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Early Inflammatory Arthritis Care Pathway - Overview

Key Point

The EIA pathway is designed specifically for patients with suspected rheumatoid arthritis. The pathway has been updated to reflect some changes to the EIA access criteria, which aim to ensure that the most appropriate patients are referred to the service.

Early treatment with modern DMARDs (disease modifying anti-rheumatic drugs) significantly reduces long term morbidity and disability. This should preferably be within three months of the onset of symptoms.

The term 'inflammatory arthritis' describes a range of rheumatological conditions - predominantly autoimmune - which cause joint pain, swelling and stiffness. Included in this group is rheumatoid arthritis where evidence shows that early diagnosis, treatment and control of disease activity result in more rapid improvement in symptoms and function as well as reduction in joint damage.

In its early stages it can be difficult to diagnose with any degree of certainty. Early specialist assessment is therefore an essential ingredient if maximal long term control of the disease or a potential cure is to be achieved. 

Please click the relevant flowchart box to be taken directly to textual information (online only).

                     

Presentation

Practice Point

Diagnosing rheumatoid arthritis early can be straightforward, but can also be tricky and complex. It requires:

see Differential Diagnosis below

  • Evidence of synovitis for 4 weeks or more but less than 1 year

AND

  • One of the following:
  1. Swelling of 3 or more joint areas.                                               
  2. Swelling of small joints of hands or feet.   

Additional features which help to raise suspicions of inflammatory arthritis also include: (click for further info)

  • Early Morning Stiffness (EMS) for >30 min
  • Inactivity stiffness
  • Constitutional symptoms e.g. wt loss, anorexia, fatigue
  • Presence of other features related to arthritis e.g. rash, painful red eyes or inflammatory bowel disease

See 2010 ACR/EULAR Rheumatoid Arthritis Classification Criteria
Red Flags
  • Systemic symptoms, eg. weight loss, fever
  • Night pain
  • Previous malignancy
  • Peripheral arterial disease
  • Monoarthritis
The red flags listed above suggest serious disease other than autoimmune polyarthritis which may require urgent treatment. These include:
  • Acute septic arthrtis
  • Osteomyelitis
  • Periarticular malignancy, including metastatic disease
  • Peripheral vascular disease (e.g. if only one foot is affected)
Differential Diagnosis

The term ‘inflammatory arthritis’ describes a range of predominantly autoimmune rheumatological conditions that cause joint pain, swelling and stiffness.

Included in this group is rheumatoid arthritis where evidence shows that early diagnosis, treatment and control of disease activity results in more rapid improvement in symptoms and function as well as a reduction in long joint damage.

  • Polyarticular gout
  • Reactive arthritis
  • Psoriatic arthritis
  • Pseudogout
  • Systemic lupus erythematosus (SLE)

See below for more information.

Acute polyarticular gout can mimic most forms of acute polyarthritis.

Useful clues include:

  • A past history of intermittent acute gout
  • Prior attacks of polyarticular arthritis
  • Previous hyperuricaemia
  • The presence of tophi.

These patients responded promptly to usual treatment for gout such as NSAIDs.

Pyrophosphate arthropathy (chondrocalcinosis) presenting as an acute inflammatory polyarthritis (pseudogout or acute choldrocalconosis) is more common in older adults. It may begin as monoarticular arthritis but is more commonly polyarticular.

It most commonly affects the knees, but also the wrists and hips.

Diagnosis is suggested by:

  • Chondrocalcinosis on plain XR
  • Joint aspirate microscopy shows rhomboid crystals which are weakly positively birefringent under polarized light and show up basophilic (deep blue) if stained with H&E.

EULAR classification of calcium pyrophosphate deposition (CPPD) - European League Against Rheumatism:

(a) Asymptomatic calcium pyrophosphate deposition (as seen on XR)

(b) Osteoarthritis with CPPD (calcium pyrophosphate deposition)

(c) Acute calcium pyrophosphate crystal arthritis (pseudogout)

(d) Chronic calcium pyrophosphate crystal inflammatory arthritis

Occurs in up to 30 percent of people who have skin psoriasis (scaly skin lesions on extensor surfaces, scalp, natal cleft and umbilicus), particularly if they are HLAB27 positive.

