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REMEDY : BNSSG referral pathways

Early Inflammatory Arthritis (EIA)

Checked: 29-10-2018 by vicky.ryan Next Review: 29-10-2019

Service Overview

It is widely recognised that delays in the diagnosis and treatment of rheumatoid arthritis has long term consequences on joint damage and quality of life for patients. It is therefore important that the symptoms and signs of possible inflammatory arthritis are recognised early and urgently referred for further assessment and treatment.

All patients with persistent synovitis of the small joints of the hands, feet or more than one large joint should be referred urgently to an Early Inflammatory Arthritis (EIA) service. Symptoms of persistent synovitis are pain, heat and/or swelling of joints with more than 30minutes of early morning joint stiffness.  Synovitis can be difficult to detect particularly in the early stages, therefore if patients are tender when squeezed across the metacarpophalangeal or metatarsophalangeal joints then there should be a low threshold for referral to rheumatology.  Rheumatoid arthritis is a systemic illness, therefore patients also often report features such as fatigue, fevers and weight loss.  Other features that might suggest early inflammatory arthritis include joint stiffness following periods of immobility, significant benefit with NSAIDs and a strong family history.

The rheumatology departments in UHB, NBT and Weston have developed Early Inflammatory Arthritis (EIA) services in line with NICE and BSR guidelines.

All referrals are triaged by the consultants and we aim to see suspected early inflammatory arthritis cases within 3 weeks from receipt of referral.  Referrals should be submitted with a completed proforma.  There are slots available on the e-referral service that can be directly referred into – it is important that patients referred into the slots meet the referral criteria. Those that don’t will be rejected and triaged into general rheumatology clinics, which may cause undue concern and distress to patients, particularly as there is often a longer wait for these clinics.


Referral Guidance

Refer using the EIA Proforma (word doc) Further clinical information and past medical history can be added the box at the bottom of the referral proforma, or submitted in a separate clinical letter.

Referral criteria

Please refer patients with suspected persistent joint inflammation of 4 weeks or more AND any one of the following:

  • Swelling of 3 or more joints

  • Swelling of the small joints of hands or feet

  • Positive MCPJ or MTPJ “Squeeze test” (i.e. pain produced by squeezing across the metacarpophalangeal/metatarsophalangeal joints)

  • Early morning joint stiffness (EMS) >30mins

UHBristol will accept referrals for the EIA service via the e-referral system only. For any queries please email:

Patients not meeting the EIA referral criteria should be referred to general rheumatology clinics.


Further Advice

  • The service recommends investigations such as inflammatory markers and X rays of hands and feet (see proforma for further details) but there is no need to wait for results prior to referral. These investigations will be helpful in making a rapid assessment in clinic.

  • Please note, the diagnosis of EIA is not excluded by normal inflammatory markers and / or a negative rheumatoid factor and/or normal X-rays.

  • Please refrain from using steroids until the patient has been seen in clinic as this can delay diagnosis and commencement of appropriate treatment.

The service aims to make a diagnosis and start disease-modifying drugs within 6 weeks from time of referral or discharge patients back if not EIA. People diagnosed with EIA have regular clinical reviews by the multidisciplinary team for education, self-management, monitoring of disease activity, therapeutic benefit and treatment safety.