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Background: The shortage of rheumatologists in some areas is a main barrier for timely consultations for patients with a suspected inflammatory rheumatic disease (IRD). Late diagnosis and delayed effective anti-inflammatory therapy increase risk of joint or other organ damage. Chronic musculoskeletal pain is a major driver for rheumatological consultations, yet up to 75% of referrals result in the exclusion of an IRD and identify other conditions, mainly osteoarthritis (OA) and nociplastic pain/ fibromyalgia syndrome (FMS). Effective positive selection of patients with IRD in primary care proved difficult in the past. An alternative approach is to identify in primary care patients with a low likelihood of an IRD and not referring with urgency such patients to rheumatology. Objectives: To explore whether the combined application of the Fibromyalgia Rapid Screening Tool (FiRST) and C-reactive protein (CRP) value has the potential to identify patients with chronic musculoskeletal pain but a low likelihood of an IRD. Methods: In this explorative, prospective single-centre study we included patients who presented as outpatients or inpatients to the rheumatology department between 01/2019 and 01/2022. The FiRST questionnaire, a validated instrument based on 6 questions with a score ≥ 5 indicating FMS, was administered to consecutive patients at the day of consultation/admission. The completed FIRST was collected by a nurse, keeping the treating rheumatologist blinded to the results. In this explorative study, patients were included regardless of i) established or new IRD diagnosis, ii) disease activity, and iii) treatment. Final diagnoses were categorized into 4 disease groups: 1) IRD, 2) chronic nociplastic pain/FMS, 3) OA and 4) others. Results: Out of 1352 FIRST questionnaires collected, 1100 patients with complete datasets were analysed; 69.3% were female, mean age was 54.8 (SD 15.7) years. An IRD was diagnosed in 566 patients (51.5%), FMS in 341 (31.0%), OA in 325 (29.5%) and other diagnoses in 204 patients (18.4%). Among 566 IRD patients, 163 (28.8%) concomitantly had OA, 111 (19.6%) concomitantly had FMS, and 33 (3.0%) had concomitantly both OA and FMS. Irrespective of treatment and disease activity, 94/566 IRD patients (16.6%) had the combination of CRP ≤ 5 mg/l and FIRST score ≥ 5, suggesting low likelihood of an IRD. Further analyses of these 94 patients (Figure 1) revealed a new diagnosis of IRD in 22, of whom 4 patients were treated with prednisolone (affecting the CRP-value) and the diagnosis IRD was dismissed in further 4 patients after meticulous review of available patient information. Among the remaining 14 patients with the combination of CRP ≤ 5 mg/l and FIRST score ≥ 5 (2.5% of all IRD), 11 were female (78.6%), and 7 (50%) had a concomitant FMS. IRD diagnoses among these 14 patients included undifferentiated connective tissue disease (CTD) (n=3), Sjögren's syndrome (n=3), nr-axSpA (n=2), PsA (n=2), RA (n=1), panniculitis (n=1), suspected scleroderma (n=1), and Behcet's disase (n=1). The disease was inactive or mild in 10/14 patients; there was no major organ involvement. Treatment initiated in 11 patients included amitriptyline, hydroxychloroquine, NSAID, colchicine, or no therapy. 3 Patients received MTX, and 2 patients were escalated to TNFi therapy (nr-axSpA n=1, PsA n=1). Conclusion: This study reveals a great potential to identify in primary care patients with musculoskeletal pain but a low likelihood of IRD and, therefore, low urgency of referral to rheumatology by using the combination of CRP ≤ 5 mg/l and FiRST ≥ 5. In this unselected cohort, only 2.5% of all IRDs had been missed. IRD diagnoses likely to be missed by such an approach will be CTD, nr-axSpA and PsA. Acknowledgements: NIL. Disclosure of Interests: None declared.
Röchter et al. (Sat,) studied this question.