Patients with rheumatism 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 as they could do before.
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 gets better with activity and movement.
So patients may feel that by the time I’ve taken a hot shower I feel 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 are that their joints can be painful and they may see visible evidence of swelling.
Many women may say you know, I cannot wear that ring anymore, 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 some patients can have atypical presentations 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, the 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.
Rheumatism, gout treated
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. Once we have our patients in remission or low disease activity, our patients are doing well. Daily they may have minimal symptoms, they may have minimal stiffness, but 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 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, depression and anxiety part kicks in during these episodes.
So yes, unfortunately, the course of rheumatoid arthritis can be punctuated by these periods of increased disease activity. 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 aflare, 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 need to do.
Many of my patients tell me that when they rest they 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.
Xrays of Joints
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 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, 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 can reduce them, we can reduce the intensity of flares so they are 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.