CPAC Guidelines - Rheumatology
RHEUMATOLOGY REFERRAL GUIDELINES
Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines
General problems include: These general symptoms may include Specific treatments depend on the It is important that the allied health • Chronic pain syndromes any or all of the general or specific specific problems identified, as noted team is skilled in rheumatological • Joint problems problems noted. A thorough history below. assessment and treatment of the and physical examination is required patient. • Multisystem / Connective Early involvement of the allied health to determine the specific diagnosis tissue disease care team (physio, OT, orthotics, (see below). Early access to these services on an • Muscle aches and pain podiatry, etc.) should be considered. interdisciplinary basis via GPs can be • Osteoporosis / Metabolic bone done via Specialist Rheumatologists disease and/or Specialist Rheumatology • Periarticular / soft tissue Nurses, and/or allied health staff. This rheumatism will include the use of phone • Rheumatological consultation, email, fax etc., which will Rehabilitation facilitate this process.
It is to be emphasised that the Specialist Rheumatologist provides a diagnostic service as well as management guidance. Chronic Pain Syndromes • Fibromyalgia (FMS). Consider medical causes of fatigue, • Explore psychosocial issues Uncertain diagnosis • Complex regional pain. myalgia, e.g. hypothyroid, depression. • Lifestyle counselling • Syndromes (reflex sympathetic • Emphasis on self management Multi/interdisciplinary rehabilitation dystrophy, causalgia). History: • Involve multidisciplinary approach Routine. • Chronic low back pain. • Trauma • Downplay medical model • Sleep disturbance • Low dose tricyclic • Psychosocial evaluation important antidepressants/ simple analgesia. Exam : • Allodynia • Tender points • Pain behaviours
Revised December 2014
CPAC Guidelines - Rheumatology
Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Chronic Pain Syndromes (Continued) Investigations: • FBC/ESR/CRP/TFTs/LFTs/ U&Es/Ca2+/CK/Vitamin D
Note: FMS can exist with other conditions. Joint Problems Acute Single Joint Dx includes the following - History: Gout - initiate non steroidal Refer patients with recurrent gout, Evaluation: Hot, red, swollen joints, inflammatories (Indocid, Voltaren, gout which is chronic and polyarticular Common presence of pyrexia or other signs of Naprosyn), &/or Colchicine & consider or if the diagnosis is uncertain Semi- • Gout, Pseudogout, reactive infection. Aspiration mandatory. intra-articular steroid. urgent – Routine. arthritis Less Common If no signs of infection, consider gout If sepsis cannot be satisfactorily • Septic arthritis, haemarthrosis, and joint aspiration. Diagnosis of gout excluded refer urgently to Psoriatic arthritis and pseudo-gout is made by Rheumatologist for aspiration and Rare examination of joint fluid by polarised diagnosis- Urgent.
• Ankylosing Spondylitis, avascular light microscopy. Refer to specialist for aspiration and/or necrosis If confirmed pseudo-gout: treat with injection for difficult anatomical sites or Consider pseudo-gout: • intra-articular steroidal injection. problems requiring particular expertise Blood: FBC, ESR, CRP, uric acid, Ca2+ Urgent - Semi-urgent. • Urine: PCR (Chlamydia / Gonorrhoea)
Revised December 2014
CPAC Guidelines - Rheumatology
Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Subacute Single or Several Joints Osteoarthritis History: Simple analgesia (Paracetamol) Uncertain diagnosis Semi-urgent. • Oligoarticular synovitis • Trauma NSAID Local injection therapy Routine. • Intercritical Gout • Psoriasis Physiotherapy referral Refer patients with oligoarticular Rare • Colitis synovitis - Urgent - Semi-urgent. • Tumour (Primary or Secondary) • GU/GI Infection
Exam: • Synovial swelling • Joint tenderness • Other joints
X-Ray: • Affected joint
Bloods: • FBC, ESR, CRP, LFTs, Ca, uric acid, RF, ACPA • Consider joint aspiration Multiple Joints Rheumatoid Arthritis History: Early referral to rheumatology All cases of polyarticular synovitis • As above service. should be assessed by the SLE / Connective tissue disorder - • Include family history Institute NSAID. rheumatology service - Urgent - • Psoriatic arthritis. • Systemic symptoms Semi-urgent. • Pattern of joint involvement
Exam: • Rashes • Anatomical swelling (c.f oedema) • BP
Bloods: • FBC, ESR, RF, ACPA, ANA, U&Es, LFTs, CRP • Urinalysis.
