Managing a flare

A flare, or flare-up, is a period when the condition behind your arthritis becomes more active for a time. Joints that had been manageable hurt more, swell more and stiffen, morning stiffness drags on, and tiredness often gets worse as well, sometimes with low mood and broken sleep. You may feel generally unwell, and a flare can bring night sweats or a raised temperature. Tiredness is also part of these conditions in its own right, and fatigue and arthritis deals with it. Flares vary: in rheumatoid arthritis, psoriatic arthritis, gout and other conditions, one may touch a single joint and the next several, and one may be over in hours or days while another needs treatment to settle.

The aching that follows an unusually busy day is something else: it is felt in the muscles as much as the joints, and it passes without real swelling, heat or lasting stiffness. A flare is not an infection either, even though the two can look alike. Although a flare can bring a raised temperature of its own, a fever is never simply blamed on the flare: with a hot, swollen joint it is treated as an infection until proved otherwise, and any fever that comes with a flare needs checking the same day, all the more on a medicine that weakens the immune system, as the list under When to seek help sets out.

Sometimes there is an obvious trigger. An infection or another illness can stir the immune system more widely; a chest or urine infection is one example. Some people notice stress or emotional upset in the days beforehand, or doing too much, whether a single heavy day or a string of them. Missing doses of your regular treatment, or stopping it, is a trigger that can be avoided: disease-modifying medicines hold inflammation down day by day, and they can only do so if you take them.

At other times, no trigger can be found. A flare that comes from nowhere is not your fault, and a long hunt for a cause uses up energy you may need; a plan for dealing with the flare serves you better. Gout is a special case, with triggers and treatments of its own that the gout guide covers; the general approach here still applies.

In the early days of a flare, simple measures, kept up steadily, help.

• Rest the joints that are worst, not your whole body. Ease off the most inflamed joints but keep everything else gently moving, with short walks and light stretches. Staying still tends to stiffen you up.
• Use heat or cold, with a towel between. Something cold, wrapped in a towel, calms a hot, swollen joint, while a heat pad or a warm shower helps stiff, aching parts that are not visibly swollen. Keep each to 15 minutes at most.
• Pace yourself. Split tasks into smaller pieces with breaks in between, leave what can be left, and let those around you know what is going on, so they can share the load.
• Keep taking your regular medicines. Carry on at your prescribed doses unless your team has told you otherwise. A flare is never a reason to stop treatment on your own, and stopping usually makes things worse. The one exception is infection: some medicines are sometimes paused on your team's advice, as our guide to infections and arthritis medicines explains.

If your team has agreed a flare plan with you, start it as the flare begins, as the plan says, since acting early often helps.

Simple painkillers have a proper place while a flare calms down. Paracetamol dulls the pain. Anti-inflammatory painkillers (NSAIDs), such as ibuprofen and naproxen, can ease stiffness as well as pain, but they carry the familiar cautions: they can upset the stomach and affect the kidneys, and they call for care in older people, in pregnancy, with a heart, liver or kidney condition, and alongside other medicines, those for blood pressure among them. For one sore joint, an anti-inflammatory gel rubbed into the skin over it is another choice, with fewer side effects than tablets. If you use ibuprofen gel, do not smoke or go near naked flames, since clothing the gel has touched can catch fire more easily. If in doubt, ask a pharmacist or your GP. On a prescribed anti-inflammatory already, do not buy another to take alongside it: doubling up adds risk without adding benefit.

Painkillers carry you over a flare; they are not the answer to it. A flare that needs regular painkillers for more than a few days is one to tell your team about rather than to keep treating yourself.

Your team may well use steroids to bring a flare under control, as tablets for a short spell, an injection into a muscle, or an injection straight into the joint, the injections that steroid injections: when they help describes. Timed well, they work well, though they can also hide or aggravate an infection, which is one more reason the team decides.

The thing to avoid is turning to them on your own. Do not start, raise or add steroid tablets yourself during a flare, tablets left over from a previous course included, unless a flare plan agreed with your team tells you to. The right use of steroids for a flare turns on the rest of your treatment, any other conditions you have and what the flare reveals to your team, so it is their decision, made with you. If steroid tablets are part of your long-term treatment, never stop them abruptly; doses come down gradually and under supervision.

