Referral to Rheumatology Guide

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NHS Tayside

Emergencies

Septic arthritis (please liaise with orthopaedic surgeons)

Any patient with an acutely painful, red, swollen joint who is systemically unwell or where there is a suspicion of septic arthritis.

Systemic vasculitis (please discuss with Rheumatology Mon-Fri 9-5, or on call physician OOH)

A systemically unwell patient with features of vasculitis such as weight loss, purpuric rash, haemoptysis, neuropathy etc.

Giant Cell Arteritis

Please follow the separate GCA referral pathway and guidance.

Suspected inflammatory arthritis - refer as URGENT

Suspected rheumatoid arthritis (RA)
- Refer if persistent symptoms for >4 weeks, even with normal CRP and negative antibodies. Symptoms affecting the small joints of the hands or feet. Patients may describe acute onset joint pain and swelling with clinical signs of inflammation such as swelling/heat/erythema, or elevation of inflammatory markers. Please arrange CRP, cyclic citrullinated (anti-CCP) antibody, hand and foot x-rays as a baseline.
Suspected psoriatic arthritis (PsA) and other peripheral spondyloarthritides
- Patients may have dactylitis, enthesitis (without apparent mechanical cause, persistent or in multiple sites), past/current uveitis, past/current psoriasis, GI/GU infection, IBD or a first degree relative with spondyloarthritis or psoriasis. Please arrange CRP and hand and foot x-rays as a baseline.
Persistent synovitis/arthralgia (mono/polyarticular) of unknown cause.

Suspected axial spondyloarthritis (inflammatory back pain) - refer as URGENT

3+ months of back pain plus 4 or more of the following criteria:

Started before age of 35
Waking during second half of night because of symptoms
Alternating buttock pain
Improvement with movement
Improvement within 48h of taking an NSAID
First degree relative with spondyloarthritis
Past/current arthritis
Past/current enthesitis
Past/current psoriasis
Past/current uveitis
Positive HLA B27.

Suspected vasculitis

(please check CTD screen and anti-MPO/PR-3 antibodies) – refer as URGENT

Consider if systemically unwell with raised inflammatory markers in the absence of infection or other explanation. Be alert to evidence of end organ damage, e.g. skin infarction, visual loss, respiratory failure, cardiac failure, acute abdomen, acute kidney injury, acute sensory/motor loss.

Other symptoms that might be present:

Respiratory – haemoptysis, shortness of breath
Oral health – mouth ulcers
GUM – genital ulcers
Renal – haematuria, elevated creatinine
Ophthalmology – scleritis, visual loss
ENT – hearing loss, nasal crusting, nosebleeds, sinus pain
Other possible symptoms include rashes, weight loss, night sweats, fatigue, joint pain.

Suspected autoimmune connective tissue disease

(please check CTD screen) – refer as URGENT only if concern about organ involvement.

SLE
- Rash, photosensitivity, oral ulcers, Raynaud’s, joint pains, chest pain (pleuritis/pericarditis), dyspnoea, cytopaenias, haematoproteinuria, raised creatinine, acute sensory or motor loss, recurrent miscarriages).
Systemic sclerosis
- Raynaud’s, puffy fingers, dyspnoea, indigestion, dysphagia.
Inflammatory myopathies
- Progressive muscle weakness (usually proximal) +/- rashes, raised CK, dysphagia, ILD.
Sjogren’s
- Dry eyes, dry mouth, parotid or submandibular swelling.

Other

Crystal arthritis
- Referral is indicated in patients with recurrent attacks of gout or pseudogout which are difficult to control despite following the standard treatment regime (see separate guidance), diagnosis is uncertain, treatment is contraindicated/not tolerated/ineffective, the patient has CKD 3b-5 or they have an organ transplant.
Polymyalgia rheumatica (PMR)
- Rheumatology review is only required in those where there is diagnostic uncertainty or inadequate response to standard prednisolone reduction regime (see separate guidance).

Referral not required

Patients with the following conditions should not usually be referred. It is acknowledged that occasionally referrals may take place if there is doubt about diagnosis or because of patient pressure. Although we are happy to see these patients, it should be made clear to the patient that rheumatology are likely to have little to offer other than confirmation of diagnosis.

It is necessary for the referrer to specify the reason for referral and the expected outcome. In some of these cases a discussion with a rheumatologist may suffice.

Fibromyalgia
Chronic fatigue syndrome
Joint hypermobility
Non-inflammatory back pain
Raised plasma viscosity with no inflammatory features
Ill-defined rheumatic symptoms and normal investigations
Patients who have weakly positive auto-antibodies but no symptoms or signs
Osteoarthritis
Carpal tunnel syndrome (refer to hand surgeons)
Mechanical neck or back pain (refer to physiotherapy)
Localised joint or tendon problems with no inflammatory features (refer to physiotherapy)
Mechanical foot problems (refer to podiatry / orthotics).

Contact details

SCI-gateway referrals and advice requests	Response within 1 working day
On call email tay.rheumatology@nhs.scot (secondary care only)	Response within 1 working day
On call rheumatology page #4844 (urgent queries only)	Monday – Friday 9am – 5pm

This guidance is intended to enable you to make best use of the Rheumatology services in Tayside and ensure that patients with serious systemic inflammatory conditions are seen and managed quickly. Rheumatology has most to offer those with inflammatory arthritis and other autoimmune conditions where early intervention with disease modifying agents will reduce the degree of joint or organ damage. Below are conditions that should be referred on to secondary care. If there is doubt as to whether a referral is necessary, please contact rheumatology and we will be happy to offer advice.

Minimum dataset

This allows us to vet effectively and prioritise the patients who require urgent rheumatology review.

Clinical history
Examination findings
FBC and CRP, plus relevant immunology. If there is a strong concern, referrals can be sent to us prior to immunology results returning.
- Anti-CCP antibody where there is concern about inflammatory arthritis
- CTD screen where there is a query over an autoimmune connective tissue disease
- MPO/PR-3 where there is concern about small vessel vasculitis
Hand and foot x-rays for suspected inflammatory arthritis
Clinical impression and question for rheumatology.