We know that even in patients with RA with LDA, the disease has not completely gone away. We used to think that RA would “burn out” over time in cases of long-standing disease, but this is not the case. In fact, those patients with a 15- to 30-year history of RA still have clinical features of the disease. There may be systemic manifestations, such as anemia, fatigue, and depression, among others. So, when a patient has LDA, it does not mean that you can say, “Okay, I will see you in 2 years.” These patients still need to be monitored every 3 to 4 months.

Flares can manifest in a variety of ways as the immune system resets from a more normal homeostasis to an angry pattern of inflammation. The presentation will vary from patient to patient. For instance, some individuals may go to bed at night and wake up the next morning feeling as if they have been hit by a truck. A lack of sleep and fatigue may be predominant at first, but then, 1 or 2 days later, boom—they will notice that they are stiff and cannot button their shirt or fasten a bra. Other patients may have mild depression or mood swings, or may just not feel “right,” prior to experiencing an arthritis flare.

There are several things that we can do to prevent flares, including monitoring the patient’s C-reactive protein levels and sedimentation rate, as well as using tools such as the Vectra DA (a multibiomarker disease activity test) and ultrasound to measure disease activity. In particular, I want to make sure that the joints are not showing signals of activity, or Doppler signals, on ultrasound because such joints are more likely to flare. It is critical to see patients with LDA at least every 4 months because they will experience a reduced quality of life and worse structural damage if we do not keep them in LDA. There are also data showing that flares increase the risk for an adverse cardiovascular outcome. Every time there is a flare, it acts like a hit to the immune system that affects the cardiovascular system. This is important because cardiovascular disease is the number 1 cause of death in patients with RA.

Thus, we want to prevent flares for a number of reasons, and this study by Bechman et al reinforces that. Another finding from this study was that patients with LDA but high functional disability seem more likely to flare. These individuals may have many persisting pro-inflammatory cells that have already done significant structural damage, which puts them at risk of additional damage in the future. For example, a patient with LDA may have a functionally impaired hand from a past activity, and then in a flare it moves over to the other hand, the shoulder, or the knee. So, the bottom line is that even patients with LDA need to be monitored by the rheumatologist frequently (eg, in my practice, every 3-4 months) to ensure that disease activity remains low and that they do not flare.