Background/Purpose: Flares are inherent to the rheumatoid arthritis (RA) disease course and associated with poor clinical outcomes including low quality of life, joint damage and disability, suggesting the need for their early detection and timely management. The self-administered Flare Assessment in Rheumatoid Arthritis (FLARE-RA) questionnaire was devised and validated for detection of current and recent flares in RA, taking into account both patient and provider perspectives [1]. The FLARE-RA questionnaire includes arthritis-related subscale and general subscale. The overall score for the questionnaire is defined as the global scale, with scoring from 0 (no flare) to 10 (maximum flare). We aimed to define the cross-cultural criterion validity of the FLARE-RA questionnaire and cut-off(s) for definition and decision in four different countries, using different anchor items in patients with RA.

Methods: This cross-sectional study included adult patients with prevalent RA (per 2010 ACR/EULAR criteria) attending outpatient rheumatology clinics in four countries. Flare occurrence over the past 3 months was assessed using the FLARE-RA questionnaire. The cut-offs for the FLARE-RA score were defined using the following anchor items obtained at the same encounter: 1) Patient report of flare; 2) DAS28-CRP >3.2; 3) Change of anti-rheumatic treatment, based on the area under the receiver operating characteristic curve (AUC) and distance to (0,1).

Results: The study included 571 patients with RA (mean age 56.9 years, 75.3% female). The discrimination for the FLARE-RA was acceptable-to-excellent: AUC for the global FLARE-RA score ranged from 0.71 to 0.92. The summary of optimal cut-offs for the FLARE-RA questionnaire is presented in the Table. The cut-offs for the FLARE-RA score were overall lowest using “patient’s report of flare” and highest using “change of anti-rheumatic treatment” as an anchor item: cut-offs for the global score for patients with RA duration 2-5 years: 1.82 and 4.55, respectively; for patients with RA duration >5 years – 2.18 and 3.18, respectively. The cut-offs corresponding to DAS28-CRP >3.2 were lower in patients with RA disease duration >5 years than in those with RA duration 2-5 years.

Conclusion: The FLARE-RA questionnaire has acceptable-to-excellent discriminative capacity across the tested anchor items. Patient report of flare corresponds to a lower FLARE-RA cut-off score than DAS28-CRP and change of anti-rheumatic treatment, suggesting the hierarchy of flare recognition from flare self-perception to its detection by DAS28 to treatment change by the rheumatology provider. More studies are needed to ensure the early recognition of flares and the appropriate alignment between flare and the adjustment of anti-rheumatic and other medications.

References

1. Fautrel B, et al. Validation of FLARE-RA, a Self-Administered Tool to Detect Recent or Current Rheumatoid Arthritis Flare. Arthritis Rheumatol 2017, 69(2):309-319.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/criterion-validity-of-the-flare-assessment-in-rheumatoid-arthritis-flare-ra-questionnaire-and-flare-ra-cut-offs-for-clinical-decision-making-international-collaboration/