Background
Diagnosing RA quickly is important because early treatment can prevent it getting worse and reduce the risk of permanent joint damage.
RA is associated with a number of complications and comorbidities, including increased risk of cardiovascular disease, osteoporosis, anaemia, and infection.
Symptoms
RA usually affects the hands, feet and wrists, but some people also experience problems in other parts of the body, or more general symptoms (e.g., tiredness, weight loss).
Presentation of RA is variable; most people have an insidious onset, but others can have a rapid, or relapsing and remitting course (palindromic presentation or ‘flares’).
Symptoms include:
- Pain: usually a throbbing and aching pain; often worse in the mornings and after a period of inactivity.
- Stiffness: patient may not be able to fully bend fingers or form a fist; often worse in the morning or after a period of inactivity.
- Swelling, warmth and redness: the lining of joints becomes inflamed, leading to swelling, and thus joints become hot and tender to touch.
- rheumatoid nodules - firm swellings that develop under the skin around affected joints.
- General symptoms:
- tiredness and a lack of energy
- high body temperature
- sweating
- poor appetite
- weight loss
Inflammation due to RA can also cause problems in other areas of the body:
- dry eyes – if the eyes are affected
- chest pain – if the heart or lungs are affected
Refer people with persistent synovitis with an unknown cause for specialist assessment within 3 weeks of referral.
Refer urgently, (within 3 working days of presentation) if there are any of the following:
- symptoms persistent for >4 weeks, even with normal ESR/CRP and negative CCP or rheumatoid factor
- symptoms in small joints of the hands or feet and/or in more than one joint.
- there has been a delay of ≥3 months between the onset of symptoms and patient seeking medical advice.
N.B. Initial management of suspected RA should include considering offering a nonsteroidal anti-inflammatory drug (NSAID) at the lowest effective dose for the shortest possible time along with a proton pump inhibitor (PPI) until a rheumatology appointment is available.
Morning stiffness that is a symptom of osteoarthritis, usually wears off within 30 minutes of getting up, but morning stiffness in RA often lasts longer.
Our responsibilities
The role of primary care as part of the multidisciplinary team managing people with RA is to ensure that all adult patients have rapid access to specialist care for flares and regular medication reviews to check concordance/adverse effects and manage where appropriate.
GPs should also organise appropriate cross-referral within the multidisciplinary team, providing the patient with information about when and how to access specialist care, including physiotherapy, occupational therapy and podiatry services for advice on mobility, pain control, work-related issues and foot health.
Annual review appointments
NICE guidelines state that a routine review of all people with RA, including those who have achieved the treatment target, should be made in primary care at least once a year for the following.
- Assess risk of falls.
- Assess symptoms that suggest complications and/or co-morbidities.
- Assess need for surgery referral (see Surgical Opinion box).
- Identify and manage RA flares appropriately (see Management of Rheumatoid Arthritis (RA) flare box).
- Liaise with the patient's specialist team, particularly in relation to changes in medication.
- Improve the patient's understanding of RA.
Suspect RA flare if there are worsening symptoms of stiffness, pain, joint swelling, or general fatigue, signs of joint synovitis, joint tenderness, or loss of joint function, and/or presence of inflammatory markers (e.g., C-reactive protein increased from previous levels).
Appointment overview
Review medications
Resources for patient info/referral
- Scenario: Confirmed RA | Management | Rheumatoid arthritis | CKS | NICE
- Recommendations | Rheumatoid arthritis in adults: management | Guidance | NICE
- South East London CCG Rheumatology Referrals and Triage SOP.pdf
- Immunmodulatory shared care (selondonics.org)
- South East London Joint Medicines Formulary Formulary (selondonjointmedicinesformulary.nhs.uk)