Buku Medicine

Acutely swollen joint

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New polyarthritis

General principles

Early introduction of DMARDs in rheumatoid arthritis prevents joint damage and improves long-term outcomes. As such, NICE states that all adults with persistent synovitis of undetermined cause should be referred urgently if any of the following apply: 

  1. The small joints of the hands or feet are affected 

  1. More the one joint is affected 

  1. There has been a delay of ≥3 months between symptom onset and seeking medical advice 

Referral pathways vary nationally but often Rheumatology departments will have an Early Arthritis Clinic service to see patients fulfilling these criteria urgently. 

Useful investigations 

  • Bloods 

  • FBC, U&Es, LFTs (this is not only helpful in diagnosis and ruling out other causes, but is also useful to have when starting new medication in clinic) 

  • Inflammatory markers – CRP and ESR 

  • Autoantibodies – rheumatoid factor and anti CCP antibody (ACPA) 

  • Others – consider urate if gout is possible 

  • Imaging – often not needed in primary care and should not delay referral - patients with suspected inflammatory arthritis will get XRs of hands and feet as a baseline investigation and most will get a musculoskeletal ultrasound 

Treatment (while awaiting rheumatology review) 

  • Rest and ice 

  • NSAIDs if not contraindicated (e.g. naproxen 250-500mg BD with PPI cover) 

  • Discuss with local rheumatologist if this is not sufficient while waiting for review. Corticosteroids can be helpful but it is often better for rheumatology to assess the patient first 


NICE (2018a) Rheumatoid arthritis in adults: management. National Institute for Health and Care Excellence. http://nice.org.uk [https://www.nice.org.uk/guidance/ng100] 



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