How to Refer | RheumReferral

What every referral should include

Referral letters for truly urgent patients are often under-triaged because a few basics are missing. In one clinic audit, 47% of referrals changed urgency grade after the consult, and 17% were upgraded to urgent; the letters for those urgent patients often lacked a working diagnosis, symptom duration or the joints involved.

1

Your question

Diagnosis, treatment advice, a shared-care plan, or a second opinion. One clear question helps the triager most.

2

Working diagnosis and level of concern

Even a tentative one ("possible early RA"), and why you are worried.

3

Onset and duration

The date symptoms began, and whether they are getting worse.

4

What you found on examination

Which joints are swollen, not just painful; morning stiffness in minutes; rash, eye or nail findings; muscle strength.

5

Red flags present or absent

Fever, weight loss, visual symptoms, weakness, breathlessness, kidney findings. Stating that they are absent helps too.

6

Results with dates

Include titers, patterns and reference ranges. Attach reports rather than summarizing them where you can.

7

Treatments tried

NSAIDs and glucocorticoids with doses, dates and response. Steroids can mask synovitis and change test results.

8

Context that changes the plan

Pregnancy or plans for it, infection history (TB, hepatitis), kidney or liver disease, cancer history, and access needs such as an interpreter or travel distance.

9

Photos

With consent, photos of a transient rash, swelling or color change are often more useful than a description.

10

How to reach you

A direct number or secure message route, in case the triager has a quick question.

Download the referral template (Word)Download the workup checklist (PDF)See an example referral

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Inflammatory arthritis

Suspected RA, psoriatic arthritis, reactive or undifferentiated arthritis

Don't hold the referral while waiting for results. Normal ESR, CRP, RF and anti-CCP do not exclude inflammatory arthritis.

History and examination

Swollen joints drawn or listed (the strongest single clue), tender joints, and morning stiffness in minutes
Symptom onset date and pattern: symmetric small joints, asymmetric large joints, DIP joints, dactylitis or enthesitis
Psoriasis (personal or family), nail changes, inflammatory bowel disease, uveitis, recent GI or GU infection
Function: grip, work, sleep. Smoking history.

Usual workup recommended before the referral is seen

CBC with differential, metabolic panel with creatinine and liver tests
ESR and CRP
RF and anti-CCP
Hepatitis B (HBsAg, anti-HBc, anti-HBs) and hepatitis C antibody, which are needed before most DMARDs
Uric acid if gout is possible; urinalysis
ANA only if there are features of connective tissue disease; HLA-B27 only with back pain, enthesitis or uveitis

Imaging

X-rays of both hands and both feet (a baseline for erosions, even in early disease)
X-ray of any other swollen joint

While the patient waits

An NSAID is reasonable if safe for the patient.
If possible, avoid glucocorticoids before the first visit. If they were needed, note the dose and dates.
Ask the patient to photograph any swelling that comes and goes.

Covers: New inflammatory arthritis (suspected RA), Psoriatic arthritis (suspected), Reactive arthritis (persistent or recurrent), Established RA: treatment change or review, Positive anti-CCP or high-titer RF with joint pain, no swelling, Checkpoint inhibitor rheumatic adverse events (irAEs), Drug-induced rheumatic disease

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Axial spondyloarthritis

Chronic back pain that began before 45 with inflammatory features

A normal pelvic X-ray does not rule out axSpA. HLA-B27 alone, without symptoms, is not a reason to refer.

History and examination

Age at onset, duration (3 months or more), and inflammatory features: night pain, morning stiffness over 30 minutes, better with activity, alternating buttock pain
Response to a full-dose NSAID (a good response supports axSpA)
Uveitis, psoriasis, IBD symptoms, enthesitis (heel pain), dactylitis, family history

Usual workup recommended before the referral is seen

CRP and ESR
HLA-B27
CBC and metabolic panel

Imaging

AP pelvis radiograph as the first test. The 2026 ACR guideline prefers it over lumbar spine films or dedicated SI joint views.
If X-rays are non-diagnostic, SI joint MRI without contrast is the next step. Follow your local pathway on who orders it.