Revised December 2014
CPAC Guidelines - Rheumatology
Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Reactive Arthritis History Refer to rheumatology service Urgent • GU/GI infection – Semi-urgent. • Family history • Back pain/stiffness
Polyarticular Gout History Refer to rheumatology service Semi- NSAID/Colchicine • Aspirate joint for crystals urgent – Routine. Consider Allopurinol
Multisystem / Connective Tissue Disease SLE (uncommon) • False positive tests common Beware high dose Prednisolone Referral to rheumatology service • None of these conditions can be (>20mg). Urgent - Semi-urgent. Others are rare: diagnosed by a single test Consider high dose prednisolone (50 Referral to rheumatology service • Scleroderma • Raynaud’s Phenomenon often – 75mg). Urgent. • Poly/Dermatomyositis associated • Sjogren’s Syndrome Investigations: Vasculitis • FBC/ESR/CRP//LFTs/U&Es/Ca2+/CK/ • Giant Cell Arteritis ANA/MSU/urine prot:creat ratio • Full history and physical exam Others are rare: • Takayasu's arteritis Reasonable initial investigations: • Polyarteritis nodosa • FBC, ESR, CRP, U&Es, LFTs, CK, • Wegener’s granulomatosis ANA, ANCA • Churg-Strauss vasculitis • MSU, urine prot:creat ratio • Behet's disease • CXR
Revised December 2014
CPAC Guidelines - Rheumatology
Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Muscular Aches and Pain Polymyositis/Dermatomyositis • Weakness (rising unassisted from Refer to rheumatology service
chair) Urgent. • Muscle tenderness • Raised CK, ESR, CRP • Rash Polymyalgia Rheumatica / giant cell • Muscle pain and morning stiffness Symptoms of giant cell arteritis Refer to rheumatology service arteritis (marked) shoulders and hips mandate urgency Urgent if GCA suspected. • No true weakness Therapeutic trial of medium dose Otherwise Semi-urgent. • Raised ESR Prednisone (15-20mg daily) for PMR • Normal CK • Consider symptoms of headaches • Consider symptoms of Amaurosis Fugax Fibromyalgia • Morning stiffness/fatigue. Patient education Uncertain diagnosis Routine. • Widespread myalgias. Low dose tricyclic antidepressants Multidisciplinary rehabilitation • Tender points. Simple analgesia Routine. • Disturbed sleep pattern. Lifestyle counselling • Normal ESR.CK. • No clinical weakness. Osteoporosis / Metabolic Bone Disease Postmenopausal osteoporosis History: Consider bisphosphonates/strontium/ Management of complicated or • Secondary Osteoporosis • Family history denosumab as per PBS guidelines atypical presentations Semi-urgent – (inflammatory arthritis, steroid • Age at menopause Dietary and exercise advice Routine. therapy) • Fracture Cessation of smoking, limiting alcohol • Osteomalacia • Dietary Ca2+ Optimise dietary Ca and Vit D and • Paget's Disease • Steroid therapy supplement as required
Exam: • Vertebral deformity
Revised December 2014
CPAC Guidelines - Rheumatology
Diagnosis / Symptomatology Evaluation Management Options Referral Guidelines Osteoporosis / Metabolic Bone Disease (continued) Investigations: • BMD (dexa) • XR • Ca”, PO4, thyroid, Vit D, U&Es, LFTS, FBC, ESR, CRP • Androgens in males • Consider pathologic fracture
Periarticular / Soft Tissue Rheumatism Shoulder Rotator Cuff History: Local injection therapy Uncertain diagnosis Semi-urgent - • Tennis/Golfer's Elbow • Trauma NSAID Routine. • Anserine Bursitis • Occupation Physio of doubtful value save ROM Local injection Routine. and strengthening exercises Failure to settle Routine. • Trochanteric Bursitis • Pain pattern Consider splinting • Carpal tunnel syndrome
• Plantar Fasciitis etc. Exam: • Normal passive • ROM • Clinical diagnosis
Investigations - • FBC/ESR/XR if fails to settle Rheumatological Rehabilitation Chronic Arthritis • Established diagnosis • Education (Arthritis Foundation) Significant disease or disability • RA • Progressive worsening of disability • Physiotherapy assessment Semi-urgent. • Multijoint OA • Threat to independence • Occupational Therapy Lack of comprehensive local support systems Routine. • Mnkylosing spondylitis • Difficulty with primary economic assessment • Psoriatic arthritis activity • (including work options) • Polyarticular gout • Need for help with self-management • Self-management skills • Joint hypermobility syndrome • Lifestyle counselling • Recent onset Arthritis. • Orthotic Assessment.
Revised December 2014