Given the importance of early recognition in rheumatoid arthritis, the most accurate indicator is stiffness, not pain, writes Dr Adam Bajkowski.
Arthritis is a relatively common condition where accurate and timely diagnosis can make a real difference to patients’ lives. There is a lot that GPs can do to ensure these patients are not defined by their illness.
Given the complications that result from missing the ‘window of opportunity’ to treat rheumatoid arthritis (RA), GPs need to be in a position to diagnose the condition accurately and feel confident in making timely referrals to specialists.
RA can afflict any age group, so GPs must not dismiss the possibility in any patient who presents with joint pain.
Spotting the early signs
The standard symptoms and signs apply in well-established RA, such as symmetrical joint synovitis, tender joints with hours of early morning stiffness, raised inflammatory markers, and often a positive rheumatoid factor with erosions present on X-ray.
However, GPs often see patients much earlier in the disease process, where all of the classic symptoms and signs may not be present.
Treatment of RA is radically effective, so it is essential that we act on our suspicions at this stage and refer early, rather than wait until the disease is established beyond doubt.
GPs will typically have no more than 10 minutes with a patient, who is unlikely to walk into the consulting room with classic and established features of RA.
General joint pain is common and, as with other presentations of illness, you are looking to exclude serious conditions if possible.
Focus on joint stiffness
What, then, should raise your suspicion and what should assuage it?
Patients with RA often present in a worried state. They might have noticed something is wrong with their joints relatively suddenly, but be unable to articulate exactly what it is.
They will naturally focus on the pain, but the most accurate indicator for RA is stiffness. Patients should be drawn on this point and those who report extended periods of joint stiffness in the morning should ring alarm bells.
In these situations, ask the patient to explain how long this stiffness lasts, but give them understandable metrics – for example, how long is it before they can ‘get going’? Is it before or after they get dressed? If this time is significant – in excess of half an hour – patients should be considered for urgent referral, even if there is little in the way of synovial swelling.
Similar to those with RA, patients with osteoarthritis – the most common form of arthritis – are usually most aggrieved by their level of pain, which has been present for a long time but may have recently become worse.
They might respond affirmatively to questions about joint stiffness in the morning, but in contrast to RA, it will seldom be more than half an hour before they become mobile.
These patients can also present with swelling to their hand joints, as well as stiffness, but in this case it will be a firm, bony swelling. Thus, if your patient has minimal stiffness with bony swelling, you can dismiss the possibility of RA.
When talking with patients about this, remember their ideas, concerns and expectations. A positive family history of RA may be the extra clue you are looking for.
While blood tests, such as FBC (possible anaemia), ESR, CRP, rheumatoid factor and anti-CCP, do play a part in supporting your clinical diagnosis, they should not be used to make or refute it.
Timely treatment is very important if RA is suspected and in this circumstance, referral before blood test results, the presence of classic clinical signs or radiographic evidence might mean the difference between effective treatment and potentially irreversible joint destruction.
Reasons for referral
Always be open with patients about the reason for early referral. Aggressive treatment is essential if rheumatic disease is suspected and if it turns out that a patient has inflammatory joint disease such as RA, there are treatments that will help to improve their symptoms and keep them in work.
If diagnosed positively with RA after referral, aftercare will be as important as initial treatment.
GPs will be responsible for prescribing and monitoring medication, so it is vital to keep an eye on the patient’s physical, psychological and social wellbeing. These patients require continuing support, which can be spread across the practice team.