score based on C-reactive protein (DAS28-CRP) < 3.2 and no swollen joints were examined at baseline, Month 6, and Month 12. Assessments included joint counts, DAS28-CRP, visual analog scale-evaluator's global assessment (EGA), and PRO. Every third month, patients completed the Flare Assessment in Rheumatoid Arthritis and RA Flare Questionnaire, and disclosed self-management strategies. Flaring and non-flaring patients were compared and longitudinal associations between self-reported flare status (yes/no) and disease activity, PRO, and treatment escalation were explored.

RESULTS

Among 80 patients with RA [74% females, mean (SD) age 63 (10) yrs, disease duration 11 (7) yrs, and baseline DAS28-CRP 1.9 (0.6)], 64 (80%) reported flare at least once during 12 months. Fifty-five percent of flares lasted less than 1 week. Common self-management strategies were analgesics (50%) and restricted activities (38%). Patients who reported being in flare had consistently higher disease activity measures and PRO compared to patients without flare. In a partly adjusted model, all flare domains, patient-reported swollen and tender joint counts and disease activity measures were associated with flares. In fully adjusted analyses, present flare was independently associated with pain (OR 1.85, 95% CI 1.34-2.60), patient-reported swollen joints (OR 1.18, 95% CI 1.03-1.36), and higher EGA (OR 1.15, 95% CI 1.04-1.28). Treatment escalation was associated with present flare (p ≤ 0.001).

CONCLUSION

In RA, self-reported flares were frequent, mainly managed by analgesics, substantiated by higher disease activity measures, independently associated with pain and patient-reported swollen joints, and related to treatment escalation.