Rheumatoid arthritis

• 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: clinicalr@aapct.scot.nhs.uk)
• Rheumatology page 1439 – covered by resident doctor
• Rheumatology helpline  - 01292513316 – Service run by Rheumatology Specialist nurses.
• Clinical Rheum Spec Nurse Patient Helpline: aa.clinicalrheumspecnurse@aapct.scot.nhs.uk

Suspected rheumatoid arthritis

Refer if persistent symptoms for >four weeks, even with normal ESR/CRP and negative CCP or rheumatoid factor:

• Small joints of the hands or feet
• More than one joint
• Delay of three months or longer between onset of symptoms and seeking medical advice.

History

• Joint pain stiffness and swelling in a symmetrical distribution affecting the wrists, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the hands and metatarsophalangeal joint (MTP) joints of the feet. Large joints may also be affected.
• Early morning stiffness (typically >30min)
• Inactivity related stiffness.

Examination

• Soft tissue swelling and tenderness of affected joints
• Pain on squeezing metacarpophalangeal (MCP) and metatarsophalangeal joint (MTP) joints (the squeeze test)

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

Investigations prior to referring

• FBC, ESR, CRP, LFTs, U&Es, RA factor
• X-ray of the hands/ region of interest (periarticular osteoporosis, erosions)
• Anti-CCP antibody can be recommended only by the rheumatology consultant.
• Normal investigations do not rule out a possible inflammatory/rheumatoid arthritis, but make the diagnosis unlikely in the absence of relevant symptoms and soft joint swelling on clinical assessment.
• Rheumatoid arthritis never affects the lumbar spine, thus do not check rheumatoid factor for patients with back pain. I weakly positive test is incidental and can be source of health anxiety.
• Rheumatoid factor can be weakly positive for active smokers.
• ANA can be positive for patients with rheumatoid arthritis, with no relevance to support the diagnosis.

Main differential diagnoses

• Reactive arthritis – Can present similarly but usually resolves within 3 -12 months
• Osteoarthritis – The distribution is different (affects distal interphalangeal (DIP), proximal interphalangeal (PIP) and 1^st carpometacarpal (CMC) joints of the hands). There is bony joint enlargement rather than swelling due to osteophytes. Levels of ESR and CRP are normal and RAF is negative.
• Psoriatic arthritis – the distribution can mimic rheumatoid arthritis or is asymmetrical including DIPs. In most cases, RAF is negative.
• Septic arthritis and Crystal disease usually are mono/oligoarthritis.

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