While the patient waits

A continuous NSAID trial (2–4 weeks at full dose) if safe
Physical therapy referral, which the 2026 guideline strongly recommends
Ask about eye pain or redness with light sensitivity, which needs same-day eye care

Covers: Suspected axial spondyloarthritis (axSpA), Mechanical (non-inflammatory) back pain

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Gout and CPPD

Complex or refractory gout, recurrent pseudogout, diagnostic uncertainty

A hot, swollen joint with fever needs same-day aspiration to exclude infection. Crystals and infection can coexist.

History

Flare dates, joints involved and frequency over the past year
Tophi, kidney stones, CKD, transplant, diuretics, alcohol and diet, family history
Urate-lowering therapy: drug, highest dose reached, duration, adherence, flare prophylaxis, and why anything was stopped

Usual workup recommended before the referral is seen

Serum urate, ideally 2 or more weeks after a flare (it can be normal during one)
CBC, metabolic panel with eGFR and liver tests
Joint fluid results (crystals, cell count, culture) if aspiration was done
HLA-B*58:01 result if tested
For CPPD starting before about 60: calcium, phosphate, magnesium, ferritin and transferrin saturation, alkaline phosphatase, TSH

Imaging

X-rays of affected joints (erosions, tophi, chondrocalcinosis)
Ultrasound or dual-energy CT can help in specialist hands; they are not needed before referral.

Covers: Gout: complex or refractory, Gout: new, uncomplicated, Calcium pyrophosphate deposition (CPPD), Asymptomatic hyperuricemia

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Connective tissue disease

Lupus, systemic sclerosis, myositis, Sjögren's disease, MCTD, antiphospholipid syndrome

Kidney involvement, lung hemorrhage, rapidly worsening breathlessness, new severe hypertension in scleroderma, or swallowing or breathing weakness are emergencies. Call rather than refer.

Lupus (SLE)

ANA with titer and pattern, anti-dsDNA, ENA panel (Sm, RNP, SSA/Ro, SSB/La)
C3 and C4, CBC with differential, metabolic panel
Urinalysis with microscopy and urine protein-to-creatinine ratio
ESR and CRP; direct antiglobulin test if anemic
Antiphospholipid antibodies if there is a history of clots or pregnancy loss
Photos of rashes; pregnancy status or plans

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Systemic sclerosis

ANA with pattern, anti-centromere, anti-Scl-70, anti-RNA polymerase III
CBC, metabolic panel, urinalysis, and blood pressure
PFTs with DLCO and HRCT chest (ACR/CHEST 2023 screening), echocardiogram
Note digital ulcers, skin thickening extent and speed of change, reflux or swallowing problems
Nailfold capillaroscopy if available locally

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Myositis

CK, aldolase, AST/ALT, LDH, TSH
CBC, metabolic panel, ESR/CRP, ANA, and a myositis-specific and myositis-associated antibody panel
Troponin and ECG if there are any cardiac symptoms
PFTs and HRCT if there is cough or breathlessness
Statin history (dates, doses), swallowing and voice symptoms
Age-appropriate cancer screening status

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Sjögren's disease

ANA, SSA/Ro, SSB/La, RF
CBC, metabolic panel, urinalysis, IgG or serum protein electrophoresis, C3/C4
Cryoglobulins if there is purpura or neuropathy
List of drying medicines (anticholinergics, antihistamines, antidepressants)
Dental and eye findings, gland swelling (location and duration)

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Mixed connective tissue disease

ANA and anti-U1 RNP
CK, CBC, metabolic panel, urinalysis
PFTs with DLCO, HRCT chest, echocardiogram

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Antiphospholipid syndrome

Lupus anticoagulant, anticardiolipin IgG/IgM, anti-β2-glycoprotein I IgG/IgM
Repeat positive tests at least 12 weeks apart
Which anticoagulant the patient was on at the time of testing (it affects lupus anticoagulant results)
Thrombosis history (sites, dates, provoking factors) and full pregnancy history
CBC including platelets

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EULAR 2019 APS recommendations

General or undifferentiated

ANA titer and pattern, ENA panel, anti-dsDNA, C3/C4
CBC with differential, metabolic panel, urinalysis, ESR/CRP, TSH
A symptom diary and photos of anything that comes and goes

