Inflammatory Arthritis Referral Guideline

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The inflammatory arthritides are a heterogeneous group of autoimmune conditions that are characterised by inflammation within the synovial lining of joints or tendons. Each of the inflammatory arthritidies has a characteristic pattern of joint involvement, associated features and risk of complications.

A diagnosis of an inflammatory arthritis can only be made once inflammation within the affected joint (synovitis or joint effusion), tendon (tenosynovitis) or digit (dactylitis) has been confirmed by examination or, in some cases, imaging.

Prompt, early diagnosis of inflammatory arthritis and initiation of disease modifying anti-rheumatic (DMARD) therapy is vital to reduce the long term risk of permanent joint damage and disability; however, recognition of the early stages can be difficult.

History

Symptoms that are suggestive of an inflammatory arthritis include:

  • Joint pain – usually localised to the joint; feels worse after inactivity and may improve with repeated movement or activity.
  • Joint swelling – localised to the joint or tendon, usually persistent.
  • Stiffness – inactivity gelling and prolonged morning stiffness.
  • Loss of function.
  • Constitutional – fatigue, weight loss, fevers / night sweats, loss of appetite, low mood.

Associated features – are useful to confirm specific diagnosis once joint inflammation has been confirmed

  • Seronegative Arthropathies – inflammatory back pain; preceding infection (especially urinary, GI or GU) and past or first degree relative history of Psoriasis, Inflammatory Bowel Disease or Uveitis.
  • Connective Tissue Symptoms – mouth ulcers, sicca symptoms, alopecia, rash and photosensitivity, Raynaud’s phenomenon, serositis.
  • Sarcoidosis – dry cough, increased breathlessness, rash, erythema nodosum, painful red eyes.

Examination

Focuses on identification of inflammatory change in, or around, the symptomatic joint; determining the distribution of affected joints and identifying evidence of joint deformity and dysfunction.

  • Synovitis – soft tissue swelling / thickening; may be tender, warm and erythematous with restricted movement; needs to be differentiate from hard, smooth, nodal swelling of osteoarthritis.
  • Tenosynovitis – linear or fusiform swelling and tenderness of the affected tendon.
  • Dactylitis – inflammation of a whole digit; suggestive of seronegative arthritidies (especially psoriatic arthritis) but can be a feature of gout and sarcoidosis.

Helpful Investigations

Most inflammatory arthritidies remain a clinical diagnosis where investigations support the clinical diagnosis. Negative investigations should not delay referral in patients with clinically evident joint swelling.

  • UE, LFT, FBC – assess suitability for DMARD therapy
  • CRP, ESR – normal in 10-15%
  • Rheumatoid Factor – positive in 65-70% of cases of rheumatoid arthritis
  • ANA – if there are features suggestive of a connective tissue disease
  • Xrays of Hands / Feet - often normal in the early stages of an inflammatory arthritis.

Primary Care Management

Patients with clinically suspected inflammatory arthritis should be referred urgently to the rheumatology department, especially if there is clinically evident synovitis or dactylitis.

Prior to rheumatology clinic review, useful measures to manage symptoms include:

  • NSAIDs – taken regularly at maximal doses. E.g Ibuprofen (upto 600mg qds), Naproxen (500mg bd), Etodolac (600mg od), Meloxicam (15mg od), Etoricoxib (60mg od)
  • Simple analgesics – as tolerated – E.g Paracetamol, Cocodamol 8-30/500, Codydramol 10-30/500.

Empirical corticosteroid therapy should be avoided wherever possible unless the patient is experiencing significant levels of pain or functional impairment.

Who to Refer

Any patient where there is a high degree of clinical suspicion for an inflammatory arthritis, especially if there is clinically evident synovitis or dactylitis.

Who Not to Refer

  • Patients with elevated Rheumatoid Factor and/or ANA titres but no suggestive symptoms / signs of inflammatory arthritis or connective tissue disease
  • Patients in whom an alternative cause for symptoms seems more likely, e.g.
    • Osteoarthritis
    • Fibromyalgia (pain, myalgia and fatigue but low risk features for inflammatory arthritis - no evidence of synovitis or dactylitis, or deformity, normal autoantibodies and normal inflammatory marker levels).

Last reviewed: 01 November 2020

Next review: 01 November 2022

Author(s): Dr Anna Ciechomska

Co-Author(s): Rheumatology team: Dr Robin Munro, Dr Karen Donaldson, Dr Elizabeth Murphy, Dr James Dale, Dr Sanjiv Nandwani, Dr Georgiana Young, Dr May Chee, Mr Nico Groenendijk; GP representatives: Dr Tyra Smith, Dr Mark Russell, Dr Linda Findlay, Dr Paul Deehan, Dr Lucy Munro; Medical directorate: Dr Mehrdad Malekian

Approved By: Dr Karen Donaldson

Reviewer Name(s): Dr Anna Ciechomska