June 2026
This guide for GPs, developed by MFT’s clinical immunology and rheumatology teams, aims to support the early identification of rheumatoid arthritis (RA) to prevent irreversible joint damage and long-term disability.
1. Clinical assessment: Recognising the signs
The diagnosis of RA is primarily clinical; there is no single pathognomonic laboratory test. General practitioners should maintain a high index of suspicion for clinical synovitis and should refer patients with clinical synovitis urgently to rheumatology without delay, regardless of symptom duration.
- Key symptoms: Persistent joint pain, swelling, heat, and loss of function.
- Early morning stiffness: Typically lasts more than 30 minutes and often recurs after rest.
- Joint distribution: Classically affects the small joints of the hands and feet in a symmetrical distribution, though any synovial joint can be involved.
- Systemic features: Patients may also experience fatigue, malaise, sweats, or weight loss.
2. Investigations: When (and when not) to test
Laboratory tests should be used to support a clinical suspicion, not as a general screening tool.
- Rheumatoid Factor (RF) and Anti-CCP (ACPA):
- When to test: Only when RA is clinically suspected to help speed up the diagnostic process or inform treatment decisions.
- When NOT to test: Avoid using these as screening tests for patients with widespread pain or fatigue alone.
- Interpretation: A negative result does not exclude RA, and a positive result does not equate to a diagnosis. Notably, RF is positive in approximately 5% of the healthy population. While anti-CCP is highly specific for RA, up to 50% of patients may be seronegative at presentation.
- Repeat testing: This is not normally indicated unless the clinical picture changes significantly, as results rarely change over time.
- Inflammatory markers: Measure CRP and/or ESR. Be aware that these markers are normal in up to 40% of people with RA and a normal result should not delay referral.
- Baseline tests: If RA is suspected, perform FBC, renal, and liver function tests to guide future treatment and identify comorbidities.
- Imaging: Arrange X-rays of the hands and feet early in the disease course, as these help determine disease severity and identify erosions.
3. Referral: The importance of speed
Early specialist intervention is critical; patients who wait over a year for referral have a 73% risk of developing erosive changes.
- Referral timing: NICE Quality Standards recommend that adults with suspected persistent synovitis be referred to rheumatology services within 3 working days of presentation in primary care.
- When to refer urgently:
- The small joints of the hands or feet are affected.
- More than one joint is involved.
- There has been a delay of three months or longer between symptom onset and seeking medical advice.
- Crucial instruction: do not wait for test results. If RA is clinically suspected, refer the patient immediately. A referral should never be delayed by a negative RF or normal inflammatory markers.
4. Primary care management and shared care
While the specialist team initiates disease-modifying therapy (DMARDs), primary care plays a vital role in ongoing management.
- Symptom control: Use simple analgesics in preference to long-term NSAIDs. If NSAIDs are necessary, they should be used at the lowest dose with a proton pump inhibitor.
- Steroids: Short-term glucocorticoids can manage flares, but patients should not be managed on steroids alone in primary care.
- Patient education: Offer verbal and written information (e.g., from Versus Arthritis or NRAS) to improve understanding and counter misconceptions.
- Annual review: Coordinate or support a comprehensive annual review to check for disease activity, functional ability, and common comorbidities such as cardiovascular disease, osteoporosis, and depression.
This article was created using evidence-based guidelines from NICE and the British Society for Rheumatology (BSR).