When treating rheumatic diseases, less can be best

The American College of Rheumatology has issued  a list of five tests and treatments commonly used in rheumatology, the use of which should be questioned and discussed between rheumatologists and their patients.  Kenneth Saag, M.D., professor in the  Division of Clinical Immunology and Rheumatology at the University of Alabama at Birmingham, was a co-author of the review and chairs the American College of Rheumatology Quality of Care committee that oversaw the process.

The list is published in the ACR’s journal, Arthritis Care & Research, and it was created as part of the ACR’s participation in the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.

The ACR’s Top Five list includes diagnostic tests and treatments that: are commonly ordered or provided by rheumatologists; are among the most expensive services provided in rheumatology; 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.

“Rheumatology is a very complex field, and rheumatic conditions can be very difficult to treat,” said Saag. “The ACR’s Top Five offers a strong starting point for evaluation and conversation about providing the most effective care to the more than 50 million Americans with arthritis and rheumatic diseases.”


The Top Five list is:

Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings. The musculoskeletal effects of Lyme disease include brief attacks of joint pain or intermittent or persistent 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. Joint pain alone is not criteria for Lyme disease testing.

Do not perform magnetic resonance imaging (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 in clinical practice. Using MRI routinely is not cost-effective compared with the current standard of care, which includes clinical disease activity assessments and plain film radiography.

Do not prescribe biologic drugs for rheumatoid arthritis before a trial of methotrexate or other conventional non-biologic drugs. High-quality evidence suggests that methotrexate and other conventional non-biologic disease-modifying antirheumatic drugs (DMARD) are effective in many patients with RA. Initial therapy for RA should be conventional, non-biologic DMARDs unless there are other reasons to avoid their use. If a patient has had an inadequate response to methotrexate with or without other non-biologic DMARDs during an initial three-month trial, then biologic therapy can be considered. Exceptions include patients with high disease activity and poor prognostic features, such as functional limitations, disease outside the joints or bony damage, where biologic therapy may be an appropriate first-line treatment.

Do not routinely repeat Dual-energy X-ray Absorptiometry (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 DXA scans is uncertain. Because changes in bone density over short intervals are often smaller than the measurement error of most DXA scanners, testing more frequently than every two years is unnecessary in most patients. Therefore, DXAs should only be repeated if the result will influence clinical treatment, 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.

Do not test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease. Tests for ANA sub-serologies 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; the choice of autoantibodies should instead be guided by the specific disease under consideration.

“Rather than being a prescriptive set of rules, the list is meant to leave room for clinical judgment,” said Charles King, M.D., co-chair of the ACR’s Top Five task force. “This list will help the rheumatology community — patients, rheumatologists and rheumatology health professionals — have open conversations and identify the best, most cost-effective care for each individual.”

King and Saag point out that clinical autonomy is paramount; the choice of treatment is ultimately between the rheumatologist and his or her patients based on each patient’s clinical needs, values and preferences.