Within a few days, ring your rheumatology team (or your GP, if no team looks after you) about a flare that is severe, one that shows no clear sign of easing after several days, or flares that recur; a joint that has suddenly turned hot and very swollen, or is worsening quickly, is a same-day matter instead, as the list under When to seek help says. Repeated flares are no failing on your part and nothing to bear in silence. They tell you something, often that the condition is less well controlled than before and that the treatment should be reviewed, perhaps with a dose change, an extra medicine or a switch to another of the DMARDs or the biologics and JAK inhibitors. There is a harder reason not to put up with them, too: every flare is a period of active inflammation, and joints do not tolerate repeated inflammation indefinitely. The effect is cumulative: the more flares you have, the more lasting joint damage tends to follow over the years, and preventing exactly that is what a treatment review is for.

You can help that review along. Make brief notes as you go: the day it began, the joints affected, any likely trigger and what gave relief. Take photographs of the swelling, too, while you can see it. Swelling often goes down before the appointment, and a clear picture of the swollen knuckle or knee, best taken beside the same joint on the other side, tells the doctor far more than a description given afterwards.

Timing counts as well. Inconvenient though it is, the middle of a flare is often a good time to be examined. Dr Borukhson does the point-of-care ultrasound scan at the appointment itself, so a flaring joint can be looked at and scanned in one visit. The scan can show whether the joint lining or the tendon sheaths are inflamed, and if a single joint is the cause, it can often be treated by an ultrasound-guided injection in the same appointment, where suitable.

The steps above, with a planned call to your team, are enough for most flares. The lists below cover the signs that go beyond a flare's usual aches, stiffness and tiredness, the most urgent first.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Numbness or tingling around the back passage, genitals or inner thighs, new difficulty passing urine or controlling your bladder or bowels, a change in feeling during sex, or pain, tingling, weakness or numbness in both legs, since these can mean pressure on the nerves at the base of the spine, which needs emergency treatment
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time
• An eye that suddenly and completely loses its sight
• Sudden severe pain in the abdomen or back, since the pancreas can react to prednisolone
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• Vomiting blood, or bleeding from the back passage that is heavy or will not stop, most of all with faintness, confusion or pain in the abdomen, or vomit that is black or dark brown, since anti-inflammatory painkillers can make the stomach bleed, and a stomach ulcer on prednisolone can bleed too
• Thoughts of harming yourself or ending your life, which steroids can bring on

Any of these needs an assessment that is urgent, on the same day, from your GP, your rheumatology team or NHS 111:

• A fever, or feeling generally unwell, on immunosuppressant, biologic or steroid treatment, since an infection has to be treated early; during a flare a fever is checked that day rather than put down to the flare, since an infection can be more serious on these medicines and steroids can hide its signs, and without such treatment a fever, or feeling hot, cold or shivery, that comes with a flare needs the same day too, so that an infection in or around a joint can be ruled out
• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one; a joint that will take no weight at all, or that cannot be moved, is a 999 or A&E emergency, whether or not there is a fever
• Weakness in an arm or a leg that is new, or numbness or pins and needles that are new and spreading, coming on over hours or days, since a nerve or the spinal cord may be under pressure; a limb that turns weak or numb in a moment belongs to the first list, and so does new weakness, numbness or tingling in both legs
• A new red, painful eye, or sight that has blurred, dimmed or changed, which needs an eye casualty or urgent eye clinic the same day, as does an eye that light hurts, since several of the conditions behind flares can inflame the eye, where inflammation left untreated puts sight at risk, as the uveitis guide explains
• A marked change in mood or behaviour, confusion, or seeing or hearing things that are not there, on steroid treatment, since prednisolone can do this, the more so the higher the dose; confusion that comes on suddenly is a 999 or A&E emergency, as the first list says
• Unusual thirst or hunger, passing urine more often, or feeling sleepy or confused, on steroids, or swelling of the arms or legs, bruising or bleeding that is not normal, black or dark red stools, severe stomach pain, severe back pain, a severe upset stomach, being sick, or very bad dizziness or passing out, since each can be a steroid effect that needs checking without delay; pain in the abdomen or back that comes on suddenly and severely is a 999 or A&E emergency, as the first list says
• Contact with measles, chickenpox or shingles, since these infections can be severe on steroids and a medicine to protect you may be needed
• Being near someone with measles, chickenpox or shingles, while you take a medicine that weakens the immune system, since measles and chickenpox can be dangerous when the immune system is weakened, and you can catch chickenpox from someone with shingles if you have never had chickenpox; NHS 111 can tell you what to do that day
• Black or dark red stools, on anti-inflammatory tablets, since a bleed in the stomach or gut has to be found that day

