Five high-priced tests and treatments routinely used in rheumatology are often unnecessary, according to the American College of Rheumatology (ACR). The list of procedures, published recently in Arthritis Care & Research, is the ACR’s contribution to the Choosing Wisely campaign, a joint venture of the American Board of Internal Medicine Foundation and Consumer Reports. More than 35 other medical specialty societies have joined the campaign, which seeks to reduce the use of services that drive up health care costs and don't benefit patients.

Debate has been raging over how to cut back on high medical expenses. Choosing Wisely is not meant to dictate what is or isn’t appropriate, but to encourage “physicians, patients and other health care stakeholders to think and talk about medical tests and procedures that may be unnecessary, and in some instances can cause harm,” according to its website.

Charles M. King II, MD, a practicing rheumatologist at North Mississippi Medical Center in Tupelo, co-chaired the ACR’s Top 5 Task Force with Jinoos Yazdany, MD, assistant professor of medicine in the division of rheumatology at the University of California, San Francisco. Both say the selection process for picking the Top 5 was rigorous and based on scientific evidence.

“The task force generated a list of more than 100 [tests and treatments] commonly ordered by rheumatologists that were expensive and/or lacked evidence of significant benefit,” Dr. King explains.

After being pared down to 22 items, the list was sent to all ACR members in the United States. The membership survey resulted in 10 items, from which the top five were selected based on the best scientific evidence.

“We were expecting that some of these issues might be thorny or lead to a lot of debate … but in fact, there was far more agreement than there was disagreement,” Dr. Yazdany says.

The following recommendations are the Top 5:

1. Don’t test antinuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.

An ANA test is used to help screen for autoimmune disorders, such as lupus, Sjögren’s syndrome and juvenile arthritis. Antinuclear antibodies are seen in many medical conditions as well as in some healthy people, so a positive ANA test is often followed by a panel of tests – subsets of the original – to confirm the diagnosis. Because these tests are usually negative if the ANA test is negative, the ACR recommends against performing them in the absence of a positive ANA. Exceptions include a test called anti-Jo-1, which can be positive in some forms of myositis, and an anti-SSA test in lupus or Sjögren’s syndrome.
 

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.