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Diagnosing inflammatory arthritis

Treating inflammatory arthritis early can halt disease progression. Musculoskeletal GPSI Dr Louise Warburton gives her tips on early diagnosis

Treating inflammatory arthritis early can halt disease progression. Musculoskeletal GPSI Dr Louise Warburton gives her tips on early diagnosis

1 The diagnosis will often be made on the strength of the history. Listen to what the patient tells you. Key points to ask about are ‘morning stiffness'. How long does it take the patient to get going in the mornings? Do they need to take a hot shower in order to limber up? Do they stiffen up after resting during the day? Patients with OA stiffen up after exercise.

2 Fatigue is a large factor in inflammatory arthritis. How does the patient feel? Have they had to make changes in their day-to-day life because of the way that they feel?

3 Inflammatory arthritis will cause pain and swelling in joints. Ask the patient about pain and where the pain is felt. Are they sleeping well or is the pain interfering with sleep? How far can they walk now and how far could they walk before?

4 The pattern of joint involvement is key. In typical rheumatoid arthritis, the metacarpophalangeal and metatarsophalangeal joints tend to be involved. In seronegative arthritis, large joints such as knees, hips and ankles can be involved as well as hands and wrists. But don't be put off by an atypical presentation of joint swelling and pain.

5 Refer as early as possible to either a secondary care rheumatology service or intermediate care clinic. There is a clear window of opportunity of six weeks to three months during which starting therapy has a very good chance of preventing progression or even aborting the arthritis1.

6 Check FBC, ESR, CRP and rheumatoid latex test if you suspect an inflammatory arthritis. There is no point taking X-rays as joint erosions don't appear until 12 months after the disease starts.

7 Raised inflammatory markers and a normochromic, normocytic anaemic result suggest a diagnosis of inflammatory arthritis. But even if inflammatory markers are normal, the patient may still have arthritis, so refer if you suspect an inflammatory arthritis.

8 Rheumatoid factor can be positive in many cases that are not inflammatory arthritis. There are many situations when it is a false positive, for example some infections. The diagnosis should not be made on the strength of a positive rheumatoid factor alone.

9 Gout can masquerade as inflammatory arthritis. If the patient is overweight, hypertensive and drinks or has the metabolic syndrome, check uric acid as well. Widespread gout can cause pain and inflammation in many joints, not just the big toe.

10 Beware the trap of polymyalgia rheumatica. Not all patients with a raised ESR and vague aches and pains, who respond to oral steroids, will have polymyalgia. Steroids will often mask an inflammatory arthritis, or worse, an underlying malignancy.

Dr Louise Warburton is a GP in Shropshire and a GPSI in musculoskeletal medicine

Competing interests None declared

Inflammatory arthritis

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