the rheumatology pathway

Inflammatory Arthritis can result in long-term physical disability if left untreated, and may affect the social and financial well-being of the person with the disease and their families. Successful treatment for IA, of which Rheumatoid Arthritis (RA), which affects around one percent of the population, is the most frequently diagnosed, is improved greatly by access to recommended treatment by a rheumatologist and regular monitoring and adjustment of medication to suppress the disease and reduce the likelihood of severe complications as early as possible in the course of the disease.

When a person has an IA, their immune system, which normally fights infection, mistakenly attacks their joints. It can also affect internal organs and cause a general feeling of exhaustion and unwellness. Disease modifying medication (DMARDs) can halt this process and reduce damage to the joints and help prevent irreversible disability. But if the underlying disease (not just the symptoms) is treated it carries a high burden for the individual in terms of pain and disablement, and also a high burden for the community and health system because of the high costs of treatment and support as the disease advances. For some forms of IA, in particular RA, remission is rare, and lifelong medication is almost always required to supress disease activity and prevent damage to joints and long-term disability.

The key to successful treatment is identifying the RA early (ideally within three months of the first symptoms) and obtaining appropriate treatment and healthcare support. But early identification of RA can be difficult because there are many conditions that can produce similar symptoms, and far too often, it is not considered a serious disease. Timely and continuous treatment*, as well as meeting other health and well-being needs that result from RA, is problematic in areas where health services are scarce. Taranaki, like many regions in New Zealand, has a shortage of Rheumatologists and services to support people with IA and understanding how to make the best use of the rheumatology pathways is essential for timely and effective healthcare and support.
But Why Me?
The short and frustrating answer is: Doctors might not know why you, and not someone else.

The longer answer is that Rheumatologists and clinical researchers have made great progress in understanding these diseases although reseach has not yet idendified all the factors in developing an IA. It is known that some other autoimmune conditions, like psoriasis and irritable bowel syndromes underlie non-rheumatoid IAs called Spondyloarthropies (SpA). SpAs without one of these underlying conditions may themselves have specific presentations that can help with diagnosis, as can genetic testing. RA, on the otherhand is not known to be linked to other diseases. In many cases RA can be diagnosed by markers found in blood tests - the Rheumatoid Factor (RF) and an Anti-CCP marker. People with these markers have sero-positive RA. People without these markers, but with characteristic RA presentation (or who the Rheumatologist has enough other information to suspect RA) have sero-negative RA. There is no evidence in New Zealand that ethnicity, social class, or income have any impact on developing and IA. There are some differences in gender though. - women are three times more likely to develop RA, and men are three times more likely to develop an SpA called Ankylosing Spondylitis (arthritis of the spine), but gender does not appear to be a factor in the onset of other types of IA. You can possibly see from this summary that there are still a lot of unknowns about IA - both SpAs and RA.

"But you're to young to have arthritis." This is often the reacton of people when you tell them of your diagnosis. It was probably your own reaction as well. It is a common misconception that IAs are diseases that old people have. Although this is true to an extent - the number of people diagnosed rises as we age, and many older people with IA have been living with it for many, many years. But the reality is that IA can occur at any age. ATT has members who were diagnosed at 18 and some have had IA as children. The most common time for the onset of RA in women for example, is between 30 and 50 years of age.

If people with IA are asked about how their symptoms developed, almost always they have sense that there was something that "set it off" and on reflection they'll talk about how this happend during a period in their lives when they were unsettled by stress or life events (death of a loved one, changes in living circumstances, redundancies and so on). It can be useful sometimes for people newly-diagnosed with an IA to think of the development of IA as a 3-step process:
  • Genetics: A person must have certain genetic factors to develop an IA. This does not meant the disease is entirely genetic though. But it's highly likely that an aunt, grandparent, cousin (if not a parent) has been diagnosed with an IA.


  • Environment: An environmental background can set the conditions for an IA to develop. For example, smoking is clearly identified as the leading environmental factor in developing sero-positive RA with the anti-CCP marker. People with psorisis or an IBD may consider these conditions their environmental backgroud. Other potential environmental factors are being investigated; including workplace materials and environmental factors, however conclusive evidence for these environments causing IA is scarce. In patient interviews for this project all people have described a period of high stress as the background to the onset of their IA.


  • Trigger: A trigger could be a specific event that patients recall as having occurred around the time of the onset of symptons, There are also triggers that are known for example, there is a known increase in the risk of developing RA in the few months after giving birth. Another example is people developing an SpA called Reactive Arthritis (ReA) after contracting an infection (e.g. gastroenteritis, a streptococcal infection or a sexually transimitted disease). Most often ReA disappears withing 6 months, however it can also remain as a chronic SpA.
When describing the onset of an IA people in our interviews associated the onset of their persisitent joint pain with an injury, over-use of a joint, accident or illness. This association of symptoms with for example, a sports injury or accident at work, is the main reason they gave for delaying seeking advice from their GP. And it is a factor in a GP not immediately thinking your symptoms might be caused by an IA.

It is hard to determine if these events are the cause of symptom onset, or they are coincedental, for example, did early joint inflammation led to the injury? or did the pain from the event focus the mind on a joint that already had niggling pain and inflammation.

Further reading:
Cautions apply with this information: Despite commonalities in IA processes and treatment, we're all individuals. Your unique circumstances may affect processes and appearance of your IA. Referral processes and resources available to you can also vary by area.
ALWAYS seek clarification from your medical team
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