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Rheumatology

  

Rheumatologists are doctors who investigate, diagnose, manage and rehabilitate patients with inflammatory disorders of the musculoskeletal system.


Early Arthritis Clinic

Allows rapid access to Rheumatology services for assessment of patients with painful, stiff or swollen joints which may represent the onset of rheumatoid arthritis. These referrals should be sent directly via the NHS eReferral Service into the dedicated referral assessment clinic;

Early Arthritis Clinic RAS -Rheumatology – University Hospital Coventry – RKB

Please advise patients to stop taking any NSAIDs for 24 hours before clinic and DO NOT prescribe steroids before referral. Simple analgesics like paracetamol or codeine can be prescribed.

Patient must have:

  • Joint pain present for at least 4 weeks but LESS than one year
  • Early morning stiffness in joints of > 30 mins

PLUS either of the following:

  • 2 or more swollen joints
  • Tender metacarpophalangeal joints hands by squeeze test

NB It is not for patients with probable osteoarthritis, widespread pain symptoms or raised inflammatory markers ? cause patients.

If your patient is systemically unwell with raised ESR /CRP please discuss with medical Registrar on call.

If your patient has developed an acutely swollen, hot joint which may be septic or gouty in origin please contact the Registrar on call in Orthopaedics or Rheumatology to discuss the patient that day.

The E-referral will be reviewed by a Consultant and if felt appropriate for this particular clinic, an appointment will be sent out to the patient directly.

If not, then a routine appointment will be made in the general clinics and the referring GP will be informed of the outcome.

Please ensure we have up to date contact details, including a mobile telephone number for the patient, on the form.

For those confirmed with inflammatory arthritis, follow up appointments will be arranged approximately every 4-6 weeks in order to escalate the treatment until the disease activity is felt to be either in remission or at the  lowest level possible for that particular patient.

Please note that a summary letter outlining the patient’s history, joints affected, analgesics and anti-inflammatories used together with previous medical history is also required.

Referral criteria for this clinic are also outlined on the NHS eReferral Service under Rheumatology ‘Early Arthritis Clinic’.

Ask yourself has this patient got the ‘S’ factor?

Suspected Giant Cell Arthritis

For suspected cases of Giant Cell Arteritis please bleep one of the rheumatology registrars (bleep 2531 or 1365) for further advice and/or to arrange an urgent review of the patient.

It would be useful if an urgent ESR could be sent off either from the GP practice or on arrival at hospital.

Out of hours 9-5 Monday to Friday, patients with suspected GCA should be sent to A&E or the AEC Clinic for further assessment.

Back Pain: Suspected Ankylosing Spondylitis / Spondyloarthritis

What is Ankylosing Spondylitis (AS) and Spondyloarthritis (SpA)?

Ankylosing Spondylitis (AS) is a rheumatic disease that causes arthritis of the spine and sacroiliac joints.

The term ‘Ankylosing’ means fusing together, while Spondylitis refers to the inflammation of vertebrae.

AS is typically a painful, progressive rheumatic disease. It primarily affects the spine, but can also affect other joints, tendons, and ligaments. Sometimes, other areas like the eyes, lungs, bowel, and heart can also become affected. AS is the prototype of Spondyloarthritis (SpA).

There are two main types, which can also co-exist:

  • Axial Spondyloarthritis – involving SIJs/spine/costovertebral joint region
  • Peripheral Spondyloarthritis – including dactylitis (whole digit inflammation and swelling), enthesitis, peripheral joint inflammation and tendonitis

Key points about Spondyloarthritis:

  • If persisting back, tendon or joint pain – ask about psoriasis, inflammatory bowel disease, uveitis
  • AxSpA affects women and men equally
  • Inflammatory markers (ESR & CRP) can be normal
  • Do not exclude possibility of SpA if HLA B27 –ve
  • MRI for AxSpA differs from lumbar MRI protocol

Why is it important to screen for Spondyloarthritis?

