American College of Rheumatology – Pediatric Rheumatology

Five Things Physicians and Patients Should Question

Released October 27, 2013

  1. 1

    Don’t order autoantibody panels unless positive antinuclear antibodies (ANA) and evidence of rheumatic disease.

    Up to 50% of children develop musculoskeletal pain. There is no evidence that autoantibody panel testing in the absence of history or physical exam evidence of a rheumatologic disease enhances the diagnosis of children with isolated musculoskeletal pain. Autoantibody panels are expensive; evidence has demonstrated cost reduction by limiting autoantibody panel testing. Thus, autoantibody panels should be ordered following confirmed ANA positivity or clinical suspicion that a rheumatologic disease is present in the child.

  2. 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. 3

    Don’t routinely perform surveillance joint radiographs to monitor juvenile idiopathic arthritis (JIA) disease activity.

    There are no available data to suggest that routinely obtaining surveillance joint radiographs to monitor for the development or progression of erosive changes in children with juvenile idiopathic arthritis (JIA) improves outcomes. Radiation exposure and cost are potential risks. In the absence of data to support clear benefit, radiographs should be obtained by the pediatric rheumatologist only when history and physical exam raise clinical concern about joint damage or decline in function.

  4. 4

    Don’t perform methotrexate toxicity labs more often than every 12 weeks on stable doses.

    Laboratory abnormalities in JIA patients taking methotrexate are usually mild and rarely prompt significant changes in management. Screening low-risk children every 1–2 months may lead to unnecessary interruptions in treatment. More frequent monitoring may be required in the first six months after methotrexate initiation or dose escalation and in patients with risk factors for toxicity including obesity, diabetes, renal disease, psoriasis, systemic JIA, Down syndrome and use of alcohol or other hepatotoxic or myelosuppressive medications.

  5. 5

    Don’t repeat a confirmed positive ANA in patients with established JIA or systemic lupus erythematosus (SLE).

    ANA is important in the diagnosis of SLE and positivity guides more frequent slit lamp examination for detection of uveitis in children with JIA. Beyond this, there is no evidence that ANA is valuable in the ongoing management of SLE or JIA. It is recommended that following diagnosis of SLE or JIA, ANA should not be repeated unless a child with JIA has evolution of symptoms suggestive of an autoimmune connective tissue disease.

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.

Over 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 (ACR) 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) used a multi-stage process combining consensus methodology and literature reviews to arrive at its Pediatric Rheumatology Top 5 list. Items were generated by a group of practicing pediatric rheumatologists using the Delphi method. Items with high content agreement and perceived prevalence advanced to a survey of ACR members who listed pediatric rheumatology as their specialty. Based on member input related to content agreement, impact and item ranking, candidate items advanced to literature review. The ACR Special Committee on Pediatric Rheumatology discussed the items in light of their relevance to rheumatology, level of evidence to support their inclusion in the final list and the member survey results, and drafted the final pediatric rheumatology Top 5 list. The list was reviewed and approved by the ACR Board of Directors.

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

ACR Special Committee on Pediatric Rheumatology

  • Polly Ferguson, MD, Chair – University of Iowa Carver College of Medicine, Iowa City, IA
  • Stacy Ardoin, MD – Ohio State University, Columbus, OH
  • Mara Becker, MD – Children’s Mercy Hospital, Kansas City, MO
  • Ashley Cooper, MD – University of Texas Southwestern Medical School, Dallas, TX
  • Leonard Dragone, MD, PhD – National Jewish Hospital, Denver, CO
  • Anna Huttenlocher, MD – University of Wisconsin Medical School, Madison, WI
  • Karla Jones, RN, MS, CPNP – Nationwide Children’s Hospital, Columbus, OH
  • Karen Kolba, MD – Pacific Arthritis Center, Santa Maria, CA
  • Lakshmi Moorthy, MD, MS – Robert Wood Johnson Medical School, New Brunswick, NJ
  • Peter Nigrovic, MD – Brigham and Women’s Hospital, Boston, MA
  • Kelly Rouster-Stevens, MD – Emory Children’s Center, Atlanta, GA
  • Jennifer Stinson, RN, PhD, CPNP – The Hospital for Sick Children, Toronto, ON, CA

American College of Rheumatology Pediatric Rheumatology Core Membership Group*

* Members of the Core Membership Group included: Robert Colbert, MD, PhD, Randy Cron, MD, PhD, Peter Dent, MD, Melissa Elder, MD, PhD, Don Goldsmith, MD, Roger Hollister, MD, Norman Ilowite, MD, Yukiki Kimura, MD, Marisa Klein-Gittelman, MD, MPH, Erica Lawson, MD, Murray Passo, MD, Ross Petty, MD, PhD, Marilynn Punaro, MD, Egla Rabinovich, MD, MPH, Andreas Reiff, MD, David Sherry, MD, Larry Zemel, MD.

Sources

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    Cabral DA, Petty RE, Fung M, Malleson PN. Persistent antinuclear antibodies in children without identifiable inflammatory rheumatic or autoimmune disease. Pediatrics. 1992;89:441-4.

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