Diagnosis and early initiation of disease modifying antirheumatic drug (DMARD) therapy for rheumatoid arthritis (RA) leads to improved long-term outcomes.1,2 This places a burden on primary care physicians (PCPs) to identify disease early and then initiate referral to rheumatology for further care.
To date, this paradigm has been the typical pathway of RA management, largely because the perceived and real toxicities of DMARDs have made many PCPs understandably uncomfortable with their use without direct guidance from a rheumatologist.
Given the realities of current long wait times for rheumatology visits in many areas, insurance issues, and worsening workforce issues likely in the near future, the paradigm may need to change. PCPs may play a greater role in the initiation of long-term therapy as well as management.
The PCP's typical RA referral
The following are included in a referral to rheumatology for suspected RA:
• History and physical examination, with attention to the joint examination and tender and swollen joints.
• Laboratory findings, such as rheumatoid factor (RF) and antibodies to citrullinated protein antigens (ACPA).
• Inflammatory test results, such as the erythrocyte sedimentation rate and C-reactive protein level.
• Results of other autoimmune testing (eg, antinuclear antibody testing).
• Lab results from complete blood cell counts, metabolic panels, and infection testing (eg, hepatitis B and C, HIV, and tuberculosis), which can help the rheumatologist assess the patient’s overall health and potential safety issues regarding treatment.
• Results of imaging. If possible, have the patient hand-carry the images to the rheumatologist.
• Documentation of any treatments that have been provided and their efficacy.
1. Smolen JS, Aletaha D, McInnes IB. Rheumatoid arthritis. Lancet. 2016;388:2023-2038.
2. Espinoza F, Fabre S, Pers YM. Remission-induction therapies for early rheumatoid arthritis: evidence to date and clinical implications. Ther Adv Musculoskelet Dis. 2016;8:107-118.
3. Singh JA, Furst DE, Bharat A, et al. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res (Hoboken). 2012;64:625-639.