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What Triggers an Arthritis Flare?

Flare triggers are different for different types of arthritis.

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If you have any type of arthritis, you’ve probably lived through a flare. A flare is a period of increased disease activity or worsening symptoms – a time when the medications you normally rely on to control your disease don’t seem to work. Many patients would also add that flares affect many other aspects of their life as well.

But why does this happen? According to Joseph Shanahan, MD, a rheumatologist in Raleigh, North Carolina, and assistant consulting professor in the division of rheumatology, allergy, and immunology at Duke University Medical Center in Durham, North Carolina, “The first thing I ask when a patient presents with a flare is whether they have been taking their medication as prescribed..”

The causes of flares vary by disease – so let’s look at the triggers of each.

Rheumatoid Arthritis

In rheumatoid arthritis (RA), a flare can be related to natural variations in the processes that cause inflammation. This means flares can vary in intensity, duration and frequency, but they’re usually reversible – if treated promptly.

For most people, the flare risk increases when treatments are tapered or stopped. Other triggers include overexertion, stress, infection or poor sleep. “Disease-modifying arthritis therapies are NOT cures; they maintain patients (hopefully) in states of low-disease activity or occasionally even remission. But when they are stopped, the disease is likely to come roaring back,” notes Dr. Shanahan.

According to a 2009 study conducted by the Outcome Measures in Rheumatology Clinical Trials (OMERACT) RA Flare Group, the danger of untreated RA flares is they can place you at greater risk of joint damage, poorer long-term outcomes, and contribute to worsening cardiovascular disease.  So it’s important to listen to your body and be able to identify a flare when it starts and begin early interventions -- such as medication changes (with your doctor) and self-management strategies.

Osteoarthritis

Since osteoarthritis (OA) is a degenerative disorder and gets worse over time, it may be hard to tell a flare from disease progression You might have increased joint pain, swelling, stiffness, and reduced range of motion. The most common triggers of an OA flare are overdoing an activity or trauma to the joint. Other triggers can include bone spurs, stress, repetitive motions, cold weather, a change in barometric pressure, an infection or weight gain.

Psoriatic Arthritis

Psoriatic arthritis (PsA) is an inflammatory disease that affects the skin and joints. Nearly 30% of people with the skin disease, psoriasis develop psoriatic arthritis. Most people with PsA say a psoriasis flare will often precede a flare of arthritis symptoms.

Common triggers for psoriasis flares include:

  • Stress
  • Injury to your skin
  • Certain medications
  • Bacterial infections, specifically strep throat
  • Other possible triggers: allergies, diet, alcohol intake, smoking and weather changes

Flares and their triggers in psoriatic arthritis have not been studied as much. Researchers in Leeds, United Kingdom interviewed 18 patients to understand their experiences of flare. According to the 2015 article in Rheumatology (Oxford),  their flares were more than an increase in swollen joints, psoriasis plaques or fatigue. They found psychological aspects of their disease -- such as social withdrawal, emotional distress, frustration and depression -- equally debilitating.  Their flare triggers were similar to those for psoriasis and include stress, strenuous physical activity, a change in medication and the weather.

Gout

Uncontrolled uric acid levels trigger crystals to form in and around the joints, causing inflammation and pain in people with gout. Medications can control uric acid levels and over time reduce or eliminate flares.

When you first start taking urate-lowering medications -- such as allopurinol, fuboxistat, and pegloticase – you may have an increase in flares because of the sudden changes in uric acid levels in your blood. “A common sign that long-term gout therapies are actually working is a ‘worsening’ of disease! That’s why we use colchicine and other anti-inflammatory medications to manage flares when we initiate uric acid-lowering therapy,” says Dr. Shanahan.

Consuming high-purine foods like shellfish or beer, becoming dehydrated, experiencing sudden changes in kidney function, or local trauma to a joint (like stubbing your big toe) can also trigger flares. Taking urate-lowering medicines should lessen the likelihood of having a flare due to these triggers.

Flare Awareness Develops with Experience

Regardless of how a flare is defined or triggered in RA, OA, gout, or PsA, experts agree that being aware of how your body feels and how to manage a flare is the best method for limiting the damage it can cause. Understanding your own personal flare triggers comes with experience and can certainly help with flare management.

Dr. Shanahan has another piece of advice, “It does help for patients to track their flares, such as in a diary or journal. Not all flares require medical attention, but recurrent mild flares may indicate a suboptimal control of their disease.” If you don’t already have a flare plan with your doctor, call them on first signs of a flare so you can adjust your treatment and gain control of your disease.

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