Autoimmune connective tissue disease (AICTD)

• General Rheumatology consultations (consultants, specialty doctors, specialist nurses, ANP, senior Pharmacist)
• AHP (Rheumatology Physiotherapy, Podiatry, Occupational Therapy)
• US scan of the joints (for internal referrals only)
• Intraarticular steroid injections (for internal referrals only or performed by Rheumatology Physiotherapist)
• Training for self-delivered subcutaneous injections (internal use only)
• Medical Day Unit (internal service for delivery of intravenous medication, subcutaneous medication, Short Synacthen test)
• Rheumatology on-call (quick access to the service, prompt reply to enquiries via email)
• Rheumatology page 1439 – covered by resident doctor
• Rheumatology helpline  - 01292513316 – Service run by Rheumatology specialist nurses.

Suspected autoimmune connective tissue disease

They include:

• systemic lupus erythematosus
• mixed connective tissue disease (CTD)/undifferentiated CTD
• systemic sclerosis/scleroderma
• Sjogren’s syndrome
• polymyositis/dermatomyositis
• vasculitis.

Refer to the Rheumatology Outpatient Clinic if:-

1. Clinical features consistent with systemic lupus srythematosus (SLE) – rash, photosensitivity, oral ulcers, Raynaud’s phenomenon (RP), joint pain, chest pain, fatigue, cytopenia, proteinuria, haematuria, elevated creatinine, acute sensory or motor loss.

Patients should have a combination of these features not attributable to an alternative diagnosis.

A negative ANA strongly reduces the likelihood of SLE or Sjogren’s. All patients classified as having SLE must have ANA>=1:80 (Entry criterion) at least once.

2. Clinical features consistent with systemic sclerosis – sclerodactyly, typical skin thickening, Raynaud’s phenomenon, dyspnoea.
3. Clinical features consistent with inflammatory myopathies – progressive muscle weakness, usually proximal with no alternative explanation, typical rashes, elevated CK 10-50 fold with no alternative explanation, and elevated ESR/CRP.
4. Clinical features consistent with Sjogren’s syndrome – dry mouth, dry eyes, parotid or submandibular swelling in the presence of ENA positive - anti Ro positive.
5. Raynaud’s phenomenon if it is late onset, associated with digital ulceration or associated with other symptoms of the AICTDs described above.
6. Unexplained seizures, focal neurological defects, psychosis.
7. Mouth ulcers.
8. Recurrent miscarriages or unexplained thrombosis.
9. Constitutional symptoms- unexplained fever or weight loss.

Refer to Rheumatology with urgent priority if the patient displays persistent symptoms as above, by using SCI OP Gateway

Do not send new referrals only for updates or to ask for urgent review do to flares for patients already known to rheumatology, being on the list waiting for reviews, as we cancel such referrals to avoid duplication.

Please do not hesitate to keep in touch with us regarding your patients with any updates, symptom changes or flare ups using the Rheumatology Clinical email inbox: clinicalr@aapct.scot.nhs.uk 

Do not refer to rheumatology patients with positive ANA results in the absence of the above symptoms as in most cases they are only incidentally positive.

In case of concerns, please liaise through rheumatology clinic inbox: clinicalr@aapct.scot.nhs.uk

Otherwise, you can follow the below recommendations.

Please check prior sending the referral:

• FBC, U&Es, LFTs, CK, ANA, ESR, CRP, Rheumatoid arthritis factor
• Monitor blood pressure
• Urine dip, in case of positive for protein and blood, check Urine albumin/creatinine ratio
• Possible chest x ray to rule out/in sinister pathology, pleural effusion, enlarged cardio mediastinal contour.

In case of impaired U&Es and proteinuria please refer urgently to Renal.

Please note that over 70% of elderly over 70 years of age can test ANA positive with no CTD symptoms.  One third of healthy people may have a positive ANA and do not need to be referred.

Do not refer to rheumatology but you may ask advice by using the rheumatology general clinical inbox if ANA is positive and no other symptoms, but with:

• arthralgia
• Raynaud’s
• generalised pain or fatigue.

1. British Society for Rheumatology Adult Rheumatology Referral Guidance. September 2021. Accessed at: https://www.rheumatology.org.uk/Portals/0/Documents/Policy/Adult-rheumatology-referral-guidance.pdf?ver=2022-08-04-104812-413
2. NHS Lanarkshire Rheumatology referral guidelines. March 2022. Accessed at: https://rightdecisions.scot.nhs.uk/media/2014/ebooklet-rheumatology-referrals-2022.pdf
3. NHS Lothian. RefHep. Accessed at:RefHelp – Instant Acces s to Referral Guidelines for Lothian