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 30mins), response to NSAID, & joint swelling.
•  Extra-articular features: Psoriasis, rheumatoid nodules, sicca (dry eyes and mouth), inflammatory eye disease, STI/urethritis/gastroenteritis.
• Risk Factors: family history & smoking (RA).

Examination

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

Differential Diagnoses

Include:

• Septic arthritis
• Crystal arthropathy (gout & pseudogout)
• Osteoarthritis
• Perimenopause
• Post viral arthritis
• Sarcoidosis
• Fibromyalgia

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

• aCCP, FBC, U&E, LFT, CRP, urate

If confident of an inflammatory arthritis (IA) diagnosis, please refer before waiting on blood results.

aCCP

• aCCP is a newer and more specific investigation for RA (thus greatly reducing the false positive rates and patient anxiety when compared to RhF)
• aCCP should be used when considering a diagnosis of RA in patients with MSK symptoms

Rheumatoid factor (RhF)

• RhF should no longer be requested routinely in primary care.
• RhF is useful for prognosis, predicting complications and guiding management in secondary care.
• aCCP should be used when investigating suspected early inflammatory arthritis. If aCCP is positive, RhF will be automatically requested by the lab.

CRP

• this can be very helpful in supporting clinical signs and symptoms of inflammatory arthritis.

• Please note: patients in whom IA is clinically suspected should be referred even with a normal CRP.

• CRP can be mildly raised in patients with elevated BMI. In the absence of clinical signs and symptoms of inflammatory arthritis, a raised CRP alone should not be an indication for referral

Urate

• Is not diagnostic and may be falsely normal in an acute attack of gout
• Serum urate levels should be checked 4-6 weeks after an acute attack
• The main use of urate is in titrating prophylactic treatments e.g., allopurinol

ANA

• only indicated if the patient has other features of autoimmune disease .

HLA-B27

• please only check HLA-B27 if advised by secondary care

X-Rays

• X-rays will be requested by secondary care as indicated and are NOT required prior to referral.

Please see the Formulary section on Musculoskeletal & joint diseases:

North & East Formulary

Please DO NOT administer steroid before referral & assessment in clinic unless discussed with rheumatology team.

If in doubt, please contact your local rheumatology team for advice. See referral section for the contact details for any urgent rheumatology queries.

Referral criteria

1. Suspicion inflammatory Arthritis as above

2. Symptoms more than 4 weeks & less than 6months*

3. Not explained by flare of osteoarthritis / gout

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

Referral instructions

1. Request early inflammatory arthritis clinic via DRSS referral on e-RS

2. Include duration of symptoms & examination findings - very important for triage

3. Please refer to your local rheumatology service – these patients require lots of visits, tests & monitoring, they should be seen where their acute care would be best placed

4. If in doubt, please contact your local rheumatology team for advice via an A&G referral or by telephone:

• North Devon (NDDH catchment) - rheumatology team on 01271 311571

• East Devon (RDE catchment) - rheumatology consultant mobile phone 07920 781631 answered between 9am-5pm

If leaving a message on the rheumatology team mobile, please provide a phone number (ideally a direct line) and the rheumatology team will ring you back

Referral form

DRSS Referral Form

Pathway Group

This guideline has been signed off by the Northern and Eastern Localities on behalf of NHS Devon.

Publication date: February 2024