Rheumatology Clinic

Rheumatology Referral Guidelines

Scope:

• To focus on inflammatory and autoimmune conditions that require management with immunosuppressive medications
• To avoid duplicate or unnecessary diagnostic testing

Appropriate patients for referral include:

1) Inflammatory Arthritis

• • Definition: joint swelling, warmth, effusion, and/or tenderness on exam; significant stiffness in affected joints that generally improves with activity, not worsens.
  • Conditions
    • Inflammatory arthritis NOS
    • Rheumatoid arthritis
    • Seronegative spondyloarthropathy
      • Psoriatic arthritis
      • Reactive arthritis
      • IBD-associated arthritis
      • Ankylosing spondylitis
    • Crystalline arthropathy
      • Gout – tophaceous gout, or repetitive flares DESPITE urate lowering therapy
        • DO NOT REFER patients without complicated gout as above – see below re tips for management
      • Calcium pyrophosphate deposition disease (pseudogout)
    • Juvenile idiopathic arthritis (juvenile rheumatoid arthritis) – if age >18yo
  • Helpful studies to obtain prior to referral
  • CBC w/ diff, CMP, ESR, CRP
  • RF, anti-CCP, ANA
  • HCV/HBV/HIV screening
  • Uric acid level (for gout)
  • X-rays of involved joints; if rheumatoid arthritis, please get bilat hand AND feet xrays (needed for baseline)

2) Lupus

• Conditions
  • Systemic lupus erythematosus
  • Cutaneous lupus (eg. discoid lupus, subacute cutaneous lupus erythematosus)
  • Drug-induced lupus
  • Mixed connective tissue disease
  • Undifferentiated connective tissue disease
• Helpful studies to obtain prior to referral
  • CBC w/ diff, CMP
  • ANA, dsDNA, Sm/RNP, Ro/La, C3, C4, lupus anticoagulant, anti-beta2-glycoprotein IgA/IgM/IgG, anti-cardiolipin IgA/IgM/IgG
  • UA, random urine protein:Cr ratio (note – this is different than microalbumin)
  • If already done: renal bx and skin bx pathology reports

3) Systemic Sclerosis (Scleroderma)

• Conditions
  • Diffuse/limited cutaneous systemic sclerosis (scleroderma)
  • Scleroderma mimics
    • Scleredema
    • Scleromyxedema
    • Eosinophilic fasciitis
    • Localized scleroderma (morphea)

• Helpful studies to obtain prior to referral
  • CBC w/ diff, CMP
  • ANA, dsDNA, Scl-70, Sm/RNP, Ro/La, C3, C4, CK, lupus anticoagulant, anti-beta2-glycoprotein IgA/IgM/IgG, anti-cardiolipin IgA/IgM/IgG
  • UA, random urine protein:Cr ratio (note – this is different than microalbumin)
  • If already done: CT chest w/o contrast, PFTs, TTE

4) Inflammatory Myopathy (Myositis)

• Conditions
  • Polymyositis
  • Dermatomyositis
  • Autoimmune necrotizing myopathy
  • Inclusion body myositis
• Helpful studies to obtain prior to referral
  • CBC w/ diff, CMP
  • CK
  • ANA, Sm/RNP, Ro/La, anti-Jo-1
  • If already done: EMG/NCS studies, MRI deltoid/thigh, CT chest w/o contrast, PFTs, TTE

5) Vasculitis

• Conditions
  • Giant cell arteritis
  • Takayasu’s
  • Polyarteritis nodosa
  • Cryoglobulinemic vasculitis
  • IgA vasculitis (Henoch-Schönlein Purpura)
  • Thromboangiitis obliterans (Buerger’s Disease)
  • ANCA-associated vasculitis
    • Granulomatosis with polyangiitis (Wegener’s)
    • Eosinophilic granulomatosis with polyangiitis (Churg Strauss)
    • Microscopic polyangiitis
  • Leukocytoclastic vasculitis
  • Urticarial vasculitis
  • Behçet’s Disease
• Helpful studies to obtain prior to referral
  • CBC w/ diff, CMP, ESR, CRP
  • UA, random urine protein:Cr ratio (note – this is different than microalbumin)
  • C3/C4
  • C-ANCA and p-ANCA with proteinase 3 and myeloperoxidase
  • HCV/HBV/HIV screening
  • If already done: CT angiograms, MR angiograms, renal bx or skin bx pathology reports, CT sinus or chest w/o contrast

6) Miscellaneous Rheumatology

• Conditions
  • Polymyalgia rheumatica à CBC w/ diff, CMP, ESR, CRP, RF/anti-CCP
  • IgG4-related disease
  • Adult Onset Still’s Disease
  • Relapsing polychondritis
  • Raynaud’s phenomenon
  • Sjögren’s Syndrome à ANA, dsDNA, Sm/RNP, Ro/La, c3/c4, UA, urine protein:Cr ratio, quantitative immunoglobulins, SPEP with IFE, UPEP with IFE, free light chain (kappa/lambda) ratio
  • Antiphospholipid antibody syndrome – positive serology (+lupus anti-coagulant, +anti-cardiolipin ab and/OR +anti-beta2-glycoprotein ab…WITH arterial/venous clots and/OR obstetric complications)

