Inflammatory Arthritis Toolkit

Inflammatory arthritis represents a group of diseases which includes rheumatoid arthritis, peripheral & axial spondyloarthritis and psoriatic arthritis.  These diseases are characterised by dysfunction of the immune system, and inflammation within joints, tendons or ligaments. 

There is a need to improve the healthcare of people with inflammatory arthritis, particularly reducing delays in recognition and referral.  We know that delays in diagnosis can causes patients more symptoms, results in disease which is more difficult to treat, and increases the risk of disability and inability to work.

This toolkit aims to be a user-friendly guide to inflammatory arthritis for primary care professionals, people affected by arthritis and clinical commissioning groups.

Types of inflammatory arthritis

What is Inflammatory Polyarthritis?

The term inflammatory polyarthritis (IPA) relates to a family of diseases, where immune system dysfunction causes inflammation within joint tissues such as the synovial membrane or joint entheses (where tendons or ligaments join bone). This inflammation causes pain and swelling; in some diseases, without treatment, this can result in damage to cartilage and bone which is irreversible. This contrasts with osteoarthritis, where multiple factors such as age, biomechanics, and genetics combine to effect articular cartilage loss.

Inflammation within the polyarthritis family is not just confined within the joints and soft tissues; symptoms such as fatigue are common, as are symptoms outside of the joints. The diseases can occur at any age, and affect both males and females.

Rheumatoid arthritis, spondyloarthritis and psoriatic arthritis are the commonest forms of IPA. Other autoimmune conditions such as systemic lupus erythematosus, juvenile inflammatory arthritis, and other forms of connective tissue disease and vasculitis can cause joint inflammation.

Diagnosing these diseases early prior to damage occurring is crucial; inflammation caused by inflammatory arthritis is reversible, whilst joint damage is not.

What is Rheumatoid Arthritis?

Rheumatoid Arthritis (RA) is the commonest form of auto-immune inflammatory polyarthritis; there are approximately 400,000 people with RA in the UK. RA has a peak age of incidence of 70, though the disease can occur at any age.

RA causes chronic inflammation of the joint synovial membrane, classically causing symmetrical symptoms and swelling in the small joints of the hands and feet, alongside larger joints. If not controlled, synovial inflammation can lead to erosion of cartilage and bone, causing joint damage and deformity.

Alongside joint disease, systemic symptoms such as fatigue, weight loss & fever are common, and can predate joint symptoms by several months. 

What is Spondyloarthritis?

What is Psoriatic Arthritis?

Psoriatic arthritis (PsA) is an arthritis associated with skin psoriasis. Confusingly, patients do not have to have skin psoriasis to be given the diagnosis; 20-30% of patients with PsA will not have active skin psoriasis, though will usually have a personal or family history of psoriasis of the skin or nails. 

The prevalence of psoriatic arthritis is thought to be around 0.1-0.3%. Around 10% of all people with psoriasis have PsA. PsA affects men & women equally, with peak incidence of between 30-55 years. 

The major clinical difference between PsA and RA is distribution; PsA is more likely to be asymmetrical, and more likely to involve distal interphalangeal joints, large joints, or the spine. Psoriatic arthritis is also much more likely to cause inflammation at entheses (where tendons or ligaments join to bone), or dactylitis, where a whole digit is swollen & tender. As with RA, PsA commonly causes systemic symptoms such as fatigue.

What about Crystal Arthritis?

Gout, and other forms of crystal arthritis, are important differentials to consider when assessing patients with joint inflammation.

Diagnosis and management of crystal arthritis falls beyond the remit of this toolkit. The follow resources offer further information and advice:

Diagnosis

What should I look for in the history?

Questions for GPs to consider when taking a history from patients with patients with musculoskeletal pain:

How can I tell if back pain is inflammatory?

As with joint pain, there are some hallmark symptoms and signs which can help differentiate inflammatory back pain due to spondyloarthritis from back pain due to mechanical causes:

  • Pain of more than 3 months duration
  • New onset pain in younger people; inflammatory back pain rarely starts after the age of 40
  • Pain which is insidious in onset, without a clear injury or trigger
  • Pain which eases with exercise, or worsens with rest
  • Early morning stiffness of the joints or spine which last longer than 30 minutes
  • Nocturnal pain

In addition, there are symptoms and signs of spondyloarthritis outside of the spine which can suggest an inflammatory cause for pain:

  • Persistent pain affecting tendon or ligament insertions, such as plantar fasciitis, lateral epicondylitis, or Achilles tendonitis
  • Atraumatic joint swelling, or swelling of a whole digit
  • Extra-articular disease features, such as iritis, psoriasis, or symptoms suggestive of inflammatory bowel disease

How can I tell if joints are swollen on examination?    

Can requesting investigations from primary care help me? 

Please note there is no single diagnostic test when making a diagnosis of inflammatory arthritis; your overall clinical impression is much more important.

Who should I refer?

Comorbidities and screening

Cardiovascular

In the absence of clear evidence guiding risk reduction, current best practice suggests that GPs should:

  • Undertake a review of CV risk in patients with IPA at least every 5 years
  • Use a CV risk calculator which estimates the increased risk in patients with inflammatory arthritis; in the UK QRISK2 is recommended by NICE. More information on QRISK2 can be found here.
  • Recommend lifestyle modification to reduce CV risk, including diet, smoking & exercise advice
  • Optimise other comorbidities such as hypertension and diabetes, which may compound CV risk
  • Consider statin and anti-hypertensive use as per NICE guidance, in particular: "GPs should offer atorvastatin 20mg for the primary prevention of CVD to people who have a 10 per cent or greater risk of developing CVD within the next 10 years."

