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Kim's action plan

Back to Case study – Kim

You should refer Kim because there's good evidence that early treatment offers prognostic benefits.

Your local pathways may determine what tests you can use to help your patient access a specialist opinion. But NICE guidance suggests it's desirable to refer patients even where blood tests show a normal acute-phase response or negative rheumatoid factor.

NICE guidance

NICE guidelines CG79 and quality statement QS33 suggest that you should refer any patient with suspected persistent synovitis of undetermined cause for referral.

The patient should be referred urgently (within three working days) if any of the following apply:

  • the small joints of the hands or feet are affected
  • more than one joint is affected
  • there's been a delay of three months or more between onset of symptoms and seeking medical advice.


X-rays are unlikely to be helpful in deciding whether or not to refer, since the erosive changes associated with rheumatoid arthritis may not be apparent for up to two years. If you do see erosions on a patient’s x-ray the patient should be referred urgently.

Action plan

Most patients with (suspected) inflammatory arthritis will need treatment while waiting for a specialist opinion. It's appropriate to give the patient NSAIDs and analgesia, taking into account the severity of their symptoms and any applicable contraindications or tolerance issues.

You may want to consider prescribing steroids. You should advise the specialist as steroids will mask symptoms when the patient is seen in secondary care and could potentially make diagnosis more difficult.

Back to Case study – Kim

Referral and further action

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Referral to secondary care may be required for diagnosis and/or treatment and may be appropriate even where a condition can normally be managed in primary care.

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