Inflammatory arthritis: recognising RA, spondyloarthritis and PMR in GP

Inflammatory arthritis — an immune attack, not wear and tear

Around 3–4% of Australians live with an inflammatory arthritis — rheumatoid arthritis, axial spondyloarthritis, psoriatic arthritis, polymyalgia rheumatica, giant cell arteritis, or a connective tissue disease such as systemic lupus erythematosus. These conditions share a common pathology: the immune system attacks the body’s own tissues, producing synovial inflammation, structural joint damage, systemic features, and elevated cardiovascular risk. They are fundamentally different from osteoarthritis, and they require a different diagnostic approach and a different management pathway.

The general practitioner is where most of these patients first present — often months or years before a diagnosis is made. The GP’s role is pattern recognition, targeted investigation, urgent referral when indicated, and then long-term shared care alongside the rheumatologist. Getting this right early matters enormously, particularly in rheumatoid arthritis, where the window of opportunity for disease-modifying therapy is narrow and irreversible.

A. Core clinical — the AU general-practice framework

Recognising the inflammatory pattern

The first diagnostic question is: is this inflammation or mechanical wear? RACGP guidelines on early RA identify morning stiffness lasting more than 30 minutes as the cardinal feature of inflammatory joint disease. Additional features that support an inflammatory cause:

• Gel phenomenon — stiffness after prolonged rest (cinema sign, early morning)
• Improvement with activity — unlike osteoarthritis, which worsens with use
• Nocturnal waking — pain waking the patient in the early hours
• Soft-tissue swelling — boggy, synovial thickening rather than bony enlargement
• Constitutional features — fatigue, unintentional weight loss, low-grade fever, malaise

History

Take a structured history covering:

• Pattern of joint involvement — which joints, symmetry vs asymmetry, small vs large joints, spinal involvement, dactylitis (sausage digit)
• Skin and nail changes — psoriasis plaques, nail pitting or onycholysis (psoriatic arthritis), photosensitive facial rash (lupus), Raynaud’s phenomenon, sclerodactyly
• Eye symptoms — uveitis or anterior chamber inflammation (axial spondyloarthritis), scleritis (rheumatoid arthritis, vasculitis), dry eyes (Sjögren’s syndrome), visual symptoms or jaw claudication (giant cell arteritis)
• Bowel symptoms — recent diarrhoeal illness (reactive arthritis), inflammatory bowel disease (enteropathic arthritis)
• Urogenital history — recent urethritis (reactive arthritis, Reiter’s syndrome)
• Respiratory — dyspnoea or cough suggesting interstitial lung disease (RA, scleroderma, lupus, polymyositis)
• Family history — RA, psoriasis, ankylosing spondylitis, inflammatory bowel disease, lupus
• Smoking — increases RA risk and severity, reduces biologic response
• Recent infection or vaccination — post-viral arthritis, reactive arthritis
• Medications — drug-induced lupus (hydralazine, procainamide, isoniazid, minocycline, some anti-TNF agents)

Examination

Perform a systematic joint survey:

• Inspection — swelling (effusion vs synovial thickening), erythema, deformity, dactylitis, nail changes
• Palpation — boggy synovial thickening, tenderness, warmth; distinguish from bony osteophytes of osteoarthritis
• Range of movement — active and passive
• Joint count — map which joints are tender and swollen (used in disease activity scores)
• Spine — Schober’s test for lumbar flexion, chest expansion, occiput-to-wall distance (axial spondyloarthritis features)
• Sacroiliac stress tests — FABER, Gaenslen’s
• Enthesitis sites — Achilles insertion, plantar fascia, iliac crest, greater trochanter, costochondral junctions
• Skin — psoriasis on extensor surfaces, scalp, umbilical, gluteal cleft; malar rash; vasculitic purpura; Gottron’s papules (dermatomyositis)
• Temporal artery — palpate for nodularity, tenderness, absent pulse (giant cell arteritis)

Investigations

Per eTG Rheumatology and AMH, initial GP-led workup includes:

• FBC — anaemia of chronic disease, neutropenia (lupus, Felty’s syndrome), thrombocytosis with active inflammation
• ESR and CRP — both raised in active inflammatory arthritis; CRP often normal in lupus unless infection is present
• Rheumatoid factor (RF) and anti-CCP antibody — anti-CCP is approximately 95% specific for RA; RF is less specific and can be positive in other conditions
• ANA (antinuclear antibody) — screening test for connective tissue disease; if positive, follow with anti-dsDNA, ENA panel (anti-Ro/La, anti-Sm, anti-RNP, anti-Scl-70, anti-Jo-1)
• HLA-B27 — supports axial spondyloarthritis; population prevalence around 8–10%, so not diagnostic in isolation
• Urate — to exclude gout
• Urinalysis with ACR — lupus nephritis screen
• LFT, UEC, TSH, CK — baseline and to exclude hypothyroid arthropathy or myositis
• Pre-biologic screening (when rheumatology referral initiated): hepatitis B (HBsAg, anti-HBc), hepatitis C, HIV, QuantiFERON TB test

Imaging:

• Plain X-ray — joint erosions in RA, sacroiliitis grading, syndesmophytes in AS
• MSK ultrasound (MBS item 55844) — sensitive for early synovitis and erosions
• MRI sacroiliac joints (MBS item 63507 range — specialist-initiated) — bone marrow oedema confirms active sacroiliitis before plain X-ray changes appear

Synovial fluid aspirate — if monoarthritis is present, aspirate to exclude septic arthritis and crystal arthropathy before assuming inflammatory arthritis.