  • Average time to be diagnosed for many people is 8-9 years
  • Spondyloarthritis is often mistaken as chronic back pain, or as unrelated tendonitis and joint problems
  • Symptoms can move between areas, be asymmetrical, and can flare and settle
  • This guidance links with NICE Guidance on Low Back Pain and Sciatica (2016) to ensure inflammatory back symptoms are not mistaken as chronic mechanical LBP

Diagnostic Tools
The diagnosis of Ankylosing Spondylitis is based on evaluating the patient’s symptoms, a physical examination, X-ray and MRI findings, and blood tests.

A physical examination might reveal limited spinal motion, chest expansion, or characteristic tender points termed enthesitis.

The condition can affect all age groups including children; however, the most common age group includes those in late teens or early adulthood (< 45 years).

The typical symptoms of AS include:

  • Slow or gradual onset of back pain and stiffness
  • Limited expansion of the chest
  • Hip pain and stiffness
  • Early morning stiffness and pain
  • Persistent pain for more than three months
  • Relief from pain after exercise and recurrence after rest.

Additional features:

  • Heel pain (enthesitis)
  • Dactylitis
  • Uveitis
  • Positive family history for SpA
  • Inflammatory bowel disease
  • Alternating buttock pain
  • Psoriasis
  • Asymmetrical arthritis
  • Positive response to nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Elevated acute phase reactants (ESR or CRP).

The following tests should be carried out:

  • Blood tests, which may show mild anaemia, or elevated ESR/CRP
  • HLA-B27 antigen test (present in up to 95% of Caucasian patients with AS, but also in 8% of general Caucasian population)
  • AP plain X-ray of the pelvis to include the sacroiliac joints (SIJs)

Referral if suspect Axial Spondyloarthritis

Refer to rheumatology if a person presents with Back pain > 3 mths with onset before 45 years of age and if 4 or more additional features below:

  • Onset before 35 years of age (increases suspicion)
  • Woken second half of night by symptoms
  • Improves with movement
  • Buttock pain
  • Improves with NSAIDs (often within 48 hours)
  • Close relative (parent, brother, sister, son or daughter) with spondyloarthritis
  • Current or past psoriasis, or family history of psoriasis
  • Other type of arthritis, enthesitis, or pain or swelling in tendon or joints not due to injury

If only 3 additional features, NICE recommends testing for HLA B27 – if positive – refer

Uveitis: ask people with back pain > 3months with onset before 45yrs if history of uveitis, and if HLA B27 positive or has a history of psoriasis – refer

Referral if suspect Peripheral Spondyloarthritis

Refer to rheumatology if a person presents with:

  • Dactylitis (whole swollen digit- ‘sausage’ finger or toe) or
  • Persistent or multiple-site enthesitis without apparent mechanical cause and with other features, including:
  • Back pain without apparent mechanical cause
  • Current/past psoriasis
  • Inflammatory bowel disease (Crohn’s disease/ ulcerative colitis) or uveitis
  • Close relative (parent, brother, sister, son or daughter) with SpA or psoriasis
  • Symptom onset following GIT or genitourinary infection

Further resources

National Axial Spondyloarthritis Society: https://nass.co.uk/

AStretch: www.astretch.co.uk

RCGP -free eLearning module: http://elearning.rcgp.org.uk/course/info.php?id=229

Rheumatology Services

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

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 (Early inflammatory arthritis/transitional care) UHCW ext 26708
  • Dr Kaushik Chaudhuri (Osteoporosis) UHCW/George Eliot ext 26708
  • Dr Phillip Perkins UHCW/George Eliot ext 26708
  • Dr Shirish Dubey (Connective tissue diseases/Vasculitis) UHCW/St Cross ext 26707
  • Dr Price-Forbes UHCW/George Eliot ext 26707
  • Dr Gillian Peffers UHCW ext 26707 (Early Arthritis, General Rheumatology, Sjogrens)
  • Dr Nicola Gullick UHCW (Psoriatic Arthritis and Research)
  • Dr Tim Blake UHCW (Acute Medicine, Spondyloarthropathy, Connective Tissue Diseases).
  • The Rheumatology Registrars carry bleeps (2531 or 1365) and are contactable 9am-5pm for advice.
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