Inflammatory Arthritis

Inflammation is the underlying pathology in many types of arthritis – rheumatoid arthritis (RA), ankylosing spondylitis, psoriatic arthritis and lupus. RA is the most common. Some 690,000 people in the UK have RA, so every GP has several patients.

However, in primary care most patients with joint pain don’t have inflammatory arthritis. The challenge is to spot those who do and refer them promptly, as early treatment with disease-modifying anti-rheumatic drugs (DMARDs) has lasting benefits.

The hallmarks of inflammatory arthritis are:

 Several joints involved, often in typical distribution of RA

 Marked early morning stiffness (EMS), usually >1 hour

 Systemic symptoms – feeling unwell, tired or losing weight.

History

• Establish whether there is pain, stiffness, loss of movement and/or swelling, in which joints, and the time-course. Inflammatory arthritis often begins suddenly, although the onset can be insidious.
  
• Family history is important for RA, psoriatic arthritis and ankylosing spondylitis.
  
• Ask about Raynaud’s phenomenon or photo-sensitivity: ‘Do your fingers go cold and blue?’ and ‘Do you get a rash from the sun?’ These suggest lupus.

Examination

• Look for synovitis (tender swollen joints).
  
• Is there a rash? Check knees, elbows and scalp for psoriasis. A butterfly rash on the face points to lupus.
  
• Back involvement in ankylosing spondylitis and psoriatic arthritis.

Investigations

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