B. Evidence — why early referral and DMARD therapy matter

The Australian Living Guideline for Pharmacological Management of Inflammatory Arthritis — a continuously updated evidence synthesis — establishes methotrexate as first-line conventional synthetic DMARD (csDMARD) for RA in almost all patients without contraindication. The evidence base is unambiguous:

• Window of opportunity: multiple cohort studies and RCTs demonstrate that DMARD initiation within 12 weeks of RA symptom onset significantly reduces long-term joint erosions, functional disability, and the need for escalation to biologic therapy. Smolen et al. (Lancet 2016) synthesised this evidence base comprehensively.
• Treat-to-target: aiming for remission or low disease activity using validated tools (DAS28, CDAI) improves long-term outcomes. Rheumatologists use a treat-to-target strategy rather than fixed-dose maintenance.
• Methotrexate first-line: 7.5–25 mg weekly oral or subcutaneous, with folic acid 5 mg weekly on a different day. Combination with sulfasalazine and hydroxychloroquine (“triple therapy”) if inadequate response.
• Biologics for refractory disease: TNF inhibitors (adalimumab, etanercept, infliximab, certolizumab, golimumab), non-TNF biologics (abatacept, rituximab, tocilizumab, sarilumab), and JAK inhibitors (tofacitinib, baricitinib, upadacitinib) — all PBS Authority Required (specialist initial application). JAK inhibitors carry an FDA/TGA black-box warning for cardiovascular events, VTE, and malignancy, particularly in older patients, as established by ORAL Surveillance (NEJM 2022).
• Giant cell arteritis: tocilizumab plus prednisolone versus prednisolone alone (GiACTA, NEJM 2017) demonstrated superior steroid-sparing effect; PBS Authority Required via specialist application.

Common GP pitfalls: adopting a “watch and wait” approach for symptoms suggesting inflammatory arthritis; trialling NSAID alone without DMARD (relieves symptoms but does not prevent joint damage); commencing long-term prednisolone without specialist input in early disease (masks diagnosis and delays DMARD initiation).

C. Recognising the major types

Rheumatoid arthritis (RA)

Symmetric small-joint polyarthritis — MCP, wrist, PIP, MTP joints — morning stiffness more than 30 minutes, ≥6 weeks duration. Anti-CCP approximately 95% specific; RF less so. Rheumatoid nodules in approximately 25%. Extra-articular features include interstitial lung disease, scleritis, vasculitis, and the Felty’s syndrome triad (RA, splenomegaly, neutropenia). HealthDirect provides patient-friendly information.

Axial spondyloarthritis (axSpA) and ankylosing spondylitis (AS)

Inflammatory back pain: insidious onset before age 40, morning stiffness over 30 minutes, improvement with exercise (not rest), alternating buttock pain, nocturnal waking. HLA-B27 positive in approximately 85% of white European patients. MRI of sacroiliac joints demonstrates bone marrow oedema confirming active sacroiliitis before plain X-ray changes. NSAIDs are first-line and may slow radiographic progression. HealthDirect — ankylosing spondylitis is a useful starting resource.

Psoriatic arthritis (PsA)

Occurs in approximately 25% of people with psoriasis. Patterns include oligoarticular asymmetric, polyarticular, DIP-predominant, axial, and arthritis mutilans. Hallmarks: dactylitis (sausage digit), enthesitis, nail pitting or onycholysis, skin psoriasis (may be occult — check scalp, umbilical, gluteal cleft).

Polymyalgia rheumatica (PMR) and giant cell arteritis (GCA)

PMR: bilateral shoulder and hip girdle pain and stiffness more than one hour, age over 50, ESR markedly elevated. Dramatic response to prednisolone 15–25 mg within 24–72 hours confirms diagnosis.

GCA is a medical emergency: new headache, scalp tenderness, jaw claudication, transient visual loss, or diplopia in a patient aged over 50 requires immediate prednisolone 40–60 mg (intravenous methylprednisolone 250–1000 mg if visual symptoms), urgent ophthalmology and rheumatology referral, and temporal artery biopsy within one to two weeks. Do not delay treatment pending biopsy. Vision loss is preventable with prompt treatment.

Connective tissue diseases

Lupus (SLE) is multi-system — rash, arthritis, nephritis, serositis, cytopenias, neuropsychiatric features — with ANA positive and specific autoantibodies (anti-dsDNA, anti-Sm). Sjögren’s syndrome presents with dry eyes and dry mouth (anti-Ro/La). Scleroderma includes Raynaud’s phenomenon, sclerodactyly, interstitial lung disease, and pulmonary hypertension. All require specialist input.

