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- Patients with rheumatoid arthritis
typically start noticing symptoms
that are very gradual in onset.
So it's not like an explosive onset
where one day they have multiple tender, swollen joints
and they cannot move.
That can happen, it's very unusual.
But in most patients what they are experiencing is
when they wake up in the mornings
they're not able to jump out of the bed
like they could do before.
In fact, they're somewhat stiff.
They get to the side of the bed,
they walk to the bathroom,
they feel like their joints are not well-oiled.
Some people describe it as feeling like a tin man
and that the sense of stiffness of the joints
actually gets better with activity and movement.
So patients may feel that by the time I've
taken a hot shower I feel really well.
They may not think much about it and then kind of go on.
But then what may happen is that they're experiencing
this day in and day out,
and that might be the first trigger for them,
what's happening to me in the mornings?
Some of the other symptoms that they may experience
is that their joints can actually be painful
and they may actually see visible evidence of swelling.
Many women may say you know,
I cannot wear that ring any more,
or the ring that I'm wearing is tight on me,
particularly in the mornings.
By the evenings my rings are loose on my fingers again,
or I can put them back on,
but they become tight again in the mornings.
So remember that symptoms of rheumatoid arthritis
are worse in the mornings, they improve as the day goes on,
improve with a hot shower, improve with activity.
Now this is the typical presentation
of rheumatoid arthritis.
But there are patients who can have atypical presentation
where the onset can be relatively abrupt, explosive,
where they're fine a week ago
and then within a week they are struggling
with activities of daily living.
Again pain, stiffness, swelling, small joints of hands,
wrists, shoulders can be involved,
involvement of ankles and feet.
And again, remember what we mentioned about was
fatigue can be a prominent part of this presentation.
Stiffness can be a prominent part of this presentation.
When you have inflammation,
patients often have sleep disturbance
so they may not sleep well.
They may feel as if they have almost like
a flu-like illness.
All of these symptoms can be the beginning of
the presentation of rheumatoid arthritis.
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Once we have our patients in remission
or low disease activity, our patients are doing well.
On a daily basis they may have minimal symptoms,
they may have minimal stiffness,
but really they're not struggling with their disease.
But often during this period when the patients
are doing very well, they may start experiencing
increased disease activity.
We call that a flare.
A flare is described in many different ways
by different patients, but typically
what they're experiencing is increased disease activity.
That can be manifested as worsening fatigue
in the mornings or throughout the day,
worsening stiffness particularly in the mornings,
increased joint pain, swelling,
difficulty with activities of daily living.
Some patients may experience a flu-like illness,
low-grade fevers, they just don't feel well,
their energy levels drop,
and that is a typical description of a flare
for most patients.
Many patients also experience fragmented sleep
or poor sleep, they tell us
that they don't sleep well during the flare.
In some patients the depression and anxiety part
really kicks in during these episodes.
So yes, unfortunately the course of rheumatoid arthritis
can be punctuated by these periods of
increased disease activity.
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This can often be triggered by some change in medications
or by medication non-compliance,
or sometimes it can be triggered by
increased stress in people's life.
Sometimes trauma or some kind of physical stress
can also trigger flares.
So patients will give us a sense of different things
that can trigger a flare, but I can tell you
that stress is the one thing that I often hear the most.
The flares can punctuate the disease
and then there's a specific way we take care of flares.
We can often increase some of the medications
such as nonsteroidal anti-inflammatory medications,
or we can give a short course of prednisone.
Often we ask the patients to rest more during a flare,
to pace out their life so that if they really
cannot achieve five things in a day
maybe they can prioritize and do
that one thing that they really need to do.
Many of my patients tell me that when they rest
they definitely feel that they can
handle their flare better.
So yes, is flare a part of living with rheumatoid arthritis?
I would say it is.
Unfortunately, it can be unpredictable.
Sometimes it comes from nowhere
and this can be a very frustrating thing
for the patients to live with.
But I would say when you live with rheumatoid arthritis
and you learn to live and manage your flares,
patients can often self-manage many of these things.
They can sometimes predict that because
they're going through a difficult time,
they may have a little flare,
and then they can self-manage some of their joint symptoms.
But again, our goal as rheumatologists will always be
for our patients not to experience any flare.
So if one of my patients is experiencing
many flares within a short period of time,
this is a very good time for me to sit down
and evaluate whether the medications are working or not,
whether I need to change medication or add more medications.
So I think with that approach,
even though at this point our patients do live with flares,
I think the frequency of flares we can really reduce them,
we can reduce the intensity of flares
so they are really not struggling that much
and we can help patients kind of self-manage some of this
and reach out to their physicians
when they feel that there needs to be
a discussion about changing therapy, and if they feel
that the medications are not working as well.
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