The history to include, pattern of joint invovement, stiffness (early morning), swelling and inflammation of joints, relation of joint symptoms to rest. Family History, Smoking.
The examination should check for the presence of joint swelling (synovitis) tendon tenderness (enthesis) reduced movement. Mental health assessment.

Comprehensive Assessment in rheumatology service. This could be in secondary care or in a community based IACTS with consultant input. The assesment should be by a MDT. In patients with high distress, early involvement of pschological medicine is helpful - see chronic pain pathway

Comprehensive assessment in supraspecialist unit, Full MDT assessment. Patients with linked multi organ disease - renal or lung should be cared for in multidisciplinary clinics

Patient most often complain of pain with significant early morning stiffness, problems dressing and other ADLs

Inflammatory arthrits covers a range of conditions including Rheumatoid Arthritis, Psoriatic Arthrits and Ankylosing Spondylitis

Early presentation and referral is vital to minimise long term disability.
Exercise, healthy diet and maintaining ideal body mass index
Smoking is linked to the onset of RA

Smoking cessation

Work absence, problems with ADLs

Monoarthritis - consider septic arthritis

Life threatening complications

Indications for x-ray guidance: MBURB6 and Right Test, Right Time, Right Place

Routine bloods in suspected Inflammatory arthritis - see supplemental

All patients should have written information and a management plan

Share care protocol for DMARDS

Relief of pain - Analgesics using WHO analgesic ladder
DMARDS using shared care protocol

Joint injections as part of shared care protocol

See supplementary

See 2.2.2

see 2.2.3

Individual education from named nurse,

Objective measurement of disease activity i.e.DAS28

Importance of MDT assessment psychology input, biopsycho-social pain management

Pain relief via management plan, early initiation of DMARDs and steriods, Biologics as per NICE

Injections, shared care in orthopaedics

Experimental treatment in non responsive disease

Cervical spine surgery

2.2.1 -No investigations will diagnose IA with certainty and none replace a detailed history and examination.
2.2.2
X-ray will often be normal in early disease, or may show only mild periarticular osteopenia. MRI and US are emerging as useful tools in the diagnosis of synovitis, but there is no evidence for their routine use in primary care
2.2.3
A baseline FBC ESR CRP is helpful. Rheumatoid factor can often be normal in IA no indication for routine use in primary care. Anti-CCP is more expensive than RF and no more sensitive, but more specific. No role for its routine use in primary care. No role for HLA B27 testing in primary care. Serum urate if crystal arthropathy suspected. Synovial fluid analysis should be used where possible. Serology in reactive arthritis
2.2.4 - Screen tests for depression - PHQ-9 identify patients for psychological medicine

Imaging
Role for Ultrasound in early diagnosis for synovitis is growing, it give an indication of early synovitis and identifying patients in remission
Role for MRI in early diagnosis of synovitis, also in imaging SIJs in suspected AS

Role for anti CCP, ongoing bloods (ESR, CRP) DMARDs and Biologics assessment
HLA B27 testing in AS

As IA can be multi system disease diagnositics shouldcover lung function testing, advanced immunology, cadiovascular assessment, renal assessment.

Joint pain and swelling, early morning joint stiffness, systemic illness, Symmetrical joint involvement, pain in hands and feet, <16 with low back pain direct to paediatric services

Refer any patient with suspected IA, even with normal investigations, any exsisting patient who have been lost to specialist follow-up. Urgent referral : Delayed presentation to GP, small joints of hand/feet affected, multiple joint involvement, Admission for suspected septic arthritis

Spondyloarthropathy (SpA), covering Ankylosing Spondylitis (AS), Psoriatic Arthritis, (PSA), enteropathic (EA) and Reactive Arthritis, can sometimes present with associated infectious episode(gastroenteritis/urethritis), mimic RA with single or asymmetrical joint involvement or with enthesitis. Iritis can also be a feature.

Rheumatoid Arthritis is the commonest, with a prevalence of 1.1% of the population, 2-4 times commoner in women and a peak age of incidence of 70 years, but can present at any age. Prevalence of AS 0.5% 3:1 male to female. The economic burden of IA is considerable with RA costing between 3.8-4.75 billon per anum. One third of patients with RA stop work within two years of diagnosis
The average GP will see 4 new cases of IA every year. 20% of patients with RA will have mental health issues mainly anxiety and depression

Development of "Care Management Plans" for all patients, covering diet, exercise, management of pain relief, coping skills, guidelines for self referral. Giving the patient thier own management plan improves compliance with treatment. People with IA have a shorter life expectancy than the general population, prevention of IHD is vital. The most important step in the prevention of long term disability is early presentation to primary care with early onward referral to specialist services. Increasing general public awareness of IA - and associated risks like CHD prevention

Environmental pollution may add to risk, diets low in polyunsaturated fats and western lifestyle increases risk. Encourage healthy diet(Mediterranean) and exercise. Supported programmes for smoking cessation, weight loss and exercise. Use of CVD risk tools - JBS or QRisk 2.

