Inflammatory Arthritis Toolkit

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?

• Practical implications for primary care of NICE guideline NG65 - Spondyloarthritis in over 16s: diagnosis and management

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:

• BSR Guideline for the management of gout
• NICE Gout Clinical Knowledge Summary

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?

• Guidance for primary care: Identifying and referring spondyloarthritis, BMJ

• 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

Can requesting investigations from primary care help me? 

• Clinical Assessment of Musculoskeletal System, Versus Arthritis
• If you suspect a patient has inflammatory arthritis, then there is an early window of opportunity for treatment. Waiting for test results should not delay referral, which is recommended within three days of seeing the patient: British Society for Rheumatology, Choosing Wisely UK recommendations

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?

• NICE quality standards around referral in rheumatoid arthritis    
• Recommendations for recognition and referral in non-specialist care settings, NICE guidance NG65: Spondyloarthritis in over 16s: diagnosis and management
• The PEST screening tool (Psoriasis Epidemiology Screening Tool) has been shown to help detect psoriatic arthritis, and should be undertaken annually in patients with skin psoriasis.

Top Tips

• Ten top tips in Gout: This document highlights the recommendations relevant to GPs from the British Society for Rheumatology Guideline for the Management of Gout, published in 2017

Cardiovascular

• Cardiovascular risk in rheumatoid arthritis, The British Journal of Cardiology

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.

• NICE Guideline CG91: Depression in adults with a chronic physical health problem: recognition and management
• NICE Guideline CG100: Rheumatoid arthritis in adults: management

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.

• Managing your AS at work: answers and practical advice [PDF], National Ankylosing Spondylitis Society (NASS)

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

• Fatigue beyond tiredness, National Rheumatoid Arthritis Society (NRAS) 
• Fatigue and AS [PDF], NASS

Synthetic Disease Modifying Anti-Rheumatic Drugs (DMARDs)

• BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs. Guidelines governing the prescription and monitoring of DMARDs will vary locally throughout the UK. National guidelines were published in 2017 by the British Society for Rheumatology. These cover frequency of monitoring, use of DMARDs during infection & preoperatively, and recommended shared care agreements.

Biologic DMARDs in primary care

• Medicines in rheumatoid arthritis [PDF], NRAS
• General principles of managing DMARDs, NICE

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

• BSR and BHPR guideline on prescribing drugs in pregnancy and breastfeeding - guideline offering advice for individual drugs during conception (for both males and females), 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.

• Managing your flares, NASS
• Managing a flare-up of rheumatoid arthritis, ARUK

• Management of an rheumatoid arthritis flare, NICE

Podcast 1: Patient Perspective - Diagnosis

RCGP Inflammatory Arthritis Spotlight Project Clinical Champion Dr Danny Murphy talks to Jayne Eley, a patient diagnosed with rheumatoid arthritis, about her symptoms, experiences of diagnosis and wider support, and Dr Richard Haigh, a consultant rheumatologist, about recommended investigations and referral. (21 mins 30 secs)

Podcast 2: Chronic Management

Dr Danny Murphy talks in more detail with Dr Richard Haigh and Senior Specialist Nurse, Jill Moran, about the role of the specialist nurse, DMARDs, annual reviews and flare management. (26 mins 53 secs)

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.

• Versus Arthritis: a national charity, supporting patients with all forms of inflammatory arthritis.
• National Rheumatoid Arthritis Society: UK patient organisation offering wide range of support, information and self-management resources specifically for rheumatoid and juvenile idiopathic arthritis.
• National Ankylosing Spondylitis Society: UK charity dedicated to providing life-changing support to anyone affected by Axial Spondyloarthritis/Ankylosing Spondylitis.
• The Psoriasis and Psoriatic Arthritis Alliance (PAPAA): a source and provider of information to support and advise people affected by psoriasis and psoriatic arthritis.

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 & legislation

• HQIP National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis - this report was commissioned by HQIP as part of the National Clinical Audit and Patient Outcome Programme (NCAPOP) and carried out by the British Society for Rheumatology (BSR).

• Rheumatoid arthritis guidelines
• Rheumatoid arthritis quality standards
• Spondyloarthritis  
• Psoriasis (incorporating psoriatic arthritis)

Elearning

• Inflammatory Arthritis elearning module
• Core skills in musculoskeletal care
• Axial Spondyloarthritis
• Managing uncertainty in autoimmunity

• Clinical assessment of joint pain, including examination, ARUK

• BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs
• HQIP National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis
• BSR and BHPR guideline for the treatment of axial spondyloarthritis (including ankylosing spondylitis) with biologics
• The 2012 BSR and BHPR guideline for the treatment of psoriatic arthritis with biologics