Kennebec Region Health Alliance

Background:

Arthritis and musculoskeletal pain are among the most common chief complaints in primary care clinics. MaineGeneral rheumatologists are available to help providers diagnose and treat patients with inflammatory arthritis, systemic autoimmune connective tissue diseases and vasculitis, musculoskeletal pain, soft tissue rheumatism, and unexplained systemic symptoms and findings. Early diagnosis and treatment have been shown to improve long-term outcomes in many of these conditions, so these general referral guidelines are intended to improve the efficiency of the consultative process and to assure that urgent consultations are appropriately prioritized.

Indications for referral include patients with established or suspected:

1. Inflammatory arthritis (RA, PsA, AS, Lyme arthritis, et. al.)
2. Systemic autoimmune connective tissue diseases (SLE, polymyositis, MCTD, et. al.)
3. Vasculitis and related syndromes (GCA, PMR, ANCA, et. al.)
4. Gout and other crystal-induced arthropathy
5. Sarcoidosis
6. Unexplained multi-system illnesses or laboratory abnormalities with symptoms and/or findings suggestive of an autoimmune process
7. Soft-tissue rheumatism (tendinitis, bursitis, etc.)

Pre-referral evaluation and treatment:

Appropriate pre-referral laboratory/imaging should be based on the clinician’s thorough history and physical examination and depends upon the nature of the patient’s problem(s). Most referred patients should have a recent CBC, CMP, urinalysis, and both ESR and CRP. Beyond these basic studies, additional initial laboratory testing should be considered based upon the diagnosis under consideration. As examples:

1. Inflammatory polyarthritis: Rheumatoid factor and ACPA (CCP antibody)
2. Crystal related arthritis: uric acid
3. SLE, MCTD, Sjogren’s: ANA with titer, ENA (if ANA is positive), and C3 and C4 complements
4. Myositis: CK and aldolase
5. Vasculitis: ANCA, PR-3, MPO, C3 and C4 complements, and biopsy of affected tissue(s) when possible
6. Lyme arthritis: Lyme serologies

In addition, we have the following recommendations on appropriate pre-consultation lab/imaging ordering:

1. Avoid ordering broad laboratory panels (i.e. rheumatoid panel/immune survey) as these are costly, generally unnecessary, and provide information that is often not clinically useful.
2. Limit laboratory testing to studies that are relevant to the practitioner’s clinical impression.
3. Certain studies (e.g. RF, ANA, HLA-B27) do not need to be re-ordered unless patient’s symptom(s) significantly change.
4. Avoid x-ray studies for early arthritis, as they are seldom helpful.
5. Do not order an MRI to evaluate possible synovitis. The rheumatology clinic now has musculoskeletal ultrasound capabilities, and we are happy to perform appropriate US on referred patients.

If you have specific questions regarding what to order prior to referral, please call the Rheumatology clinic at 207-621-9580.

When to call (to receive treatment recommendations and/or earlier appointment):

Certain patients require urgent/emergent consultation and may require immediate therapeutic or diagnostic interventions. Please call rheumatology to discuss appropriate immediate care. Urgent/emergent consultation may be necessary for the following:

1. Acute, unexplained inflammatory mono-articular arthritis with or without systemic symptoms - emergent
2. Possible temporal arteritis or systemic vasculitis - emergent
3. For suspected temporal arteritis, please simultaneously refer for bilateral temporal artery duplex and to vascular surgery for bilateral temporal artery biopsies
4. New onset or early untreated inflammatory polyarthritis - urgent
5. Possible clinically active SLE or autoimmune disease with systemic manifestations - urgent

When possible, avoid high dose corticosteroids (e.g. prednisone, Medrol dosepak, etc.) therapy prior to consultation, unless discussed with a rheumatologist.

Ideal coordinated care requires teamwork between primary care clinicians and specialists. Rheumatologists will usually continue to follow patients with inflammatory conditions and will assume responsibility for primary management of these rheumatologic problems. Primary care clinicians play a critical role in assuring that co-morbidities are assertively managed and in assuring that necessary preventive health interventions (e.g. immunizations and surveillance screenings) are accomplished. Patients who do not require on-going rheumatology follow-up (e.g. fibromyalgia, low back pain, chronic pain syndromes) will be referred back to their primary care clinicians with advice and recommendations for the subsequent care of their musculoskeletal symptoms.