Take a severe flare, one that has not clearly eased after several days, or flares that keep returning despite treatment to your rheumatology team or GP within a few days; a joint that has suddenly turned hot and very swollen, or is worsening quickly, belongs to the same-day list above. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. If you cannot tell how urgent something is, asking is never a mistake.

After a long spell of good control, a flare can feel like a setback, and it is tempting to look for something you did wrong: a food, a missed dose, a thing you should have done. Now and then there is a lesson in it; more often there is none. Blame helps least and is usually mistaken. Today's treatment aims to make flares rare, though it cannot always stop them altogether, and a flare tells you about the disease rather than about you. Handled well, it can even be useful: a flare recorded in notes and photographs shows your team how your condition behaves when it is active, which is the evidence good treatment decisions rest on. So settle the joints, keep safe by the lists above, and let the flare serve its one purpose, which is to feed the review that makes the next flare less likely.

Is it a flare, or could the joint be infected?

Do not try to decide that at home. A joint infection (septic arthritis) and a flare can look very alike, and an infection left untreated can damage a joint badly. A joint that will take no weight at all, or that cannot be moved, is a 999 or A&E emergency, whether or not there is a fever. Call 999 and do not drive yourself to A&E. A joint that is hot and swollen, with a fever or feeling unwell, is for A&E or NHS 111 the same day, never a routine appointment. A joint that has become hot and very swollen suddenly, or is worsening quickly, without a fever, needs your GP, your rheumatology team or NHS 111 the same day, even in a flare. Short of those and of the other signs under When to seek help, if the flare is in your usual joints, in its usual pattern and without a fever, following your flare plan and ringing your team is generally enough.

Should I take extra steroid tablets myself when a flare starts?

No. Steroids may well be the answer to a flare, but whether to start, increase or add them is for your rheumatology team to decide, looking at your treatment as a whole and at what the flare tells them, unless a flare plan you have agreed with them already says what to do. Taking old tablets, or raising your own dose, can cause harm and can hide an infection your team needs to know about. If you are on steroid tablets long term, do not stop them abruptly either; any change is made step by step, with guidance.

In a flare, is it better to rest or to keep moving?

A balance of the two. Rest the joints that are most inflamed, but keep the rest of your body moving gently with short walks and light stretches. Resting completely tends to stiffen the whole body and weaken the muscles. As the flare eases, build up again a little at a time; arthritis and exercise shows how.

My swelling always goes before my appointment. How can I show it?

Photograph it while it is there, ideally beside the matching joint on the other side; a picture helps a consultation far more than a description recalled later. Add a line or two on when it began, the joints it touched and what made it better. If you can, book an examination with your team, or a specialist appointment here, while the flare is still active or soon after.

I take my medicines properly, so why do the flares keep coming?

Flaring is simply part of how these conditions behave, and the odd flare can happen even when treatment is going well; a flare is not a sign that you have done something wrong. Repeated flares are a signal, though: often the disease is less well controlled than it might be, and your treatment deserves a look, whether that means a change of dose or a different medicine. That review matters, because every flare is a period of active inflammation, and the effect is cumulative: the more flares you have, the more lasting joint damage tends to follow over the years. Let your team know about every significant flare, even one that settled without help.