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ACR classification criteria

Covers: Suspected systemic lupus erythematosus (SLE), Suspected systemic sclerosis (scleroderma), Suspected inflammatory myopathy (myositis), Sjögren's disease with systemic features, Sjögren's disease: sicca-predominant, Mixed connective tissue disease (MCTD), Antiphospholipid syndrome (APS), Undifferentiated connective tissue disease (UCTD), Interstitial lung disease in autoimmune disease, Raynaud's phenomenon with secondary features, Connective tissue disease with organ-threatening features, Sarcoidosis with rheumatologic features, Positive ANA without symptoms

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Vasculitis and systemic inflammatory disease

GCA and PMR, Takayasu, ANCA vasculitis, cryoglobulinemia, Behçet's, PAN, adult autoinflammatory disease

Ischemic symptoms, organ involvement or suspected MAS need a same-day call.

GCA and PMR

Suspected GCA: call the same day and start glucocorticoids; don't wait for the workup
ESR, CRP, CBC, metabolic panel with glucose
Headache, jaw claudication, scalp tenderness, visual symptoms, limb claudication
For PMR: CK, TSH, RF/anti-CCP and serum protein electrophoresis to look for mimics
Glucocorticoid start date and dose, if already started

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Takayasu arteritis

Blood pressure in both arms, pulses, bruits
ESR, CRP, CBC, metabolic panel
CTA or MRA of the aorta and branches if available

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ANCA-associated vasculitis

PR3- and MPO-ANCA by antigen-specific immunoassay
Urinalysis with microscopy, urine protein-to-creatinine ratio, creatinine
CBC, CRP, chest imaging (X-ray or CT)
ENT history (crusting, epistaxis, hearing), neurologic findings, eye symptoms

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Cryoglobulinemic vasculitis

Cryoglobulins (sample kept warm until the lab separates it), RF, C3/C4 (a low C4 is typical)
Hepatitis C, hepatitis B, HIV, serum protein electrophoresis
Urinalysis and creatinine

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ACR/VF 2021 vasculitis guidelines

Behçet's syndrome

Ulcer history: frequency, sites, photos
Eye symptoms (needs ophthalmology), skin lesions, thrombosis history
CBC, CRP, urinalysis. There is no diagnostic blood test, and HLA-B51 testing is not needed for diagnosis.

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Polyarteritis nodosa

Hepatitis B and C serology, ANCA (to exclude ANCA vasculitis)
Urinalysis, creatinine, blood pressure
Skin or nerve findings that could be biopsied; any angiography
In younger patients, especially with stroke: consider DADA2 testing

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ACR/VF 2021 vasculitis guidelines

Adult autoinflammatory disease (Still's, VEXAS, FMF)

A fever diary and photos of any rash
CBC with differential (note MCV and platelet trend), ferritin, CRP/ESR, liver tests, LDH
Family history and ancestry (relevant for FMF)
Infection and malignancy workup done so far

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When to call instead of referring

Suspected GCA, especially with any visual symptom
Pulmonary-renal features: hemoptysis, rising creatinine, active urine sediment
Mononeuritis multiplex, mesenteric ischemia, or a threatened limb or digit
Persistent fever with cytopenias and a very high ferritin (possible MAS)

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Covers: Giant cell arteritis (GCA), Polymyalgia rheumatica (PMR), Takayasu arteritis / large-vessel vasculitis, ANCA-associated vasculitis with organ threat, Palpable purpura / small-vessel vasculitis (adult), Behçet's syndrome, Polyarteritis nodosa (PAN), Adult-onset Still's disease (AOSD), VEXAS syndrome, Relapsing polychondritis, IgG4-related disease, Macrophage activation syndrome / HLH (adult)

Sources

ACR/VF 2021 vasculitis guidelines

Pediatric rheumatology

JIA, fever syndromes, childhood lupus and dermatomyositis, vasculitis, and other conditions

A child with fever and an acutely painful joint or bone, or refusal to bear weight, needs same-day assessment for infection. Night pain, cytopenias or a high LDH should prompt urgent evaluation for malignancy.

