HNY Policy and Pathway Repository - York

Inflammatory arthritis describes a large group of conditions whichcan cause pain, stiffness, swelling and in time joint damage if untreated. They are immune related conditions.

Inflammatory arthritis in its early stages may not exhibit the typical patterns of established disease. However, it is in the early stages that treatment with appropriate disease-modifying medication can have maximum impact on outcome and remission rates.

Rapid referral of people with suspected persistent synovitis is important to avoid delay in diagnosis and prevent irreversible joint damage and long-term impact on quality of life. People with these symptoms and signs should be considered to need urgent action

Refer urgently if persistent synovitis (symptoms >2 weeks) is suspected and any of the following apply:

• The small joints of the hands or feet are affected (particularly wrists, metacarpophalangeal or metatarsophalangeal joints)
• More than one joint is affected
• There is symmetrical synovitis of the small joints of the hands and feet, although any synovial joint may be affected  
• Stiffness in the morning and after inactivity that usually lasts more than 30 minutes.

NICE Quality statement
People with suspected persistent synovitis affecting the small joints of the hands or feet, or more than 1 joint, are referred to a rheumatology service within 3 working days of presentation

Symptoms of synovitis:

Pain, swelling, and heat in affected joints.

• Pain — usually this is worse at rest or during periods of inactivity
• Swelling

Signs of synovitis include:

• Swelling, around the joint (not bony swelling) giving a 'boggy' feel on palpation,
• Tenderness
• Reduced range of movement

Other features which should raise suspicion of inflammatory arthritis include:

• Constitutional upset, such as loss of appetite, weight loss, fatigue
• The presence of other conditions associated with inflammatory arthritis such as
• psoriasis, iritis or uveitis, inflammatory bowel disease
• A family history of RA

If Spondyloarthritis (inflammation of the spine or sacroiliac joints) is suspected please see specific guidance on this (guidance currently unpublished).

 

Investigations to undertake before referral

It would be helpful if the following investigations could be arranged before clinic appointment and the results sent with the patient or original referral. However, the results should not influence the decision to refer, as normal or negative results do not exclude an inflammatory condition:

• full blood count
• renal function
• liver function tests
• urate
• c-reactive protein (CRP)
• rheumatoid factor and anti-CCP
• antinuclear antibody

In addition, it would be helpful if X-rays of the hands and feet could be arranged if these joints are affected, otherwise they will be arranged when the patient attends the clinic.

Information to include in the referral letter

• Date of onset
• Joints involved and distribution
• Frequency of attacks
• Medication history including NSAID response if not contraindicated
• Duration of early morning stiffness
• Personal or family history of associated disorders e.g. inflammatory bowel disease, psoriasis, uveitis, etc.
• History of pro-dromal illness e.g. URTI, GU/ GI infection etc

Patient information leaflets/ PDAs

https://www.versusarthritis.org/about-arthritis/treatments/the-inflammatory-arthritis-pathway/