MSK Rheumatology Homepage

Reviewed on : 3 Nov 2021

Reviewed by : Dr Tim Blake Consultant Rheumatologist UHCW

Expires : 3 Nov 2023

MSK Rheumatology Referral Guidelines

See chapters below:

Click on link for more information or see summary table below

Gout

Psoriatic Arthritis (PsA)

Giant Cell Arteritis (Temporal Arteritis)

Positive Antinuclear Antibodies (ANA)

Connective Tissue Diseases

Back Pain – Suspected Ankylosing Spondylitis & Spondyloarthritis

RHEUMATOLOGY REFERRAL GUIDANCE (UHCW)
CONDITION	PRE-REFERRAL TESTS	PRE-REFERRAL Rx	REFERRAL THRESHOLD
Fibromyalgia	The Fibromyalgia Rapid Screening Tool is a brief and simple self-complete questionnaire that has been validated for screening FM in patients with diffuse chronic pain. A self-administered questionnaire developed by French researchers, the Fibromyalgia Rapid Screening Tool (FiRST) consists of six questions regarding the presence or absence of the following dimensions of fibromyalgia: Widespread pain Fatigue Pain characteristics Nonpainful abnormal sensations Functional somatic symptoms Sleep and cognitive problems	In line with recently published GIRFT recommendations and BSR’s Adult rheumatology referral guidance (October 2021), we will not accept a referral if the diagnosis is already known; we know that very few patients evolve into a different diagnosis over time. If a re-referral is being considered it is very unusual that a second opinion is substantially different from the first. Advise pacing, signposting to https://my.livewellwithpain.co.uk/	Main reason to refer: diagnostic uncertainty, e.g. where there is concern that an inflammatory rheumatological condition needs to be excluded – CLEARLY state clinical details and only use Early Arthritis Pathway if indicated. Consider the use of Specialist Advice (A&G) for any diagnostic/management uncertainty. Please note, an inflammatory condition is less likely if: Pain occurs after use or the end of the day Morning stiffness less than 30 minutes No night time pain No systemic symptoms Chronic symptoms
	Questions require only a “yes” or “no” answer, with each “yes” answer worth 1 point. A score of 5 or more has the highest sensitivity and specificity for fibromyalgia.	Consider: Duloxetine (if significant low mood too) Amitriptyline low dose (if very poor sleep pattern) Gabapentin maximum 900mg a day (if concomitant anxiety). Stop if no improvement in 4/52 Do not prescribe opiates	Refer to local pathways, making the best use of MSK expertise in Primary and Community Care. This may include use of Clinical Pharmacists, First Contact Practitioners, Advanced Practitioners as well as MSK interface services and local orthopaedic, spinal and pain management services.
	Consider checking TFTs, CRP/ESR, Calcium, Vitamin D (would have to be very low to be cause of symptoms) and Creatine Kinase. DO NOT request autoantibody screens unless symptoms of inflammatory rheumatological disease.		Do not refer patients with predominantly chronic fatigue (there is an overlap in around 50% of symptoms) as these referrals will be declined and suggested to be redirected to GEH Chronic Fatigue Service.
Gout	Check FBC, U+E, LFT, CRP, uric acid, fasting glucose, HbA1c, X ray of the affected joints, measure blood pressure	Review at 4-6 weeks Consider prophylactic medication if a person is having two or more attacks of gout in a year	Refer to Secondary Care: Immediate: if Septic Arthritis is suspected (Please note it is possible for both gout and septic arthritis to co-exist) Routine: if complications relating to gout eg. Nephropathy, requires intra-articular therapy and primary care are not able to provide this, diagnostic uncertainty, the serum uric acid is unresponsive to uric acid lowering therapy, if gout persists despite controlled uric acid levels
	Address lifestyle factors (diet, exercise, alcohol) and provide advice.	BSR guidelines for gout:
	*Patient information leaflets: www.ukgoutsociety.org*
	Assess and treat underlying cardiovascular risk factors: obesity, hypertension, lipids, diabetes mellitus
	Consider drug-induced gout: diuretics (inc. thiazide), B-blockers, ACE inhibitors and non-losartan angiotensin II receptor blockers, which increase serum urate.
	High doses of aspirin interfere with uric acid excretion and should be avoided during an attack
	*Do any of the following apply?*
	1) Definite diagnosis of gout following second or further attacks within one year
	2) Presence of tophi
	3) Presence of gouty erosive disease
	4) Evidence of gout interstitial renal disease
	**If Yes, consider Long Term Treatment with Uric Acid Lowering Therapy**
Inflammatory Myositis	Assess for muscle weakness, weight loss, appetite loss, skin rash, mechanics hands	TSH CK ANA LFTs (expect ALT to be raised in PM)	Refer with test results attached
	Most common cause of raised CK is statin use – if ANA is negative, consider stopping statins and repeating CK after 2-3 months before referral
	*Dermatomyositis* will always have skin changes some of which can be seen on:
	*https://dermnetnz.org/topics/dermatomyositis-images/*
	but CK may be normal – if CK is normal, refer to Dermatology initially
	*Polymyositis* will have raised CK (a CK of less than 400 is unlikely to be inflammatory in origin) with proximal weakness or tiredness and modest myalgia
	If concomitant neurological symptoms refer to Neurology
Polymyalgia rheumatica	Bilateral shoulder / pelvic girdle pain Age >50yrs Raised ESR / CRP	FBC ESR CRP TSH LFTs U&Es CK Chest X Ray Urine dip if possible	Consider referral in the following circumstances: Incomplete, poorly sustained or non-response to corticosteroids Inability to reduce corticosteroids Contraindications to corticosteroid therapy The need for prolonged corticosteroid therapy (>2 years)
Polymyalgia rheumatica	Refer to BSR guidance for further information: https://academic.oup.com/rheumatology/article/49/1/186/1789113
SLE	Raynauds and Livedo are common in teenage girls and usually physiological.		Refer all suspected cases with test results attached
	Ask for: History of rashes (patient to keep phone pictures if they are being referred) Photosensitivity Mouth ulcers Inflammatory joint pain (morning stiffness and / or morning swelling) Hair loss FH of autoimmune disease	ANA, CK, U&Es, LFTs, FBC, CRP and ESR ENA will be automatically done by lab if ANA is positive If anti double stranded DNA is positive, but Crithidea (done automatically by lab) is negative, then the anti DsDNA is likely to be a false positive

