Early Inflammatory Arthritis

Service Overview

It is widely recognised that delays in the diagnosis and treatment of rheumatoid arthritis has long term consequences on joint damage and quality of life for patients. It is therefore important that the symptoms and signs of possible inflammatory arthritis are recognised early and urgently referred for further assessment and treatment. Please do not therefore delay referral if criteria are met (this means that referral should not be held whilst awaiting results of investigations).

All patients with persistent synovitis of the small joints of the hands, feet or more than one large joint should be referred urgently to an Early Inflammatory Arthritis (EIA) service. Symptoms of persistent synovitis are pain, heat and/or swelling of joints with more than 30minutes of early morning joint stiffness.  Synovitis can be difficult to detect particularly in the early stages, therefore if patients are tender when squeezed across the metacarpophalangeal or metatarsophalangeal joints then there should be a low threshold for referral to rheumatology.  Rheumatoid arthritis is a systemic illness, therefore patients also often report features such as fatigue, fevers and weight loss.  Other features that might suggest early inflammatory arthritis include joint stiffness following periods of immobility, significant benefit with NSAIDs and a strong family history.

The rheumatology departments in UHB, NBT and Weston have developed Early Inflammatory Arthritis (EIA) services in line with NICE and BSR guidelines.

All urgent referrals are triaged by the consultants and the rheumatologists aim to see suspected early inflammatory arthritis cases within 3 weeks from receipt of referral.  Referrals should be submitted with a completed proforma (see Referral Section below).There are slots available on eRS that can be directly referred into – it is important that patients referred into the slots meet the referral criteria. Those that don’t may be rejected and triaged into general rheumatology clinics, which may cause undue concern and distress to patients, particularly as there is often a longer wait for these clinics.

Who to Refer

Referral criteria

Early Referral is critical and should not be delayed if referral criteria are met. Please therefore do not delay referral while waiting for results of blood tests and/or imaging to be available - these can be requested simultaneously.

• Swelling of 3 or more joints

• Swelling of the small joints of hands or feet

• Raised inflammatory markers

• Early morning joint stiffness (EMS) >30mins

*If history is of joint inflammation is >6 months then EIA is less likely and this pathway may therefore not be appropriate.

Local rheumatologists have limited urgent clinic slots so please do not refer patients to this service if they have probable fibromyalgia or other rheumatological conditions that do not require urgent review.

Patients not meeting the EIA referral criteria should should be referred to a general rheumatology clinic if an opinion is still required or alternatively consider using Rheumatology Advice and Guidance.

Patients with suspected axial spondyloarthritis should not be referred using this service. Please see the Spondyloarthritis section for further advice.

At time of referral

All patients with suspected EIA should have  physical examination in primary care before referral.

Tests to be considered at time of referral (please also see link to the referral proforma in the Referral section below):

Blood tests - FBC, UE, LFT, TFT, CRP, TFT, Rheumatoid Factor (false positives common but still considered a useful test), anti- CCP (a more specific test for IA). ANA is optional but now considered more of a secondary care test.

Radiology tests - Xrays of hands and feet - state indication when requesting on ICE.

Please also see notes below:

• The service recommends investigations such as inflammatory markers and X rays of hands and feet (see proforma for further details). To avoid delays do not wait for results prior to referral if criteria are met. These investigations will however, be helpful in making a rapid assessment in clinic.

• The diagnosis of EIA is not excluded by normal inflammatory markers and / or a negative rheumatoid factor and/or normal X-rays. Anti - CCP antibodies should also be requested as they can be a more specific indicator of inflammatory arthritis.

• Please refrain from using steroids until the patient has been seen in clinic as this can delay diagnosis and commencement of appropriate treatment.

The service aims to make a diagnosis and start disease-modifying drugs within 6 weeks from time of referral or discharge patients if not EIA. People diagnosed with EIA have regular clinical reviews by the multidisciplinary team for education, self-management, monitoring of disease activity, therapeutic benefit and treatment safety.

Referral

Refer using the EIA Proforma (word doc) which should be uploadable in EMIS and should be submitted directly to the EIA clinic via eRS marked urgent.

Please include further clinical information, examination findings and past medical history in the box at the bottom of the referral proforma, or submit in a separate clinical letter. This information is very helpful for the secondary care team and supports them in making a rapid diagnosis. Incomplete forms may be returned to the GP. This service should not be used for patients with established diagnoses of rheumatoid/ inflammatory/ osteoarthritis, fibromyalgia or symptoms > 6 months duration.

To avoid delays please also ensure that patients are aware that this is an urgent referral and that they should  make their appointment as soon as they receive their booking letter. Please also ensure that their contact details are up to date.

Due to the urgent nature of these referrals, they should be submitted directly via eRS not via the Referral Service.

EIA clinics are available at UHB, NBT and WGH via eRS.

Non-urgent Referral

Patients not meeting criteria for the EIA clinic should be managed initially through advice and guidance. If a routine referral is made then please be aware of possible long waits for these clinics.

If a patient subsequently has worsening symptoms or abnormal investigations that indicate EIA is more likely then please contact the hospital directly (email or letter) with details requesting the referral is expedited if appropriate.

Email contact details

For any UHB queries please email: Rheumatologycliniccoordinator@UHBristol.nhs.uk

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.