There is a 3 month window of opportunity for early intervention and starting DMARDs with improved outcomes. Early presentation to primary care and onward referral is vital. Education of the general public, pharmacists and other frontline staff into the signs and symptoms of IA is important for early presentation to primary care. Raising awareness of IA with podiatrists and physiotherapist to encourage early presentation

The referral threshold for IA should be low, as early dignosis is often difficult and early commencement of DMARDs can prevent long-term disability New patients should be referred urgently. Link to NICE RA and EULAR guideline. MDS for referral agreed locally, link to example

Extra articular disease - pulmonary fibrosis, upper cervical leisons, amyloidosis, highly aggressive non responsive disease, rare connective tissue disease

Recognising early inflammatory arthritis can be difficult and patients should be referred on suspicion, clinical symptoms and signs can vary.
The key sign (not AS) is the presence of synovitis, although the recognition of this can be difficult Classification Criteria: ACR 1987 (add link) - good for prognosis but poor for recognising patients with early disease. Screen for psoriatic rash behind ears and nail involvement, low back pain with early morning stiffness and buttock pain raise suspicion of AS
MCP and MTP squeeze test postive in early disease (RA) and good diagnostic sign, Ask about enthesitis (plantar fasciitis, epicondylitis) if SpA suspected, also enquire about linked conditions - iritis, bowel disease, linked illnesses with reactive arthritis. Important to consider differential diagnosis, PMR, Malignancy, connective tissue disease

Development of early arthritis clinics

Shared care between primary and secondary care in managing flares, IHD risk and DMARD monitoring

Develop "one stop" clinics with USS and X-ray available at initial assessment

Combine MDT clinics (orthopeadics, respiratory etc.)

Possible KPIs for commissioners all subject to local agreement:
Use of disease scores in first year - eg DAS28 in RA to ensure rapid control of RA
Use of PROMs -
Generic - Euroquol EQ5D
Specefic - RAQoL or ASQoL
HAD for anxiety and depression
Effective consumer scale EC-17
Ability to work and social participation
Assessment against ARMA standards of care
Other KPIs:
Speed of access to initial appointment for new and follow-up patients, number of cancelled appointments. Compliance with NICE guidance. Patient participation groups.

PROMS and QoL measures - Euroquol EQ5D, HAD see commissioning layer for further PROMs and KPIs

Onset can be acute insidious or palindromic and include fatigue, early morning stiffness, joint pain at rest, back and pain with morning stiffness

2.4.1 - There is no good evidence for complimentary therapies, but support groups and general health measures such as smoking cessation are good. Encourage self management.
2.4.2
Primary prevention of IHD (lifestyle, BP,and lipid control is a vital part of primary care monitoring. Being aware of increased risk of malignancy, need for vaccination aginst flu and pneumococcal disease, OT assessment - home adaptations, supported return to work - job centre plus. The extent of shared care should depend of patient choice and GP expertise. Shared care linked to personal health plan and make use of patient held records. Ready access by helpline to IA care co-ordinator (usually nurse).
2.4.3
Access to chronic pain management as detailed in chronic pain commissioning pathway
2.4.4
Use of Analgesics and NSAIDs, No role for use of steriods in primary care for new patients (may be used for flares as part of shared care protocol)
Links to examples of LES for Shared Care for DMARDS

Some GPs maybe skilled to inject individual joints during a flare - need to develope local competencies. Try to avoid steriods prior to definitive diagnosis

3.4.1 -Role of patient education covering exercise, joint protection, rest and management of flares improves outcomes. Referral to self management and expert patient programme. Access to telephone helpline is vital, access to patient led support groups

3.4.2 - involvement of a wide MDT in long term care, with named lead nurse. Shared care with primary care, annual MDT assessment, self referral for flares - BATH scores for monitoring AS.
Management of flares should include rapid access to specialist nurse via helpline, rapid access (within days) to specialist appointment, and treatments. Flare management should be part of a local shared care protocol with primary care.

3.4.3.
Physiotherapy, hydrotherapy increasing muscle strength and joint movement. Depression, loss of self confidence are common issues and emphasize the need for access to psychological treatments for patients with IA, There is a role for screening patients with IA for mental wellbeing. In AS use physiotherapist with special interst in AS and have access to hydrotherapy. Access to OT - health and community based

3.4.4 - Start DMARDS (methotrexate and short-term glucocorticords) first line with rapid escalation, monitor CRP and DAS28 until disease controlled. Use of combination DMARDS for active disease, monthly monitoring till disease controlled
Role of bisphosphonates in AS
NICE guidelines for Biologics. Pain relief - see chronic pain pathway. Manage co-morbidities - osteoporosis and CV risk.

3.4.5 Value in combined rheumatology orthopaedic clinics to ensure high quality peri-operative care and drug management
Invasive - joint injections, IM/IV steriods, joint replacements best as part of combined rheumatology/orthopaedic clinics to plan treatment and inpatient/post op care

For example - DAS 28 for RA, Bath AS scores for Ankylosing Spondylitis and 76/78 joint counts for Psoriatic Arthritis. PASI for Psoriatic Arthritis re skin assessment