		If history of thrombosis or miscarriages/ pregnancy loss then add lupus anticoagulant and cardiolipin antibodies
Scleroderma	Virtually all will have Raynauds and either skin tightening or very marked puffiness in hands in the early stages	ANA (usually anti centromere or anti-scl70 positive on ENA) U&Es LFTs LFTs CRP ESR CK	Refer all suspected cases with test results attached
	Many will already have very painful digital ulceration / pits at time of presentation
	Ask for history of swallowing difficulties and SOB
Sjögren’s	Persistent and excessively dry mouth (not explained by medication, ageing, chronic infection, head and neck irradiation, Lymphoma, Sarcoidosis or GVHD)	Check ANA (usually anti Ro +/- La) U&Es LFTs Igs CRP ESR	Refer patients with resistant symptoms, diagnostic uncertainty or suspected secondary or extraglandular manifestations to Rheumatology
Sjögren’s		Symptomatic treatments such as artificial tears and saliva are well tolerated and help to relieve the most obvious symptoms	Refer refractory dryness to Ophthalmology
Osteoarthritis	Only refer if joint pain previously amenable to a joint injection with longer term benefit (>6/52) or if there is diagnostic uncertainty with inflammatory arthritis	Do NOT prescribe opioids or pregabalin	Refer for physiotherapy
		Regular joint injections are not recommended as long-term therapy
		*Suggest topical agents and https://my.livewellwithpain.co.uk/*