Joint swelling or limp (JIA)

Which joints, how long (6 weeks or more suggests JIA), morning stiffness, limp, night pain
CBC with differential, ESR, CRP, metabolic panel; LDH and a blood film if malignancy is possible
ANA (for uveitis risk), RF and anti-CCP if polyarticular, HLA-B27 if enthesitis or back pain
X-ray if trauma, infection or malignancy is a concern
Arrange an ophthalmology screening exam now, and send the growth chart

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Fever syndromes (sJIA, MAS, Kawasaki, MIS-C, periodic fever)

A fever chart (pattern and duration) and rash photos
CBC with differential, CRP, ESR, ferritin, liver tests, urinalysis, blood cultures
If MAS is possible: fibrinogen, triglycerides, LDH, coagulation studies
Echocardiogram for Kawasaki disease or MIS-C (usually arranged on admission)
For periodic fevers: episode diary, labs during and between episodes, family history

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Childhood lupus, dermatomyositis, scleroderma, Sjögren's

The same antibody panels as for adults (see connective tissue disease above)
Blood pressure, urinalysis with microscopy and urine protein-to-creatinine ratio
CK, aldolase, AST, LDH for weakness; swallowing and voice symptoms
Growth chart and pubertal stage

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IgA vasculitis (HSP)

Urinalysis, urine protein-to-creatinine ratio, creatinine, blood pressure
Abdominal symptoms (intussusception risk)
A plan for urine and BP checks for at least 6–12 months

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SHARE 2019 IgA vasculitis recommendations

Other pediatric referrals

Neonatal lupus: maternal antibody results, infant ECG, CBC, liver tests
Morphea: photos with a ruler, location (face or limb), any limb-length difference
CNO: MRI and any biopsy results
Acute rheumatic fever: ASO, anti-DNase B, ECG, echocardiogram

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Covers: Juvenile idiopathic arthritis (JIA), JIA-associated uveitis, Systemic JIA / macrophage activation syndrome, Kawasaki disease, Multisystem inflammatory syndrome in children (MIS-C), Pediatric vasculitis with organ threat, Pediatric (childhood-onset) SLE, Juvenile dermatomyositis (JDM), IgA vasculitis (Henoch-Schönlein purpura), Pediatric systemic sclerosis, Acute rheumatic fever, Neonatal lupus, Pediatric sarcoidosis / Blau syndrome, Chronic nonbacterial osteomyelitis (CNO/CRMO), Periodic fever / autoinflammatory syndromes, Localized scleroderma (morphea), Reactive arthritis (pediatric), Pediatric Sjögren's disease

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ACR 2026 JIA guidelines

Other common referrals

Osteoporosis, osteoarthritis, widespread pain, soft-tissue problems, hypermobility

Many of these patients are well served in primary care or MSK services first. Some rheumatology practices see them routinely; check your local pathway or use an e-consult.

Osteoporosis

DXA results (with dates and sites), FRAX score, and fracture history including vertebral fractures
Current and past treatment with dates (bisphosphonate, denosumab with the date of the last injection, anabolic agents)
Calcium, 25-OH vitamin D, creatinine/eGFR, alkaline phosphatase, PTH and TSH if checked
Glucocorticoid exposure (dose and duration)

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Osteoarthritis with an atypical feature

Why OA seems atypical: young onset, MCP or wrist involvement, rapid progression, or swelling
X-rays of the affected joints
Ferritin and transferrin saturation if hemochromatosis is possible; ESR/CRP

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Widespread pain or fatigue

CBC, metabolic panel, ESR/CRP, TSH; CK if weak or on a statin
Treatments tried, sleep, mood and function
The specific question (for example, "Is there inflammatory disease?"). Broad autoantibody panels rarely help without specific features.

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EULAR 2017 fibromyalgia recommendations

Soft-tissue problems and hypermobility

Usually best served by an MSK pathway (physical therapy, sports medicine, orthopedics) unless inflammatory features are present
For hypermobility: dislocations, skin features, family history and vascular history (a genetics referral may fit better)

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BSR specialist advice, referral & triage

Covers: Osteoporosis: complex or refractory, Osteoarthritis, Fibromyalgia, Regional soft-tissue problems, Joint hypermobility without complications, Primary Raynaud's phenomenon

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BSR specialist advice, referral & triage

Lab-triggered referrals

When a result arrives without a clear clinical picture, this table suggests when it usually warrants a referral and when it usually doesn't.