It may remain mild and tends to be relapsing and remitting but may progress to more destructive joint disease.

Presentation:

Is with one or more joints affected, in the following patterns:

  • Asymmetrical oligoarthritis (70%) affecting fewer than 3 joints.
  • Symmetrical seronegative arthritis (25%). This type is most similar to rheumatoid arthritis and is disabling in around 50% of cases.
  • Sacroiliitis/spondylitis: characterised by stiffness of the spine or neck, but can also affect the hands and feet in a similar fashion to symmetric arthritis.
  • DIPJ arthritis (15%) which typically presents as sausage-like swelling in the fingers or toes. Nail changes may be marked.
  • Arthritis mutilans: affects less than 5% of patients and is a severe, deforming and destructive arthritis. This can progress over months or years causing severe joint damage and can be seen in rheumatoid arthritis as well.

Features to look for:

  • Personal or family history of psoriasis or psoriatic arthritis.
  • Hand joints: DIPJ arthritis not usually seen in rheumatoid arthritis, but it may also involve the proximal PIPJ as well as the MCPJs and the wrist.
  • Achilles tendinitis.
  • Plantar fasciitis.
  • Nail pitting, onycholysis sub–ungual hyperkeratosis and horizontal ridging.
  • Sacroiliac pain.
  • Extreme exhaustion that does not settle with adequate rest and which may last for days or weeks without abatement.
  • Rheumatoid factor negative.

Clinical characteristics

Arthritic symptoms in patients with SLE generally differ from those in rheumatoid arthritis (RA) because they tend to be migratory with symptoms in a particular joint often gone within 24 hours.

Features to look for (adults):

  • Presenting symptoms:
    • Skin changes: rash (80%), most commonly a butterfly malar rash (31%), but also a discoid lupus rash with keratotic scales and follicular plugging with possible atrophic scarring of older lesions; photosensitive rash; alopecia
    • Joint disease: flitting arthralgia and arthritis (48%)
    • Renal involvement: active nephropathy (28%)
    • Neurologic involvement (19%) – see below
    • Fever (17%)
    • Raynaud phenomenon (16%)
    • Pleuritis and/or pericarditis (16%)
    • Thrombocytopenia (13%)
    • Thrombosis in (9%)
  • Associated symptoms:
    • Mouth:
      • oral mucosal dryness
    • Eyes:
      • dry or red eyes, foreign-body sensation, pruritus, photophobia, pain, visual changes, and even loss of vision
    • Neurological:
      • acute inflammatory polyneuropathy (Guillain-Barre syndrome)
      • autonomic disorder
      • mononeuropathy including cranial
      • polyneuropathy and plexopathy
      • aseptic meningitis
      • cerebrovascular disease (stroke)
      • demyelinating syndrome
      • cognitive impairment
    • Psychiatric presentations can include
      • acute confusional state
      • anxiety disorder
      • mood disorders
      • psychosis
    • Women
      • Ask about a history of complicated pregnancy, including stillbirth, recurrent fetal loss, preterm birth, intrauterine growth restriction, miscarriage, pre-eclampsia.
    • Drug history
      • Causes most commonly include procainamide, hydralazine, isoniazid, methyldopa, quinidine, chlorpromazine, captopril and sulfasalazine.
    • Occupation
      • Causes include farming, mining and manufacturing, due to exposure to silica, mercury or pesticides.
Assessment

Practice Point

If Early Inflammatory Arthritis is suspected on clinical grounds it cannot be reliably excluded by normal inflammatory markers and/or a negative rheumatoid factor.

See ‘Presentation’ (above) for the clinical assessment required to suspect EIA.  

