Arthritis

When Should Arthritis Patients Be Referred to a Rheumatologist?

Patients with arthritis should be referred to a rheumatologist within the first 6 weeks following symptom onset, according to the first recommendation of the European League Against Rheumatism.

Despite this guidance, little evidence supporting this time frame is currently available, making the implementation of this recommendation difficult, according to the authors of a recent study.

For this reason, they conducted an observational cohort study of 1539 patients with rheumatoid arthritis (1025 from the Leiden Early Arthritis Clinic [EAC] and 514 from the French Etude et Suivi des Polyarthrites Indifferenciées Recentes [ESPOIR] who were categorized based on the time between onset of symptoms and their first visit to a rheumatologist. The main outcomes of the study were sustained disease-modifying antirheumatic drug (DMARD)-free remission and radiographic progression.

After 7 years of follow-up in the EAC, rates of sustained DMARD-free remission were as follows:

  • 30 (24%) of 127 patients with time to rheumatologist visit of 6 weeks or less
  • 45 (20%) of 223 patients with time to rheumatologist visit of 7 to 12 weeks
  • 100 (15%) of 675 patients with time to rheumatologist visit of more than 12 weeks


After 10 years of follow-up in the ESPOIR, rates of sustained DMARD-free remission were as follows:

  • 3 (27%) of 11 patients with time to rheumatologist visit of 6 weeks or less
  • 11 (11%) of 100 patients with time to rheumatologist visit of 7 to 12 weeks
  • 41 (10%) of 403 patients with time to rheumatologist visit of more than 12 weeks


In the EAC analysis, patients in the 6-week group had sustained DMARD-free remission more often than those in the 7- to 12-week group (hazard ratio [HR] 1.59), and the more than 12-week group (HR1.54). In the ESPOIR analysis, patients in the 6-week group also had more frequent DMARD-free remission, but the results were not significant (HR 2.81 compared with those in the 7 to 12 weeks group and HR 3.05 compared with those in the more than 12 weeks or more group).

Seeing a rheumatologist within 6 weeks was not associated with less radiographic progression than that seen in patients in the 7 to 12 weeks group but was associated with less progression than that seen in patients in the 12 weeks or more group.

—Michael Potts

Reference:

Niemantsverdriet E, Dougados M, Combe B, van der Helm-van Mil AHM. Referring early arthritis patients within 6 weeks versus 12 weeks after symptom onset: an observational cohort study. Published online April 28, 2020. Lancet Rheum. doi: 10.1016/S2665-9913(20)30061-8