Early arthritis clinic - RD&E

Early recognition & treatment of inflammatory arthritis significantly improves outcome; delay reduces efficacy of treatment and leads to poor outcome. After consultant assessment, if thought suitable then patients will be seen in The Early Arthritis clinic within 2-3 weeks.

Assessment

The following are clues to an Inflammatory Arthritis – Please see specific criteria for Referral to Early Arthritis further down page

History

  • Prolonged morning stiffness (more than 30 minutes), response to NSAID, & joint swelling
  • Extra-articular features: Psoriasis, rheumatoid nodules, sicca
  • Risk Factors: family history & smoking (RA)

Examination

  • Symmetry, small joint synovial (soft tissue) swelling.
  • Presence of enthesitis e.g. sausage digit
  • Distribution: e.g. wrists, MCP & PIP and feet MTP for rheumatoid arthritis
  • Look for extra-articular features

Differential Diagnoses

  • Post viral arthritis, drug reactions, fibromyalgia, osteoarthritis & crystal arthropathy (gout & pseudogout)

Red Flags

The S Factor? (used by RCGP & NRAS)

  • Stiffness - Early morning joint stiffness lasting more than 30 minutes
  • Swelling - Persistent swelling of one joint or more, especially MCP joints
  • Squeezing - Squeezing the joints is painful in inflammatory arthritis

Investigations

  • FBC, U&E, liver, CRP, urate, rheumatoid factor.
    • Don't delay referral waiting for test results.
  • CRP can be normal in early RA.
  • Rheumatoid factor can be negative.

Management

  • Analgesia & NSAIDs

See: 4.7 Analgesics and 10.4 Pain and inflammation in musculoskeletal disorders

Do NOT administer steroid before referral & diagnosis

Referral

Referral criteria

  1. Suspicion inflammatory arthritis as above
  2. Symptoms more than 4 weeks & less than 6 months*
  3. At least 3 swollen joints
  4. Not explained by flare of osteoarthritis / gout

*Patients with longer history will be seen in general rheumatology clinic

Referral instructions

  1. Request early synovitis clinic via DRSS referral. Patients can only be seen at the RD&E main site.
  2. Include duration of symptoms & examination findings
  3. Please refer to your local rheumatology service – these patients require lots of visits, tests & monitoring - IT systems are not shared between Trusts
  4. Discuss any queries with rheumatologist e.g. rheumatology consultant mobile phone 07920781631 answered between 12.45 = 1.45

Supporting Information

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: July 2016

 

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