When Less is More in Treating Childhood Rheumatic Diseases

ATLANTA – The American College of Rheumatology (ACR) today announced its second list of five tests and treatments commonly used in rheumatology whose use should be questioned and discussed between rheumatologists and their patients. This list, focused solely on pediatric rheumatology, will help encourage dialogue between pediatric rheumatology patients, their parents and the rheumatologists who treat them.

The list was created as part of the ACR’s ongoing participation in the ABIM  Foundation’s Choosing Wisely campaign.

“As the ACR was developing its initial Choosing Wisely list for adult rheumatology in 2012, we quickly realized that a separate list that focuses on pediatric rheumatology would be an important next step” explains ACR President, Audrey Uknis, MD. Adding this second list, and joining more than 50 specialty societies, the ABIM Foundation, and Consumer Reports in the third phase of this campaign, the ACR is continuing to define high-quality, high-value care for children with rheumatic diseases.”

Pediatric Rheumatology’s Top Five Things

The ACR’s Pediatric Rheumatology Top Five list includes diagnostic tests and treatments that are commonly ordered/provided by pediatric rheumatologists, are among the most expensive services provided in rheumatology, and have been shown by the currently-available research not to provide any meaningful benefit to at least some major categories of patients for whom these are ordered without careful consideration.

The list includes the following:

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.

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.

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.

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.

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.

The Beginning of Conversations and Joint Decision Making

Nearly 300,000 children in the United States suffer from the painful, disabling and sometimes fatal effects of arthritis and rheumatic diseases. As care leaders, rheumatologists and rheumatology health professionals play a uniquely vital role in guiding these individuals toward the most effective care. The ACR’s Pediatric Rheumatology Top Five list provides an excellent resource for patients, parents and pediatric rheumatologists to discuss the best and most appropriate treatment for these children.

“The importance of this Top 5 is that it provides pediatric rheumatology expert opinion to foster meaningful discussion between health care providers and their patients and families in an effort to optimize health care expenditure,” explains Kelly Rouster-Stevens, MD who is a rheumatologist at Emory Children’s Center in Atlanta and co-chair of the ACR task force that created the list. “This is particularly beneficial during the current era of health care reform.”

Rather than being a prescriptive set of rules, the list is meant to leave room for clinical judgment. As the ACR’s Pediatric Rheumatology Top Five lists becomes a reference tool for the rheumatology community, the ACR will discuss strategies to help the pediatric rheumatology community implement the items on the list.

“By no means should this Top 5 list replace the critical and individualized decision making that each pediatric rheumatology provider undergoes with patients and families,” adds Stacy P. Ardoin, MD, MHS who is a rheumatologist at Ohio State University and Nationwide Children’s Hospital in Columbus, Ohio.  “However, this list does provide our community with an opportunity to reconsider the evidence basis for some of our routine practices and consider whether the benefits outweigh the potential costs.”

To view the ACR’s Pediatric Rheumatology Top Five list, or its Adult Rheumatology Top Five list, visit www.rheumatology.org/fivethings. To learn more about the Choosing Wisely campaign, visit www.ChoosingWisely.org.

Media Contact: Erin Latimer – (404) 633-3777