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Suspected Rheumatoid Arthritis in PLAB 2: Safe GP Management and Early Referral Tips

Updated: Jun 26

In a suspected rheumatoid arthritis (RA) case, the General Practitioner (GP) has a structured role focused on early identification and appropriate referral:


1. Initiating Treatment (DMARDs or Steroids)

  • GPs do not initiate DMARDs (like methotrexate) or long-term steroids. These are started by rheumatologists after thorough assessment.

  • Short course of oral steroids (e.g. prednisolone) may be considered in some cases by GPs if there is a delay in specialist review, and if there's high suspicion of inflammatory arthritis, but this should be done with caution and ideally discussed with rheumatology.


2. Pain Management

  • GPs can start painkillers such as NSAIDs (e.g. ibuprofen, naproxen) or paracetamol to manage symptoms before specialist referral. This is to relieve discomfort, not to treat the disease process.


3. Investigations in GP Setting

  • Blood Tests:

    • Anti-CCP antibodies and Rheumatoid Factor (RF) can be requested by GPs if RA is suspected.

    • Inflammatory markers like ESR and CRP are also typically checked.

  • X-rays:

    • GPs may request X-rays of the hands and feet, but this is not always necessary before referral. Imaging is more commonly arranged by rheumatology.


4. Referral

  • Urgent referral to rheumatology should be made if inflammatory arthritis is suspected, especially if symptoms have been present for less than 12 weeks. Early treatment improves long-term outcomes.


If rheumatoid arthritis (RA) is suspected—even if inflammatory arthritis isn't confirmed yet—it is still considered a potential inflammatory arthritis, and urgent referral to rheumatology is recommended under NICE guidelines.

Here's the breakdown:

  • Suspected RA = Suspected inflammatory arthritis until proven otherwise.

  • Therefore, the correct type of referral is urgent (typically within 3 weeks).

This is because early RA can cause joint damage within the first few months, and early specialist assessment and initiation of DMARDs can significantly alter the disease course.


Musculoskeletal ultrasound scanning is routinely used at the assessment stage to aid in early and accurate diagnosis.


PLAB 2 Tip:


In a station, even if symptoms are vague but suggestive of RA (e.g., morning stiffness >30 minutes, small joint involvement, bilateral symptoms), always recommend urgent referral to rheumatology. Do not delay for tests or watchful waiting unless clearly instructed to do so. This reflects safe and proactive clinical judgement.


In a PLAB 2 station, if you’re acting as a GP and see a patient with suspected RA, do not offer DMARDs or long-term steroids. Explain that you'll initiate symptomatic treatment and urgently refer to a specialist. Demonstrate understanding of NICE guidelines and early intervention principles. This shows safe, evidence-based decision-making.


📚 References


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