If EIA is suspected the following tests should be arranged so that the results are available when the patient attends the EIA clinic:

  • Electrolytes + Creatinine + eGFR
  • Liver Function Tests (LFT)
  • Calcium/Albumin
  • C-Reactive Protein (CRP)
  • Thyroid Function Test (TSH)
  • FBC
  • Viscosity
  • Rheumatoid factor latex screen
  • Antinuclear Antibody Test
  • Anti-CCP antigen blood test – Note that this test is a new requirement for referral to the EIA clinic.
  • Request X-ray hands and feet; even if asymptomatic because X-ray indications may precede symptoms.  Radiology reports indicating erosive osteoarthritis (EOA) does not necessarily indicate referral to the EIA clinic.  EOA refers to a particular x-ray appearance of osteoarthritis, and does not indicate rheumatoid or psoriatic arthritis

Due to the importance of early treatment, if EIA is reasonably suspected on clinical grounds alone, early referral should be made irrespective of the findings of inflammatory and autoimmune markers which can be negative.

The diagnosis of acute inflammatory arthritis is complex and relies on assessment such as the 2010 ACR/EULAR Rheumatoid Arthritis Classification Criteria.

When to Refer

Research evidence shows that early treatment of inflammatory arthritis leads to better disease control, less joint damage and disability and improved long-term prognosis.

Refer suspected EIA to the EIA clinic promptly using the EIA referral form ensuring that the above investigations are arranged so that the results are available when the patient attends the clinic.

GHFT Early Inflammatory Arthritis Clinic

The GHFT Early Inflammatory Arthritis (EIA) Clinics at Gloucestershire Hospitals NHS Foundation Trust have been running since April 2013.  The clinic’s focus is the early diagnosis and treatment of patients referred with suspected inflammatory arthritis, aiming to start treatment within three months of onset of symptoms.  

                                                                                        

(a) Complete a referral letter which includes a summary of the patient’s presenting complaint, their past medical history and any medication or drug sensitivities which they may have.

(b) Complete the EIA Clinic referral form

(c) Submit the eReferral to the EIA clinic (found under ‘urgent rheumatology’) including the above letter and the referral form. 

(d) Arrange the following routine investigations via ICE which will then be available to the EIA clinic when the patient attends:

  • FBC, PV
  • CRP, U&E, LFT
  • Bone chemistry
  • Rh factor
  • ANA
  • TFT
  • X-ray both hands and feet even if asymptomatic (X-rays features may precede symptoms)

(e) If the patient is a smoker they should be referred to the Smoking Cessation Service as this may exacerbate the condition.

Key Point

A delay in referral can mean more damage to the joints and potentially the need for surgery.  Early diagnosis within secondary care is deemed very important in proactively managing the condition in order to minimise or prevent disability and enable them to continue to work.

                                                                                        

Initial appointment

Assessment

There will be an initial Consultant appointment to establish diagnosis.  Ideally, the correct tests will have been ordered by the GPs and the test results will then be available for the Consultant to view.  This information will be used to help inform a full assessment and the Consultant can, where possible, make a diagnosis and then in discussion with the patient decide on the appropriate course of treatment and ongoing management.  If the diagnosis is not clear then additional tests may be ordered at this point.

Treatment Plan

There will be a discussion about medication options; this normally takes place at the first appointment and a treatment plan will be put in place.

Early treatment and monitoring

At the start of treatment, patients will be seen every 4-6 weeks in the Early Inflammatory Arthritis Clinic until their condition is stable. 

General Practice will be asked to undertake regular blood monitoring.

Later management

After 1 year the patient will be transferred into a general rheumatology clinic and the frequency of review will be set according to the individual patient’s need.

Once the patient’s condition has been fully stabilised on a medication or combination of medications the patient will become subject to an annual review process.

Patients should be able to access a repeat prescription from their GP.

Managing exacerbations

If a patient is having a ‘flare up’ they are advised to make contact with their nursing team for advice and support.  They should have been provided with a contact phone number at their first appointment.

Self-management and community support

  1. Patients will be given an information pack and where appropriate a blood monitoring booklet.  They will be asked to ensure that their blood test results are entered into the booklet prior to attending clinics.  Although the Consultants have direct access to this information via ICE, these booklets highlight trends in results as well as providing information which helps patients to understand and self-manage their own condition. It is helpful if they are able to bring this information with them to their next appointment, so nurses and Consultants can talk through their results with them.
  2. New patients will also be invited to the Living with Arthritis Information Day
  3. GPs should encourage them to access community resources

 

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