Early Arthritis Clinics
Service
Locality: Mid Hampshire, South West, Southampton
Type of Care: Secondary
eRS listing: Rheumatology – Early arthritis – (Triage) – Southampton – UHSFT – RHM
Early inflammatory arthritis including Rheumatoid arthritis, Psoriatic arthritis, Ankylosing Spondylitis, Reactive arthritis and Enteropathic arthritis.
Referral Criteria
- Refer for specialist rheumatology opinion any adult with suspected persistent (more than 3 weeks) synovitis (soft tissue joint swelling) of undetermined cause.
- Refer urgently (even with normal acute phase response ESR/CRP, negative RF and normal anti-CCP) if any of the following apply:
- The wrists and/or small joints of the hands or feet are affected
- More than one joint is affected
- There has been a delay of more than 3 months between onset of symptoms and seeking medical advice
Exclusions:
Osteoarthritis, Fibromyalgia, Chronic pain syndromes, Back and Neck pain, Regional Soft Tissue Disorders, Osteoporosis, Connective Tissue Disease
Patients suspected of having any of the exclusion conditions can be considered for referral to the General Rheumatology Clinic
Suggested Investigations:
– Blood tests including FBC, UE, LFT, CRP, ESR, RF, ANA
– X ray the hands and feet, if these joint areas are symptomatic
If the above investigations are arranged in primary care, they should not delay referral for a specialist rheumatology opinion
Please see HHFT’s referrals and guidance page for more information.
Please complete the referral proforma prior to referral:
eRS listing: Rheumatology Advice & Guidance (including Early Inflammatory Arthritis) PHUT – RHU
eRS listing: Early Inflammatory Arthritis Service – Christchurch Hospital – R0D
Referral Criteria:
- 2 of the following symptoms for > 6 weeks:
- Swelling of > 1 joint
- Early morning stiffness lasting > 30 minutes
- Positive MTP/MCP joint ‘Squeeze’ test
Suggested investigations:
- FBC, ESR, CRP, Rh Factor, anti-CCP, U&Es, LFTs
- It is not usually necesssary to request ANA unless the patient has features of autoimmune connective tissue disease (such as a facial or vasculitic rash; mouth ulcers; Reynaud’s syndrome; chest pain; alopecia; proteinuria; SOB; systemically unwell). Similarly plain film x-rays are not usually necessary before out-patient review.
Please do not start the patient on steroids as this may delay diagnosis and the commencement of appropriate treatment.
A normal ESR/CRP, rheumatoid factor and anti-CCP does not exclude a diagnosis of inflammatory arthritis.
eRS listing: Rheumatology-Early Arthritis Service-Salisbury FT-RNZ
Please see their GP Portal for more information (requires an HSCN connection)
The hallmark of arthritis is joint swelling associated with pain or stiffness. If present, and affecting three or more joints, with early morning stiffness lasting more than 30 minutes and pain on squeezing hand and foot joints then early referral is recommended. It should be noted that a raised CRP or ESR and positive RF are not necessary to make the diagnosis and the clinical signs may be masked by non-steroidal anti-inflammatories or systemic corticosteroids.
Who to refer?
- All patients with a good history of inflammatory arthritis (stiffness in any of joints of hands, wrists, feet, elbows, shoulders, hips and knees lasting more than 30 minutes after awakening).
- All patients with joint pain worse in the morning or wakening patient second half of the night.
- All patients with joint pain and a family history of RA.
- Patients with either swollen or painful joints (either subjectively form history or objectively from examination).
What investigations should be ordered:
- C-reactive protein (CRP) (may be normal in small joint disease)
- Full blood count, urea and electrolytes and liver function tests
- X-rays hands and feet (often normal in early disease)
- Rheumatoid factor (RF) (+ve in 70-80%, but often not in early disease)
- Anti-cyclic citrullinated peptide (CCP) antibodies
- Anti nuclear antibodies (ANA)
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