Rheumatoid arthritis (RA) is a severe and debilitating disease which can have a devastating impact on an individual's quality of life and ability to work. This has implications not only for the individual sufferer but also for society as a whole. There is also evidence that patients with RA are at risk of premature death.
There is now increasing evidence that early treatment with disease-modifying antirheumatic drug (DMARD) therapy can delay progression of the disease, maintain function and reduce long-term disability. Although RA affects around 1% of the population, most GPs will only occasionally see a new presentation of RA.
Few GPs have specialist training in rheumatology and most will have little or no experience of initiating DMARD therapy. For these reasons it is important that all patients with RA are referred to a rheumatologist as soon as the diagnosis is suspected or established and within 12 weeks of having persistent inflammatory joint disease.
Initiation of DMARD therapy is the main reason for referral, but giving the patient access to the multidisciplinary team for therapy and education is also extremely important.
It has been argued that referral according to the SIGN guidelines would overwhelm the already over-stretched rheumatology services, and that difficulties in early diagnosis would result in many patients being referred inappropriately.
RA can certainly be difficult to diagnose in the early stages. Signs and symptoms may fluctuate and some patients with inflammatory arthritis will have complete resolution, suggesting a reactive or viral aetiology.
Other conditions presenting with persistent active inflammation of the joints, such as seronegative spondyloarthritis and connective tissue disease, should be referred to secondary care in any case.
It is very important to state on the referral letter the duration of signs and symptoms, the joints affected and the presence of synovitis, together with any laboratory test results, so that patients with persistent inflammatory joint disease can be seen sooner than other less urgent referrals.
If rheumatology services are so overstretched that they cannot cope with these RA patients for whom early treatment may radically change the course of their disease, we should be trying to provide more resources and perhaps reduce referrals for other less serious conditions. These could be dealt with within primary care by suitably trained GPs or in intermediate care by specialist GPs with particular training and expertise.
The quality of education in rheumatology in the past has been variable: many GPs have received very little training in dealing with musculo-skeletal problems.
A new core curriculum for musculoskeletal problems1 for GPs and GP registrars has been produced by the Arthritis Research Campaign, the Primary Care Rheumatology Society (PCRS) and the Royal College of General Practitioners. It is to be hoped that this will now be taken up by all those involved in postgraduate training for general practice.
There is also a postgraduate Diploma in Primary Care Rheumatology from the University of Bath in conjunction with the PCRS, and graduates of this Diploma are now involved in providing education in their own local areas and some in providing intermediate care services.
If more of the non-inflammatory conditions can be dealt with within primary care, this should reduce the present burden on rheumatology departments and provide more resources for dealing with the management of early RA.
- See also 'RA guideline advocates early intervention with disease-modifying drugs' in this issue.
- Learning Guide for General Practitioners and General Practice Registrars on Musculoskeletal Conditions. London: The Arthritis Research Campaign, 2000. ISBN 1-901815-00-5.