Please do not refer the following patients:

• Osteoarthritis → orthopedic surgery if end-stage; see PCP medical mgmt tips below otherwise
• Vertebral osteoarthritis = degenerative disc disease, spinal stenosis → orthopedic spine surgery or neurosurgery if focal neurologic deficits (do not refer for pain only)
• Fibromyalgia → see PCP medical mgmt tips below
• Sports medicine or musculoskeletal overuse injuries → orthopedic surgery and/or PT
• complex regional pain syndrome (reflex sympathetic dystrophy) → chronic pain clinic
• Chronic headache → neurology
• Sarcoidosis → pulmonology
• Myasthenia gravis → neurology
• Multiple sclerosis → neurology
• Genetic/heritable connective tissue disorders (eg. Ehlers-Danlos) → genetics, or PT for joint protection teaching if arthralgia
• Primary immunodeficiency syndromes (eg. common variable immunodeficiency = CVID) → allergy/immunology
• Chronic pain
• Chronic fatigue
• Uncomplicated gout (see above – please do not refer unless failing conventional urate lowering therapy, or tophi are present) __. See PCP medical mgmt tips below
• Positive ANA without other symptoms of autoimmune disease; fatigue alone is not sufficient
• Positive RF without inflammatory joint pain (see above)
• Elevated ESR/CRP in isolation
• Elevated CK in the absence of muscle weakness; or in the setting of acute trauma, alcohol intake, or drug use (acute rhabdomyolysis)

Documentation required for scheduling appointments:

• Past Medical History and Current Medication List
• Most recent clinic note clearly documenting reason for referral, current complaints
• Discharge summary if admitted within last 6 months
• Most recent labs, imaging studies, pathology reports, etc. IF ALREADY AVAILABLE (see Helpful Studies to obtain prior to referral)

General PCP Tips for Management:

• Gout
  • Diagnosis – monosodium urate crystals in synovial fluid is gold standard; reasonable to treat empirically if clinical hx of podagra with elevated uric acid levels.
  • Treatment
    • Flare
      • Colchicine 0.6mg bid x5d if GFR wnl; use prednisone 40mg x5d if not (colchicine is contra-indicated in CKD)
      • DO NOT stop allopurinol/febuxostat during a flare if already on it – will cause further shifts in uric acid concentration and PROLONG the flare!
    • Maintenance: AFTER the flare has subsided, start…
      • GFR wnl
        • Allopurinol 300mg daily + colchicine 0.6g daily as flare ppx (risk of flares when starting allopurinol due to shifts in uric acid concentration)
        • Check uric acid levels every 6 weeks and uptitrate allopurinol by 100mg at a time until uric acid level<6.0. Max allopurinol dose is 900mg
      • CKD – with any GFR
        • Allopurinol 50mg daily + prednisone 5mg daily as flare ppx
        • Check uric acid levels every 6 weeks and uptitrate allopurinol by 50mg at a time until uric acid level<6.0. Max allopurinol dose is 900mg
        • NOTE – allopurinol is NOT nephrotoxic and NOT contraindicated in CKD – just needs to be started low and slow due to slight increased risk of allopurinol hypersensitivity syndrome. If cannot get uric acid to goal with allopurinol, reasonable to switch to febuxostat 40mg daily → increase to 80mg daily if needed.
• Osteoarthritis
  • See American College of Rheumatology Guidelines:
    • https://www.rheumatology.org/Practice-Quality/Clinical-Support/Clinical-Practice-Guidelines/Osteoarthritis
  • General
    • Acetaminophen 1000mg TID → NSAIDs (COX2 inhibitor might be preferred – recent data do not suggest increased cardiac risk) → tramadol/narcotics AS LAST RESORT
    • Physical therapy and weight loss are paramount
    • Obtain xrays — if severe disease, obtain orthopedic surgery consult regarding possible joint replacement (if pt interested in surgery)
• Fibromyalgia
  • Patient education
    • https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia
    • https://fibroguide.med.umich.edu/
    • https://www.fmaware.org/
  • Non-pharmacologic interventions
    • Tai Chi — see landmark NEJM article. Wang C et al. A randomized trial of Tai Chi for fibromyalgia. NEJM. 2010.
  • Pharmacologic interventions – only helpful for about 30% of patients
    • FDA approved
      • Duloxetine – most helpful for co-existing osteoarthritis
      • Milnacipran
      • Pregabalin (or try gabapentin if not covered)
    • Non-FDA approved
      • Low dose TCAs
    • DO NOT USE: steroids, opiates – not effective and can worsen condition.

Samantha Shapiro, MD
Last updated: 10/16/18