Inflammatory arthritis is a collective term for a group of conditions, including rheumatoid arthritis (RA) and spondyloarthritis (SpA), that cause inflammation of the tissues around affected joints.
RA is an autoimmune condition, where the body’s immune system mistakenly attacks the joints.
SpA refers to several inflammatory conditions with shared features. These are further divided into those that most commonly affect the spine, termed axial SpA, and those that primarily affect other areas as well as joints, such as psoriatic arthritis (skin) and enteropathic arthritis (bowel), termed peripheral SpA.
390,000 people are living with rheumatoid arthritis in the UK. Source: Global Health Data Exchange, 2019
Inflammatory arthritis has a range of genetic and environmental risk factors. RA onset peaks between 40 and 60 years of age, and is more common in women, people who smoke, and people who are obese. Axial SpA usually begins between 20 and 30 years of age, is equally common in men and women, and can be more severe in people who smoke. (Versus Arthritis, State of Musculoskeletal Health, 2021.
Diagnoses of people referred into rheumatology with suspected inflammatory arthritis
Early diagnosis of inflammatory arthritis is an important factor in determining long-term patient outcomes, as symptoms can be greatly reduced or completely remitted with early treatment. Recommendations on the referral and diagnosis of inflammatory arthritis are included in our guideline on RArheumatoid arthritis and guideline on SpAspondyloarthritis.
To ensure an accurate and timely diagnosis, our quality standard on RArheumatoid arthritis states that adults with suspected persistent joint inflammation (synovitis) in more than 1 joint, or the small joints of the hands and feet, should be referred to rheumatology services within 3 working days of presenting in primary care. Similarly, our quality standard on SpAspondyloarthritis states that adults with suspected axial or peripheral SpA should be referred to a rheumatologist.
Data from the 2020 British Society for Rheumatology National Early Inflammatory Arthritis (NEIA) Audit shows that the proportion of people with suspected early inflammatory arthritis (EIA) in England and Wales that were referred into rheumatology services within 3 working days increased between 2019 and 2020.
The proportion of people with suspected persistent joint inflammation that were referred into rheumatology services within 3 working days has increased
Once referred, people with suspected persistent joint inflammation should be assessed in a rheumatology service within 3 weeks. Data from the 2020 NEIA audit shows that the number of people referred with suspected EIA being assessed in rheumatology within 3 weeks has increased.
The proportion of people with suspected persistent joint inflammation assessed in rheumatology services within 3 weeks of referral has increased
Source: British Society for Rheumatology, NEIA Audit, 2021
Delayed referral for axial spondyloarthritis
Axial SpA is a progressive form of inflammatory arthritis that mainly affects the spine, causing stiffness and pain in the lower back and hips. Improving the recognition and referral of axial SpA is important because starting treatment quickly limits damage to the spine and joints, reducing the long-term impact of the disease.
220,000 people are living with axial spondyloarthritis in the UK. Source: Versus Arthritis, State of Musculoskeletal Health, 2021
24 years: average age of symptom onset. Source: APPG for Axial SpA Report, 2020
8.5 years: average delay between symptom onset and diagnosis Source: APPG for Axial SpA Report, 2020
Our guideline on SpA and our quality standard on SpA provide a framework for the commissioning and provision of services for people with axial SpA, as well as other forms of SpA. The 2020 All-Party Parliamentary Group (APPG) for Axial SpA report, Axial Spondyloarthritis services in England, A National Enquiry looks at progress towards implementing our guidance.
Diagnostic delay is common for people with axial spondyloarthritis
Source: Russell et al, Rheumatology, 2021
I saw every healthcare professional you can think of – osteopaths, physios, rheumatologists… I had MRIs, X-rays, blood tests… If I knew then, what I know now about axial spondyloarthritis, I’d have known straight away that it’s what I had. My symptoms were textbook. Eventually, an MRI scan picked up on fusion in my spine and a rheumatologist diagnosed axial SpA.
We recommend that adults with suspected axial SpA should be referred to a rheumatologist, indicating the need for a specific referral pathway from primary to secondary care for inflammatory back pain. The APPG for axial SpA report shows that only 21% of clinical commissioning groups (CCGs) have a specific pathway in place. Some CCGs indicated that they had alternative arrangements, such as referral to musculoskeletal triage services, however this could increase time to diagnosis.
It is also important that commissioners have programmes to raise awareness of the signs and symptoms of axial SpA in primary care, as recommended by NICE. However, of the 44% (85/191) of CCGs that responded, only 34% (29/85) had these programmes in place
Insight from Zoë Chivers
Early diagnosis and intensive treatment for inflammatory arthritis is key to improving long-term outcomes and the patient experience. Currently only 48% of patients referred for suspected early inflammatory arthritis are seen within 3 weeks.
Failure to recognise the signs and symptoms of inflammatory arthritis in primary care, combined with a lack of urgent referral to specialist care, lead to delays in accessing specialist care. Workforce shortages across rheumatology, and significant regional variations in staffing levels, are also leading to unnecessary delays in assessment and diagnosis, which can result in worse patient outcomes. Shortages also make it harder to provide the treatment needed to achieve remission and prevent long-term disability.