Mental Health

As with other chronic diseases, affective disorders such as depression and anxiety are more common in patients with arthritis than in the general population. We know around 1/3 of patients with RA and SpA will suffer with anxiety or depression.  

Patients with inflammatory arthritis should be routinely screened for mood disorders; in the UK, NICE guidelines suggest that people with RA should be screened annually to:

  • check for the development of comorbidities, such as depression
  • assess the effect the disease is having on a person's life

Psychosocial interventions, in particular CBT-based therapies, have been shown to have good outcomes in arthritis, reducing pain and improving psychological outcomes.

Work

Pain, stiffness and fatigue caused by arthritis can interfere with work, as can the need to attend appointments for assessment and monitoring blood tests.

GPs can help patients manage the impact of their arthritis, both through Fit Note provision and signposting to appropriate resources for patients & employers. More information can be found on the Fit for Work website.

Bone health

  • Osteoporosis in rheumatoid arthritis, NRAS - information for GPs about the increased risks of osteoporosis in arthritis
  • FRAX - Fracture Risk Assessment Tool, Centre for Metabolic Bone Diseases, University of Sheffield. Patients with inflammatory arthritis should have their bone health assessed annually; FRAX risk assessment adjusts for rheumatoid arthritis as an independent fracture risk

Fatigue

Treatment in primary care

Synthetic Disease Modifying Anti-Rheumatic Drugs (DMARDs)

Biologic DMARDs in primary care

Vaccinations

Offer vaccinations to prevent serious infections that are more common in people exposed to DMARDs:

  • An annual influenza vaccine should be given, and a pneumococcal vaccine should be given preferably before starting the DMARD. Pneumococcal vaccine should be repeated at 10-yearly intervals if given before starting the DMARD, or at 5-yearly intervals if given after starting the DMARD.
  • Live vaccines (e.g. yellow fever, rubella) are contra-indicated for people who are on DMARDs. Always seek specialist advice if a live vaccine is being considered.
  • Specific advice for shingles vaccination in patients using DMARDs, Royal National Hospital for Rheumatoid Diseases

Conception, pregnancy and breastfeeding

Management of flares

Whilst modern treatment of inflammatory arthritis aims to completely suppress disease activity, flares of pain, swelling and fatigue can occur. Flares are painful and distressing to patients, though can be well managed in primary care.

Patient self-management is important; pacing of activities, stretching, heat/ice, and CBT-based pain management strategies can help manage symptoms.

GPs play an important role in managing disease flares, both in diagnosis and treatment. It is important that other causes of pain, such as septic arthritis, are excluded. Prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and appropriate doses of corticosteroids can rapidly alleviate flares.
 

Resources for patients

Organisations that can support patients

Diagnosis with inflammatory arthritis can be life-changing. Patient organisations can provide support and guidance on how to approach medical appointments, provide information about treatments, and the impact that disease and management can have on work, pregnancy and breastfeeding. Patient support groups provide peer support and an opportunity to share worries and successes.

Resources for quality improvement

Is your practice compliant with NICE rheumatoid arthritis quality standards for primary care

Do you refer for specialist opinion any person with suspected persistent synovitis of undetermined cause?

Do you refer urgently if any of the following apply:

  • the small joints of the hands or feet are affected
  • more than one joint is affected
  • there has been a delay of 3 months or longer between onset of symptoms and seeking medical advice?

Has your practice audited those patients on long-term NSAIDs? NICE & MHRA guidance suggests:

  • [GPs should] offer analgesics (for example, paracetamol, codeine or compound analgesics) to people with RA whose pain control is not adequate, to potentially reduce their need for long-term treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or cyclo-oxygenase-2 (COX-2) inhibitors
  • that naproxen and low-dose ibuprofen (≤1200 mg per day) are considered to have the most favourable thrombotic cardiovascular safety profiles of all NSAIDs
  • to use the lowest effective dose for the shortest duration necessary to control symptoms and re-evaluate the patient’s need for symptomatic relief and response to treatment periodically
  • when offering treatment with an oral NSAID/COX-2 inhibitor, the first choice should be either a standard NSAID or a COX-2 inhibitor. In either case, these should be co‑prescribed with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost

For more information on pharmacological management refer to Rheumatoid arthritis in adults: management NICE guidance.

At your annual inflammatory arthritis review appointments, does your practice routinely:

  • check for the development of comorbidities, such as hypertension, ischaemic heart disease, osteoporosis and depression?
  • assess the need for referral for surgery?
  • assess the effect the disease is having on a person's life?

Use of a standardised template for annual reviews has been shown to improve compliance with NICE guidance - could your practice adopt this?  

Reports and legislation

Reports & legislation

NICE guidelines

Resources for training and appraisal

Elearning

Further resources

This toolkit has been developed in partnership between the RCGP Clinical Innovation and Research Centre and the British Society for Rheumatology. Please send any feedback or suggestions to circ@rcgp.org.uk

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