American College of Rheumatology

Five Things Physicians and Patients Should Question

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1

Don’t test ANA sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.

Tests for anti-nuclear antibody (ANA) sub-serologies (including antibodies to double-stranded DNA, Smith, RNP, SSA, SSB, Scl-70, centromere) are usually negative if the ANA is negative. Exceptions include anti-Jo1, which can be positive in some forms of myositis, or occasionally, anti-SSA, in the setting of lupus or Sjögren’s syndrome. Broad testing of autoantibodies should be avoided; instead the choice of autoantibodies should be guided by the specific disease under consideration.

2

Don’t test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.

The musculoskeletal manifestations of Lyme disease include brief attacks of arthralgia or intermittent or persistent episodes of arthritis in one or a few large joints at a time, especially the knee. Lyme testing in the absence of these features increases the likelihood of false positive results and may lead to unnecessary follow-up and therapy. Diffuse arthralgias, myalgias or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.

3

Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

Data evaluating MRI for the diagnosis and prognosis of rheumatoid arthritis are currently inadequate to justify widespread use of this technology for these purposes in clinical practice. Although bone edema assessed by MRI on a single occasion may be predictive of progression in certain RA populations, using MRI routinely is not cost-effective compared with the current standard of care, which includes clinical disease activity assessments and plain film radiography.

4

Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional non-biologic DMARDs).

High quality evidence suggests that methotrexate and other conventional non-biologic disease modifying antirheumatic drugs (DMARD) are effective in many patients with rheumatoid arthritis (RA). Initial therapy for RA should be a conventional non-biologic DMARDs unless these are contraindicated. If a patient has had an inadequate response to methotrexate with or without other non-biologic DMARDs during an initial 3-month trial, then biologic therapy can be considered. Exceptions include patients with high disease activity and poor prognostic features (functional limitations, disease outside the joints, seropositivity or bony damage), where biologic therapy may be appropriate first-line treatment.

5

Don’t routinely repeat DXA scans more often than once every two years.

Initial screening for osteoporosis should be performed according to National Osteoporosis Foundation recommendations. The optimal interval for repeating Dual-energy X-ray Absorptiometry (DXA) scans is uncertain, but because changes in bone density over short intervals are often smaller than the measurement error of most DXA scanners, frequent testing (e.g., <2 years) is unnecessary in most patients. Even in high-risk patients receiving drug therapy for osteoporosis, DXA changes do not always correlate with probability of fracture. Therefore, DXAs should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected. Recent evidence also suggests that healthy women age 67 and older with normal bone mass may not need additional DXA testing for up to ten years provided osteoporosis risk factors do not significantly change.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

More than 50 million Americans, including 300,000 children, suffer from arthritis and rheumatic diseases, and rheumatologists are the specialists in the treatment of those diseases. The American College of Rheumatology represents over 8,500 rheumatologists and rheumatology health professionals around the world. The ACR offers its members the support needed to ensure they are able to continue their innovative research and quality patient care.

To find a rheumatologist in your area, or to learn about the ACR, visit www.rheumatology.org.

How this list was created: The American College of Rheumatology (ACR) established a Top 5 Task Force to oversee the creation of its recommendations. As part of this group’s work, a multistage process combining consensus methodology and literature reviews was used to arrive at the final recommendations. Items were generated by a group of practicing rheumatologists in diverse clinical settings using the Delphi method. Recommendations with high content agreement and perceived prevalence advanced to a survey of ACR members, who comprise more than 90% of the U.S. rheumatology workforce. Based on member input related to content agreement, impact and item ranking, candidate items advanced to literature review. The Top 5 Task Force discussed the items in light of their relevance to rheumatology, level of evidence to support their inclusion, and the member survey results, and drafted the final rheumatology Top 5 list. The list was reviewed by a sample of patients with rheumatic disease and approved by the ACR Board of Directors. For further details regarding these methods, please see the manuscript published in Arthritis Care & Research at www.rheumatology.org/FiveThings.

ACR’s disclosure and conflict of interest policy can be found at www.rheumatology.org.

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