History
- Joint pain stiffness and swelling in a symmetrical distribution affecting the wrists, MCP and PIP joints of the hands and MTP joints of the feet. Large joints may also be affected.
- Early morning stiffness (typically >30min)
- Inactivity gelling (stiffness after a period of inactivity)
Examination
- Soft tissue swelling and tenderness of affected joints
- Pain on squeezing MCP and MTP joints (the squeeze test).
Investigations
- FBC, ESR, LFT,
- Anti-CCP antibodies
- X-ray of the hands (periarticular osteoporosis, erosions)
| JOINT DISTRIBUTION (0-5) | |
|---|---|
| 1 large joint | 0 |
| 2-10 large joints | 1 |
| 1-3 small joints (large joints not counted) | 2 |
| 4-10 small joints (large joints not counted) | 3 |
| >10 joints (at least one small joint) | 5 |
| SEROLOGY (0-3) | |
|---|---|
| Negative RF AND negative ACPA | 0 |
| Low positive RF OR low positive ACPA | 2 |
| High positive RF OR high positive ACPA | 3 |
| SYMPTOM DURATION (0-1) | |
|---|---|
| <6 weeks | 0 |
| ≥6 weeks | 1 |
| ACUTE PHASE REACTANTS (0-1) | |
|---|---|
| Normal CRP AND normal ESR | 0 |
| Abnormal CRP OR abnormal ESR | 1 |
M.A & S.R/H.B. 25-01-24
When to refer:
Patients with swollen joints, significant morning stiffness. Refer for urgent appointment if scoring( above) is high.
Main differential diagnoses
Viral arthritis – Can present similarly but usually resolves within 4-6 weeks
Osteoarthritis – The distribution is different (affects DIP, PIP and 1st CMC joints of the hands). There is bony joint swelling due to osteophytes. Levels of ESR and CRP are normal and CCP is negative.
Psoriatic arthritis – the distribution is different and CCP is negative.
Initial management
Treat symptoms with NSAID / and or analgesics pending clinic review.
Please avoid giving corticosteroids.
If patient is very symptomatic or has systemic features please discuss with on-call team for an early appointment.
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