Result	Usually refer when	Usually no referral needed when	What to send
Positive ANA More in the Assistant	Titer 1:160 or higher with compatible symptoms, any positive disease-specific antibody, or unexplained cytopenias, proteinuria or hematuria	Low titer (1:40–1:80) with no symptoms and normal CBC, metabolic panel and urinalysis	Titer and pattern, why it was ordered, CBC, metabolic panel, urinalysis; ENA and anti-dsDNA if titer is 1:160 or higher
Anti-dsDNA, anti-Sm, anti-RNP, Scl-70, centromere More in the Assistant	Usually refer, since these are disease-specific. Add urgency if kidney, blood or lung findings are present.	A low-level anti-dsDNA by a non-specific assay with a negative ANA may be a false positive. Ask the lab or an e-consult.	ANA, the full ENA panel, C3/C4, CBC, urinalysis with protein-to-creatinine ratio
Anti-CCP or RF More in the Assistant	With objective joint swelling: urgent. High-titer anti-CCP with joint pain and no swelling: routine assessment.	Low-titer RF alone, especially in older adults or with chronic infection or liver disease	Titers, joint exam findings, ESR/CRP, hand and foot X-rays
Raised ESR or CRP More in the Assistant	With features of PMR, GCA, inflammatory arthritis or vasculitis	A mild isolated rise with no symptoms. Look first for infection, malignancy, kidney disease, obesity, anemia or age-related change.	Trend over time, symptoms, CBC, metabolic panel, SPEP if ESR is high with a normal CRP
Positive ANCA More in the Assistant	PR3- or MPO-ANCA positive with any compatible feature: urgent, or emergent with kidney or lung involvement	Immunofluorescence-only (atypical p-ANCA) positivity without features, which is common in IBD, infection and with some drugs	PR3/MPO immunoassay results, urinalysis with microscopy, creatinine, chest imaging
Raised CK More in the Assistant	With proximal weakness, dysphagia, rash or a persistently raised CK after stopping a statin	A modest rise (under about 3–5 times normal) without weakness after exercise or injury, or in people of African ancestry with higher normal ranges. Repeat after a week without exercise.	CK trend, TSH, statin history, strength exam, AST/ALT, LDH
High uric acid More in the Assistant	With complex or refractory gout (see triage)	Asymptomatic hyperuricemia. The ACR conditionally recommends against urate-lowering therapy here.	Urate trend, eGFR, flare history if any
HLA-B27 positive More in the Assistant	With inflammatory back pain, enthesitis, uveitis or peripheral arthritis	Without symptoms. It is present in roughly 6% of the US population, and most carriers never develop spondyloarthritis.	Back pain features, CRP, AP pelvis X-ray
Low C3 or C4 More in the Assistant	With features of lupus, cryoglobulinemia or vasculitis, or an abnormal urinalysis	An isolated, mildly low C4 with no symptoms (inherited partial deficiency is common)	ANA, anti-dsDNA, cryoglobulins, urinalysis, creatinine
Antiphospholipid antibodies More in the Assistant	Persistently positive (12 weeks or more apart) with thrombosis or pregnancy morbidity, or triple positivity	A single low-titer positive without events. Repeat in 12 weeks or more.	All three tests with dates, anticoagulant at time of testing, event history
Very high ferritin More in the Assistant	With fever, rash and arthritis (Still's) or with cytopenias (possible MAS): urgent or emergent	A modest rise with iron overload, liver disease, alcohol or inflammation from another cause	Ferritin trend, CBC, liver tests, fibrinogen, triglycerides, CRP
Anti-SSA/Ro in pregnancy More in the Assistant	Yes. Coordinate rheumatology and maternal-fetal medicine for fetal heart monitoring and hydroxychloroquine.	—	Antibody results, gestation, any prior affected pregnancy

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