1) Suspected inflammatory arthritis

Specific symptoms suggestive of this diagnosis include one or more of:

Prolonged early morning stiffness >30 mins
Visible joint swelling
Recent change in joint function (e.g. difficulty gripping)

Avoid steroids

If an inflammatory arthritis is suspected please try and defer from starting patient on steroids Patients with suspected inflammatory arthritis are allocated an urgent appointment but we appreciate are waiting times do fluctuate and if you are concerned please contact us for advice. If there is no objective evidence of synovitis when the patient is assessed in rheumatology clinic because they have been started on steroids, this may result in a delay in the diagnosis being made and treatment being started.

Consider investigations

If an inflammatory arthritis is suspected please check inflammatory markers (ESR and CRP) and if rheumatoid arthritis is suspected Rheumatoid factor and CCP antibodies. However, do not wait for results to refer patient as none of these bloods exclude the diagnosis of an inflammatory arthritis.

2) Suspected multisystem connective tissue disease

Specific symptoms suggestive of these diagnoses include:

- Recent onset arthralgia, myalgia, fatigue
- Recent onset Raynaud’s phenomenon
- Unexplained persistent rash, particularly if photosensitive

Avoid steroids

If an inflammatory arthritis is suspected please try and defer from starting patient on steroids Patients with suspected inflammatory arthritis are allocated an urgent appointment but we appreciate are waiting times do fluctuate and if you are concerned please contact us for advice. If there is no objective evidence of synovitis when the patient is assessed in rheumatology clinic because they have been started on steroids, this may result in a delay in the diagnosis being made and treatment being started.

3) Suspected giant cell arteritis

Clinical Features which suggest GCA

1. Age of onset > 50 yrs (GCA almost never occurs below this age)
2. New onset of headache (usually temporal)
3. ESR/CRP typically raised* (always check both and ideally prior to starting steroids)
4. Polymyalgia Rheumatica-like symptoms (proximal muscle pain & stiffness)
5. Jaw or tongue claudication ( i.e. pain on chewing or talking) **
6. Systemic illness (fever, anorexia, weight loss etc.)
7. Visual disturbance (episodes of transient visual loss and/or diplopia)**
8. Upper cranial nerve palsies
9. Limb claudication or other evidence of large vessel involvement

* If clinical history is entirely typical and inflammatory markers are normal, GCA cannot be excluded; such patients should still be treated and referred

** Strong predictors of neuro-ophthalmic complications, require higher steroid dose and urgent same-day ophthalmology referral. Contact ophthalmology on-call via switchboard at Royal Preston Hospital. This applies even if symptoms have been transient

Acute Management:

If GCA is suspected, treatment with steroids must be commenced whilst awaiting review in the rheumatology clinic. The rheumatology team will refer the patient for a temporal artery biopsy if felt necessary.

- If no visual symptoms/jaw claudication - Prednisolone 40mg/day PPI

- If visual symptoms/jaw claudication - Prednisolone 60mg/day PPI

If there are any doubts with regard to diagnosis or management or patients with suspected GCA please discuss urgently with rheumatology (01772 520900 Option 2)

GCA referrals will be seen within 1 week of being referred