Practice Clinical Update

Diagnosis and early management of inflammatory arthritis

BMJ 2017; 358 doi: (Published 27 July 2017) Cite this as: BMJ 2017;358:j3248
cropped thumbnail of infographic

Infographic available

A visual summary of the four most frequently used DMARDs, including recommended monitoring and conditions that may interfere with treatment

Re: Diagnosis and early management of inflammatory arthritis- authors reply to comments

We are grateful for the responses to our review, which raise a number of important issues. We would like to offer a brief clarification and explanation of some of the points raised.

The review was commissioned to support non-specialist clinicians, in particular general practitioners, in the diagnosis and early management of inflammatory arthritis. This is a vast topic and the article was restricted in length and therefore in the detail that could be included. All 3 authors, along with editors from the BMJ, were involved in selecting the aspects covered.

Timely referral is a key message In the UK primary care has a “gatekeeper” function in onward referral to specialist rheumatology services. The National Clinical Audit for Rheumatoid and Early Inflammatory Arthritis in England and Wales showed that the median time from first presentation in primary care to referral to rheumatology is 34 days, and more than 25% of people with arthritis wait more than 3 months. This is too long, and we would argue that earlier recognition of even the more stereotypical clinical features outlined in our review has considerable potential to reduce delays in referral. We avoided any specific definition of persistence as we felt that severity and progression of symptoms should be the main drivers for referral.

We recognise and tried to highlight the varied ways in which inflammatory arthritis can present (including with non-musculoskeletal symptoms such as fatigue and with little obvious joint swelling). Our patient authors history was included to reflect a non-stereotypical presentation that we hope highlights the challenge of diagnosing inflammatory arthritis in primary care, where symptoms of musculoskeletal pain and fatigue account for around 25% of patient visits, and where access to diagnostic tests may be limited (most UK general practices do not have rapid access to musculoskeletal ultrasound or anti-CCP antibodies).
Because of the focus on early diagnosis and treatment issues relevant to primary care, we only had the opportunity to touch briefly upon important aspects of chronic disease management such as psychological support, signposting to patient organisations and the vital role of the multi-disciplinary team but were keen to highlight these crucial aspects of support at an early stage. We did not discuss the role of biologics as, in the UK, early use is not supported by NICE. However, we agree that these are central to the management of many people with inflammatory arthritis. We also fully support active involvement of patients in dealing with their arthritis, making full use of shared decision making and supported self-management.

We also acknowledge the challenges of living with a diagnosis of inflammatory arthritis, that help is required for patients to help them manage all aspects of their disease, that achieving ‘remission’ with treatment and tolerating DMARDS is difficult for many patients. Nevertheless, outcomes from inflammatory arthritis have improved considerably in recent years, and while there is still a long way to go before we can talk about “cure”, the outcomes are likely to be better if people are seen promptly and given the chance of early, intensive treatment; the rationale for this article. Latest National Audit data show that just under 40% of people are seen in rheumatology within 3 weeks of referral - we would also like to see this improve (a detailed breakdown of local waiting times can be found in the National Audit reports)

In response to specific questions with regard to treatment:

1) Evidence about stopping DMARDs during infection is limited, and there is probably no need to stop during minor infections, such as URTIs and uncomplicated UTIs. It does, however, seem a sensible precaution to stop immunosuppressive DMARDs in people who are systemically unwell.

2) Both the US CDC and the Public Health England Green Book consider that the live shingles vaccine can be given safely in most people taking rheumatological DMARDs. In the UK, we would only consider the vaccine in the limited age group defined by the Green Book. The Green Book advice has changed slightly in recent years, and factors such as steroid exposure need to be considered, so our advice about discussion is to ensure that the most up to date advice is followed.

References in main article

Competing interests: No competing interests

11 August 2017
Zoe Ide
Neil Snowden, Joanna Ledingham
National Rheumatoid Arthritis Society
Maidenhead, UK