Guidelines for GPs
Below are referral guidelines for GPs for
- Suspected inflammatory arthritis
- Suspected axial spondylitis
- Suspected connective tissue disease
- Suspected giant cell arteritis
- Suspected polymyalgia rheumatica
- Suspected gout
- Suspected fibromyalgia
Suspected inflammatory arthritis
Suspected Polyarthritis, eg: Rheumatoid Arthritis, Psoriatic Arthritis
Refer urgently if suspected new inflammatory arthritis
Note duration of symptoms e.g. <6 weeks , <6 months <2 years
3 “S “ rule
- SWELLING Swollen Joints 1 or more
- SQUEEZE test positive MCP and MTP involvement
- STIFFNESS Early morning stiffness more than 30 mins
Personal history of psoriasis, colitis, uveitis
Family history of psoriasis
Bloods (suggested tests when indicated – not essential prior to referral but will help with triaging)
FBP, U&E, LFT, ESR, CRP, Anti CCP
Suspected Axial Spondylitis
- LBP started before age 35
- Waking second part of night with symptoms
- Buttock pain
- Improvement with movement
- Improvement within 48 hours of taking NSAIDS
- First degree relative with SpA
- Current or past arthritis
- Current or past enthesitis
- Current or past psoriasis
Referral if >4 present
If exactly 3 – check HLAB27 and refer if positive
MAY BE TRIAGED AS URGENT or EARLY SYNOVITIS
Suspected Connective Tissue Disease (CTD)
Joint pains/symptoms with association of one of more body systems e.g.
- Skin tightness/puffiness of hands
- Mouth ulceration
- Pleurisy / Pericarditis
- Muscle Weakness
- Swallowing difficulties
- Photosensitive rash
- Sicca symptoms – dry eyes/mouth
- Neurological symptoms
- Proteinuria / Haematuria
- Leucopenia, thrombocytopenia
- Raised CK
- Raised ESR/CRP
- Raised ANA titre
Suggested tests –
FBP, U&E, LFT, CK, Bone Profile, TFT, ANA, ESR, CRP
ANCA if vasculitis suspected
NB the most appropriate specialist to look after cases of CTD depends on the predominant system involved e.g.
- proteinuria / haematuria / renal dysfunction – nephrology
- rash / skin disorder – dermatology
- joints / muscles – rheumatology
Please don’t give empirical steroids prior to referral
MAY BE TRIAGED AS URGENT or EARLY SYNOVITIS
Suspected Giant Cell Arteritis
Suspect giant cell arteritis if the person is aged 50 years or older with at least one of:
- A new onset localized headache that is usually unilateral, in the temporal area, but is occasionally diffuse or bilateral.
- A temporal artery abnormality such as tenderness, thickening, or nodularity. Pulsation may be reduced or absent.
Other symptoms and signs suggestive of giant cell arteritis include:
- Systemic features (fever, fatigue, anorexia, weight loss, and depression) — affect most people. Fever is usually low grade, but may occasionally be higher.
- Features of polymyalgia rheumatica
- Scalp tenderness
- Intermittent jaw claudication
- Visual disturbances —blurred vision, amaurosis fugax, diplopia, partial or complete visual loss
- Neurological features
- Peripheral arthritis
- Respiratory tract symptoms — for example cough, sore throat, and hoarseness.
Please follow flow chart for initial primary care management – –Temporal Arteritis Guidance
Refer directly to DAU in Antrim to arrange fast track assessment
If visual loss refer directly to Eye casualty in RVH Belfast or Altnagelvin Hospital depending on patients address
DO NOT REFER TO OUTPATIENTS – Direct Access via Direct Assessment Unit (DAU)
Suspected Polymyalgia Rheumatica
Polymyalgia Rheumatica can usually be diagnosed and managed in primary care. Refer only to secondary care if there is uncertainty regarding the diagnosis, difficulty weaning steroid or complex/atypical features or concern regarding suspected GCA
NICE CKS for PMR polymyalgia-rheumatica
Refer to rheumatology (or relevant specialty if appropriate e.g. neurology, haematology, cancer specific specialty) if:
There are atypical features of PMR who do not have a clear alternative cause for their symptoms, including people who:
- Are younger than 60 years of age.
- Have red flags suggestive of a serious underlying condition, such as weight loss, night pain, or neurological features
- Do not have the core features of PMR, including:
- Bilateral shoulder or pelvic girdle aching.
- Stiffness lasting for at least 45 minutes after waking or periods of rest.
- Have clinical features that are uncommon with PMR, including people with:
- Normal inflammatory markers, or ESR of more than 100 mm/hour, or very high CRP.
- A chronic onset of symptoms.
Also refer for specialist management if:
- It is not possible to reduce corticosteroids at reasonable intervals without causing relapse.
- Corticosteroids are required for more than 2 years.
- The person is experiencing (or is at high risk of) adverse effects from corticosteroids.
MAY BE TRIAGED URGENT OR ROUTINE
Gout can usually be diagnosed and managed in primary care. gout
Refer to a specialist or seek specialist advice when:
- The diagnosis is uncertain, there is a suspicion of an underlying systemic illness (for example rheumatoid arthritis or connective tissue disorder), or gout occurs during pregnancy or in a young person (under 30 years of age).
- A person has persistent symptoms during an acute attack despite maximum doses of anti-inflammatory medication (alone or in combination).
- An intra-articular steroid injection is indicated but the facilities or expertise are not available.
- A person requires urate-lowering treatment and:
- Allopurinol and febuxostat are not tolerated or contraindicated; or
- Allopurinol or febuxostat is at maximum dose but there is failure to reach urate level target or the person is still having recurrent attacks of gout.
- Complications are present, including urate kidney stones, urate nephropathy, recurrent urinary tract infection, joint damage or troublesome tophi.
- The person is at risk of adverse effects of drug treatment
- See Febuxostat statement for guidance on using Febuxostat as treatment of gout following recent drug safety update regarding Febuxostat and the increased risk of cardiovascular death.
There is a concern regarding a possible septic joint – Refer directly to Emergency Department (ED) in Antrim or Causeway.
MAY BE TRIAGED URGENT, ROUTINE OR TO JOINT INJECTION CLINIC
Fibromyalgia can be diagnosed and managed in primary care. A specialist opinion is not required for the diagnosis and there are no interventions offered from rheumatology that are not accessible from primary care
Link to Fibro pathway
Refer if there is concern regarding an additional rheumatological condition but do not delay initiating fibromyalgia management if the diagnostic criteria are fulfilled.
Please describe the expectations of the referral
If there is a previous history of psychological/psychiatric issues please indicate this in the referral
Please consider other differentials for pain and fatigue prior to referral
WILL BE TRIAGED ROUTINE