Adults
New inflammatory arthritis (suspected RA)
Joint swelling with prolonged morning stiffness. Refer early; outcomes are best when treatment starts within about 12 weeks of symptom onset.
What to look for
- Soft, boggy joint swelling (synovitis) of one or more joints, especially the small joints of the hands and feet
- Morning stiffness lasting 30–60 minutes or more, and pain that improves with use
- A positive squeeze test across the MCP or MTP joints
- RF or anti-CCP positive, or raised ESR/CRP. Normal blood tests do not exclude inflammatory arthritis.
What to do
- Refer as soon as synovitis is suspected; don't wait for test results. EULAR recommends that people with arthritis are seen by a rheumatologist within 6 weeks of symptom onset, and NICE advises urgent referral even when blood tests are normal.
- Send RF, anti-CCP, ESR, CRP, CBC with differential, and a metabolic panel with liver tests.
- Add hepatitis B (HBsAg, anti-HBc, anti-HBs) and hepatitis C antibody, which are needed before DMARDs. Add uric acid if gout is possible.
- Get X-rays of the hands and feet as a baseline for erosions.
- NSAIDs can help symptoms. If possible, avoid starting glucocorticoids before assessment, since they can mask synovitis. If symptoms are severe and the wait is long, discuss a short course with rheumatology.
About this urgency level
Early specialist assessment changes outcomes. Send the usual workup with the referral, but don't hold the referral while waiting for results.
Timeframes are typical targets. Local pathways, capacity and clinical judgment come first.