# Rheumatoid arthritis in crisis: investigating the impact of stress on RA flares during the COVID-19 pandemic

## TL;DR

This study found that stress during the pandemic worsened rheumatoid arthritis flares, with financial stress and poor sleep being key factors.

## Contribution

The study provides new evidence linking pandemic-related stress to increased rheumatoid arthritis flares and identifies specific stressors and demographic factors involved.

## Key findings

- 69.3% of RA patients reported at least one flare during the pandemic, with financial stress and poor sleep significantly associated with flare frequency.
- Asian race was negatively associated with the number and frequency of RA flares during the pandemic.
- Patients not in remission were more likely to experience flares during the pandemic, suggesting stress exacerbates disease activity.

## Abstract

Psychological stress impacts rheumatoid arthritis (RA) disease activity, and California’s response to the COVID-19 pandemic created historically significant stressors for patients. This study examined factors associated with changes in RA flares during the pandemic.

In this cross-sectional COVID-19 RA study, patients with RA ICD-9/10 codes were emailed a questionnaire in July/November of 2020 containing questions on RA disease activity, Routine Assessment of Patient Index Data 3 (RAPID3), flare number and frequency, RA Flare Questionnaire (RA-FQ), Perceived Stress Scale 4 (PSS-4), stressors, and demographics. Age, anti-cyclic citrullinated antibody, and rheumatoid factor were extracted from medical records. Analyses examined associations between current flare status, number of flares, and changes in flare frequency with PSS-4 and stressors.

Of 1138 respondents (22.6% response rate), 69.3% reported at least one RA flare, 43% multiple flares, and 36.3% currently experiencing a flare. Compared to pre-pandemic levels, 36.3% noted more frequent flares, while 9.2% reported fewer. Increased stress was noted across all flare groups. Regression analyses revealed significant associations between current flare and PSS-4 scores, financial stress, and sleep quality (all p < 0.03). A higher number of flares were significantly associated with PSS-4, financial stress, and home stress (p < 0.03). Increased flare frequency was associated with PSS-4, apprehension, panic, financial stress, and sleep quality (all p < 0.05). Asian race was negatively associated with the number of flares and flare frequency (both p < 0.05).

This study reports a link between stress and RA flares during the pandemic, underscoring the need for targeted strategies to manage RA patients at risk of flare during heightened stress.
Key Points• During the COVID-19 pandemic, patient-reported RA flares increased significantly compared to pre-pandemic levels, signifying there may be value in reevaluating RA management strategies during periods of heightened stress.• Financial stress, home stress, and poor sleep were major pandemic stressors linked to current and increased frequency of RA flares.• RA patients not in remission may be more susceptible to disease exacerbations while under stress, as those experiencing flares during the pandemic were less likely to have been in remission beforehand.• Asian race was associated with fewer RA flares and reduced flare frequency, suggesting racial and ethnic differences may influence flare patterns.

Key Points

• During the COVID-19 pandemic, patient-reported RA flares increased significantly compared to pre-pandemic levels, signifying there may be value in reevaluating RA management strategies during periods of heightened stress.

• Financial stress, home stress, and poor sleep were major pandemic stressors linked to current and increased frequency of RA flares.

• RA patients not in remission may be more susceptible to disease exacerbations while under stress, as those experiencing flares during the pandemic were less likely to have been in remission beforehand.

• Asian race was associated with fewer RA flares and reduced flare frequency, suggesting racial and ethnic differences may influence flare patterns.