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

Lyme disease, a tick-borne infection, can cause many problems, including arthritis in large joints such as the knee. But people with mild joint or muscle pain who don’t fit the Lyme disease profile often undergo testing, leading to false-positive results and unnecessary treatment. Dr. King says patients who have not been exposed to ticks and show no symptoms other than widespread aches and pains should not be tested.

3. Don’t perform magnetic resonance imaging (MRI) of the peripheral joints to routinely monitor inflammatory arthritis.

The ACR says MRI tests don’t provide enough information to justify their use in routine monitoring of rheumatoid arthritis (RA). Instead, it recommends that doctors continue to follow the current standard of care: monitoring with clinical disease activity assessments and X-rays.

4. Don’t prescribe biologics for RA before a trial of methotrexate or other conventional, non-biologic disease-modifying antirheumatic drugs (DMARDs). 

Genetically engineered biologics such as adalimumab (Humira), etanercept (Enbrel) and abatacept (Orencia) are used to treat RA and other types of autoimmune arthritis. They help about two-thirds of people who take them, but are expensive – about $2,000 per month on average – and can have serious side effects. Dr. King says use of biologics is not recommended until other medications have been tried and failed to provide relief. “There is abundant evidence that for most patients with newly diagnosed arthritis, conventional, non-biologic DMARDs are effective with much lower cost compared to the biologics. In fact, the 2012 update of the ACR treatment guidelines recommends that initial therapy for most patients should be with a non-biologic DMARD [such as methotrexate].” Exceptions are patients with high disease activity and a poor prognosis.

5. Don’t routinely repeat dual-energy X-ray absorptiometry (DXA) scans more than once every two years.

DXA scans help predict fracture risk, which increases with RA and with corticosteroid therapy. Although some people have these tests annually, bone-density changes over such short intervals are smaller than the measurement error of DXA scanners. The tests should be repeated only if the result will change the treatment for a patient, or if rapid changes in bone density are expected.

Dr. Yazdany stresses that the ACR list is not meant to be prescriptive or take the place of a provider’s clinical judgment. Instead, it’s intended to facilitate discussions between patients and physicians.

“The list is an important conversation-starter,” agrees Dr. King. “To initiate the conversation with my patients, I have posted the Top 5 list in exam rooms, hoping to urge patients to participate in health care decision-making. I believe the most difficult thing for providers to do is nothing. It is easy to order tests and treatments, but at times, it may be more important to explain why a test or treatment may not be appropriate. The Top 5 list is empowering and makes it easier for patients to be better informed and engaged in their care.”

Later this year, the ACR will release another Top 5 list identifying unnecessary or unusually expensive procedures commonly used in treating children and adolescents with rheumatic diseases.