When arthritis is active and painful, you have a constant reminder and strong incentive to take your medications. But when your disease is under control, it may be easy to forget a dose or two or you may even be tempted to stop taking your medication altogether. But doing so is not a good idea. The way you are feeling – particularly when you are on medication – is not always an indication of whether there is underlying disease activity. Stopping your medication could cause your disease to flare, resulting in the irreparable joint damage your doctor was aiming to prevent when prescribing medications in the first place.
Getting Tough on RA from the Start
Most doctors begin hard-hitting treatment as soon as rheumatoid arthritis (RA) is diagnosed. Research shows that even in the first months after diagnosis, joint damage can occur if the disease is not treated aggressively, says Paul Howard, MD, a rheumatologist at Arthritis Health in Scottsdale, Ariz.
Doctors once took more of wait-and-see approach – prescribing nonsteroidal anti-inflammatory drugs (NSAIDs) early in the disease process before moving onto stronger drugs. Today, they are likely to begin treating right away with traditional disease-modifying drugs such as methotrexate (Rheumatrex, Trexall), azathioprine (Imuran) and leflunomide (Arava). If the disease is not controlled quickly, the next step is the addition of a biologic agent, says Dr. Howard, who often prescribes a biologic in three months in those cases.
Ramping Treatment During RA Flares
With the right combination of treatment, most people with RA can achieve good control of their disease, says Dr. Howard. But even when the disease is controlled, occasional flares can occur.
When rheumatoid arthritis flares, more aggressive treatment may be needed to prevent further problems, according to a 2015 study published in Arthritis Care & Research.
The study, which followed 508 patients who were treated with the specific goal of achieving remission, showed that ramping up treatment may be necessary to prevent functional disability, worsening of pain and morning stiffness, and radiographic progression of the disease, says study author Linda Dirven, PhD of Leiden University Medical Center in The Netherlands.
If you have a flare, Dirven recommends contacting your rheumatologist, who can determine the best treatment for it. “How flares should be treated depends on the treatment the individual patient is currently receiving and previous effectiveness of received treatment,” says Dirven. “For some patients it may be best to increase the medication dosage while for others the addition of another drug may be best.”
Dr. Howard says he often starts patients on a steroid at the start of a flare. “If that doesn’t work, we increase the [non-biologic] disease-modifying agents,” he says, “and if that doesn’t work we often change the type of medication.”
Whatever option is chosen, the goal should be to stop the flare and get the patient back into remission, which Dr. Howard defines as no evidence of inflammation from the patient’s or physician’s point of view or on X-ray or MRI. “We treat to remission,” says Dr. Howard. “If you don’t stay in remission the chance of progressive damage is there.”
Taking Care After a Flare
Once the flare has subsided, doctors may taper the medication back to pre-flare levels, but it is rarely wise to withdraw medication altogether, says Dr. Howard. However, research shows that when RA is controlled up to 25–30% of people who stop biologics can stay off of them up to a year before the disease flares. But that also means that that 70–75% will flare before a year. Because of the high risk of damaging disease reactivation, Dr. Howard recommends that no one try stopping a biologic on their own.
“It is critical to get and keep the disease in remission or as close as possible,” says Dr. Howard. “The reality is in this day and age most people are able to get to a state of remission.” For those who have not achieved remission or have a period of inactive disease broken by a flare, he says it’s important to continue to strive for remission. “Don’t give up. There are lots of options available.”