Of the many things that people with ankylosing spondylitis (AS)/axial spondyloarthritis (axSpA) would like the medical profession to achieve for them, among the most pressing is providing effective ways of managing or preventing flares. Flares present a difficult set of problems: They are not predictable and often occur when contact with a physician or physiotherapist is not possible; and in any event, we can neither define nor measure them. And yet they are a major problem that needs to be tackled. Moreover, whatever they are, effective treatment of axSpA ought to prevent them.
In this issue of The Journal, Jacquemin, et al1 have therefore rightly drawn attention to the issue of flares in axSpA and explored frequency and duration in a group of Canadian patients at a time when few were receiving biologic treatment. Although no definition or description of flare was used, they found that most patients admit to having flares with a mean duration of 2 weeks. Indeed, this and other studies2,3,4 agree that many people with axSpA consider that flares are very common and sometimes virtually continuous.
So what is a flare? In rheumatoid arthritis (RA), the term flare implies a periodic increase in symptoms, generally associated with an increase in inflammatory activity, evidenced by clinical signs and a rise in the acute-phase response. In RA, flare can be defined numerically according to validated criteria5. By analogy, it may be assumed that in axSpA a flare also represents a periodic worsening of symptoms associated with an increase in inflammatory activity. However, objective evidence of the latter is not generally available — especially when spinal symptoms are the issue — and a range of other associated problems may cause people with AS to feel worse. The problematic nature of …
Address correspondence to Dr. Keat. E-mail: a.keat{at}nhs.net