Psoriatic arthritis	Usually personal or family history of skin or nail psoriasis, pattern can be variable.	Weight reduction advice if appropriate	Refer all suspected cases using Early Inflammatory Arthritis form
	*Consider use of: PEST questionnaire (Psoriasis Epidemiology Screening Tool)*	FBC FBC U&Es LFTs CRP ESR AntiCCP
	Joint pain for more than 4/52, Early morning stiffness for >30 minutes, synovitis of any joint. Also consider if inflammatory back pain, or enthesitis such as tennis/ golfer’s elbow, Achilles tendonitis or plantar fasciitis
Inflammatory back pain / axial spondyloarthropathy	Early morning stiffness of spine >30 minutes in someone less than 45, or buttock pain worse in the morning	FBC, U&Es, LFTs, CRP, ESR, HLAB27 (once only) and anti CCP if peripheral joint involvement	Refer if inflammatory disease likely
	Inquire for personal or FH of Ankylosing Spondylitis, iritis, inflammatory bowel disease or psoriasis	If MRI spine requested (and inflammatory disease is less clear) request SI joints too as not visualised on a normal LS MRI	Do NOT refer to community physiotherapy at this point as will benefit from specialist physio advice later
	Ask about symptoms of peripheral joint inflammation, particularly hip (groin) or knee/ankle, or enthesitis such as tennis / golfer’s elbow, Achilles tendonitis or plantar fasciitis	If no contraindications, try at least one full dose NSAID with PPI if appropriate
Osteoporosis	Use FRAX score https://www.sheffield.ac.uk/FRAX/tool.aspx?country=1 to assess need for treatment	Depending on age and comorbidity, consider causes of secondary osteoporosis and blood test including:	Refer all patients with: non tolerance of oral bisphosphates requiring sub cutaneous or IV therapy or where treatment is not clear cut and Advice & Guidance not possible or not able to answer question after performing a FRAX score.
		Anti TTG Igs & Electrophoresis
	Nb this score is not so helpful to decide on future treatment if already on medication	Testosterone (in younger men)
	Ensure calcium and vitamin D replete and supplement if necessary	Advise weight bearing exercise
New early inflammatory arthritis symptoms	Symptoms and signs of Early Inflammatory Arthritis	Request FBC, ESR, U&Es, LFTs, RF, ANA and ant-CCP	*Refer using EarIy Inflammatory Arthritis form*
	Joint pain for > 4/52 but < 12 months	X-ray hands and feet +/- other joints if involved
	Early morning stiffness for >30 minutes PLUS either two or more swollen joints or tender MCPs by squeeze test
Possible GCA / temporal arteritis	Age >50 New onset of headache or jaw claudication (in the absence of current dental complaints) NB- GCA uncommon in ethnicity other than Caucasian Kindly follow the GCA pathway.	Bloods and temporal artery US will be arranged by acute hospital DO NOT commence steroids prior to discussion with Rheumatology / Ophthalmology as this reduces diagnostic capacity of ultrasound	9-5pm Mon – Fri Refer to Rheumatology SpR on bleep 2531 or 1365Out of hours refer to A&E or MDUAny visual symptoms, refer to ophthalmology first
Possible GCA / temporal arteritis			If visual changes, please refer to OPHTHALMOLOGY assessment in eye casualty instead that day- they will refer on to us if concern of GCA

Rheumatology Services

The UHCW rheumatology service runs various clinics, mainly at UHCW but also at St Cross Hospital, Rugby.

There is a wide range of services, including an early arthritis clinic, an ankylosing spondylitis clinic, an urgent review clinic, and an osteoporosis service.

Here is a list of the consultants, with their interests and involvement at other hospitals:

Dr Tanya Potter (Pregnancy & Rheumatic Disease, Early Inflammatory Arthritis) UHCW ext 26706 Tel 02476 966706
Dr Kaushik Chaudhuri (Osteoporosis) UHCW ext 26708 Tel 02476 966706
Dr Price-Forbes (General Rheumatology and Connective Tissue Diseases) UHCW ext 26707 Te 02476 966707
Dr Gillian Peffers (Early Arthritis, General Rheumatology, Sjogrens)UHCW ext 26707 Tel 02476 966707
Dr Nicola Gullick (Psoriatic Arthritis and Research) UHCW Clinical Lead ext 26705 Tel 02476 966705
Dr Tim Blake (Acute Medicine, Spondyloarthropathy, Connective Tissue Diseases)UHCW ext 26705 Tel 02476 966705
Dr Ganesh Kasavkar (General rheumatology)UHCW ext 26705 Tel 02476 966705
Dr Siwalik Banerjee (Connective tissue diseases/Vasculitis) UHCW/St Cross ext 26707 Tel 02476 966704/5
The Rheumatology Registrars carry bleeps (2531 or 1365) and are contactable 9am-5pm for advice.

For general enquiries use Consultant Connect or email:uhc-tr.rheumatologysecretaries@nhs.net

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