D. Australian operations

MBS items

• Standard GP consults: 23, 36, 44
• MSK ultrasound: 55844, 55848
• HRCT chest (ILD screen): 56301
• Key pathology: RF + anti-CCP 71105; ANA 71060; HLA-B27 71089; QuantiFERON TB 69487; CRP 66503; ESR 65060
• GPCCMP (chronic disease management): 965 prepare, 967 review — chronic inflammatory arthritis qualifies
• Mental Health Care Plan: 2715 / 2717 — depression and anxiety are common comorbidities
• ATSI Health Assessment: 715

PBS

Per PBS: csDMARDs (methotrexate, sulfasalazine, hydroxychloroquine, leflunomide) and prednisolone — general schedule. Biologics and JAK inhibitors — Authority Required (specialist initial application; repeat prescribing by any practitioner via streamlined). Strict PBS criteria for each biologic indication.

GP shared care for stable patients on DMARD

Monitoring per Australian Rheumatology Association protocols: methotrexate (FBC, LFT, UEC two to four weekly initially, then eight to twelve weekly); hydroxychloroquine (annual eye review for retinal toxicity); leflunomide (FBC, LFT, BP); biologics per specialist protocol. Annual vaccinations (influenza, pneumococcal, COVID-19, Shingrix — avoid live vaccines on biologics or high-dose immunosuppression), cardiovascular risk management, osteoporosis prevention during steroid use, and mental health screening are all GP responsibilities.

E. Special populations

Pregnancy and reproductive planning: methotrexate and leflunomide are teratogenic and must be ceased before conception — methotrexate at least three months before, leflunomide requires washout with cholestyramine. Coordinate pregnancy planning with rheumatology. Hydroxychloroquine is considered relatively safe. Flares of lupus and RA can occur during pregnancy and postpartum.

First Nations Australians: Aboriginal and Torres Strait Islander peoples face higher rates of inflammatory arthritis, worse outcomes due to access barriers, and greater comorbidity burden. ATSI Health Assessment 715 and partnership with ACCHOs and Aboriginal Health Workers are important. Arthritis Australia provides culturally appropriate resources.

Older adults: PMR and GCA are diseases of older age. Long-term prednisolone in older patients requires concurrent calcium 1000–1300 mg daily, vitamin D, and bisphosphonate therapy to prevent glucocorticoid-induced osteoporosis. Be alert for cataracts, raised intraocular pressure, and glucose elevation from chronic steroid use.

Cardiovascular risk: RA, psoriatic arthritis, axial spondyloarthritis, and lupus carry cardiovascular risk 1.5–3 times the background population rate — treat these patients as cardiovascular risk equivalents: manage hypertension, dyslipidaemia, smoking, and diabetes aggressively.

When to escalate

• Emergency / same day — GCA with visual symptoms, temporal headache with visual loss or diplopia: commence prednisolone 40–60 mg immediately and refer urgently to emergency + rheumatology + ophthalmology. Suspected septic arthritis (single hot joint, fever): aspirate and refer to ED. Suspected vasculitis with organ involvement: same-day hospital assessment.
• Within days — suspected GCA without visual symptoms (start prednisolone, refer urgently). Severe acute polyarthritis with systemic features.
• Within weeks — any suspected chronic inflammatory arthritis (RA, axial spondyloarthritis, psoriatic arthritis, early connective tissue disease, PMR requiring confirmation). Unexplained synovitis persisting more than six weeks in an adult warrants rheumatology referral.

What this article is and is not

This is general health information based on current Australian general practice guidelines — RACGP, eTG Rheumatology, AMH, Australian Living Guideline for Inflammatory Arthritis, Australian Rheumatology Association, NPS MedicineWise, PBS, and key trial evidence. It is not personal medical advice, does not establish a doctor–patient relationship, and does not substitute for individual clinical assessment.

For consumer-friendly information: Arthritis Australia, HealthDirect — Rheumatoid arthritis, Lupus Association of Australia.

For acute concerns — unexplained new headache with visual symptoms, fever with hot joint — seek urgent medical assessment or call 000.

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Sources cited

1. RACGP — Early diagnosis and management of rheumatoid arthritis
2. Australian Living Guideline for Pharmacological Management of Inflammatory Arthritis
3. eTG Rheumatology
4. Australian Medicines Handbook
5. Australian Rheumatology Association
6. NPS MedicineWise — Shared care in RA
7. Arthritis Australia
8. HealthDirect — Rheumatoid arthritis
9. HealthDirect — Ankylosing spondylitis
10. PBS
11. Smolen JS et al. — Rheumatoid arthritis (Lancet 2016)
12. Burmester GR et al. — ORAL Surveillance JAK inhibitor safety (NEJM 2022)
13. Stone JH et al. — Tocilizumab for GCA (NEJM 2017)