Rheumatologists Name 5 Tests to Reconsider

Janis C. Kelly

February 28, 2013

Testing antinuclear antibody (ANA) subserologies without a positive ANA screen, Lyme disease testing without exposure history and large-joint arthralgia, peripheral joint magnetic resonance imaging (MRI) for routine monitoring for rheumatoid arthritis (RA), biologics for RA without a trial of methotrexate, and dual-energy X-ray absorptiometry (DXA) more frequently than every 2 years all made the American College of Rheumatology's top 5 list of things physicians and patients should question, published in the March issue of Arthritis Care & Research.

The list, developed by a team headed by Jinoos Yazdany, MD, MPH, assistant professor of medicine and associate director of the lupus clinic at University of California, San Francisco, is rheumatology's part of the American Board of Internal Medicine Foundation's Choosing Wisely campaign, a joint effort among 17 medical societies to reduce the use of unnecessary tests and procedures.

The authors repeatedly stress clinical judgment in the use of these 5 tests. "It is important for people to realize that none of the items on our list are meant to be 'never events,' " Dr. Yazdany told Medscape Medical News. "In fact, they may be quite appropriate in certain clinical circumstances. Using blunt approaches, like using the list to deny insurance reimbursement, would be inappropriate. Instead, we see this as a tool that patients can use to make informed healthcare decisions, and that we as physicians can use to build a high-value healthcare system."

Too Much ANA Testing

The ACR's top recommendation is not to test for ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease, as most subserologies are negative if the ANA is negative.

Dr. Yazdany said, "Serial ANA testing in patients with known connective tissue diagnoses like lupus does not add new clinical information. ANA is not a useful marker of disease activity.... These are examples of unnecessary tests that add little value for patients."

Filemon K. Tan, MD, PhD, professor of medicine, Division of Rheumatology, University of Texas-Houston Medical School, reviewed the study for Medscape Medical News. Dr. Tan said, "The most difficult one is number 1, because it is largely out of our control as long as every resident, primary care physician, and nurse practitioner can order these test without thinking if this test is appropriate. The other issue is lack of standardized methods, with confusing reporting ranges (to [primary care physicians]) of the ANA among commercial labs often leading to false-positives."

Participants in the ACR survey shared Dr. Tan's concern. Dr. Yazdany told Medscape Medial News, "We need to move beyond educational initiatives like traditional [continuing medical education]. Instead, we need to build systems that allow transfer of knowledge between physicians at the point of care, [such as] electronic preconsultation exchange, where a specialist is on hand to provide advice to colleagues shortly after or during the patient's encounter."

Fewer Lyme Tests

The second recommendation is against testing for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.

According to Dr. Yazdany, almost 3 million tests for Lyme disease are done each year in the United States, at an estimated cost of $100 million dollars. She recommends against testing for patients with no risk factors for exposure, who do not live and have not traveled to endemic areas and who do not have symptoms consistent with Lyme disease.

"What most people do not realize is that when the test is sent, patients often end up on antibiotics, regardless of the results. Aside from the extra costs, unnecessary treatment can potentially harm patients because of drug side effects and increased resistance to antibiotics," Dr. Yazdany said.

Less Imaging

The ACR committee also recommended against MRI of peripheral joints for monitoring RA until that approach is validated against currently available prognostic markers. Current standard of care includes clinical disease activity assessments and plain film radiography.

Dr. Tan agreed with this recommendation with regard to monitoring, but not for diagnosis. "In cases where there is a good history, unhelpful labs, and ambiguous clinical findings, advanced imaging such as contrast-enhanced MRI or [musculoskeletal ultrasound imaging] as an initial study (when X-rays are negative) does have a role and is often helpful in my experience," Dr. Tan said.

The other imaging recommendation was not to repeat DXA scans more often than every 2 years because the changes in bone density over short intervals are often smaller than the measurement error of most DXA scanners.

RA: Try Methotrexate First

The major treatment recommendation was not to prescribe biologics for RA without a 3-month trial of methotrexate or other conventional nonbiologic disease-modifying antirheumatic drugs. Exceptions include patients with high disease activity and disability or poor prognostic features such as disease outside the joints or bony damage.

Various authors have received speaking fees, consulting fees, and/or honoraria from Abbott, Amgen, Ardea, Eli Lilly, Merck, Regeneron, Savient, URL, and UCB. Dr. Yazdany and Dr. Tan have disclosed no relevant financial relationships.

Arthritis Care Res. 2013;65:329-339. Abstract