ACR issues guidelines for the treatment of five common rheumatic diseases

As part of its participation in the American Board of Internal Medicine Foundation’s Choosing Wisely campaign, the American College of Rheumatology has listed a set of reminders for the rheumatology community when dealing with the five common tests and treatments in rheumatology.

Published in the ACR’s journal, Arthritis Care & Research, the guidelines read:

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“Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate exam findings.”

Lyme disease’s musculoskeletal manifestations include arthralgia attacks or arthritis episodes in the joints, especially the knee. Without these features, there will be an increased risk of getting false positive results.

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“Do not perform magnetic resonance imaging (MRI) of the peripheral joints to routinely monitor inflammatory arthritis.”

MRI is inadequate to monitor inflammatory arthritis. It is also not cost-effective compared to clinical disease activity assessments and plain film radiography.

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“Do not prescribe biologic drugs for rheumatoid arthritis (RA) before a trial of methotrexate or other conventional non-biologic drugs.”

RA should be treated with methotrexate and other non-biologic disease-modifying antirheumatic drugs (DMARDs) because they are proven to be effective, unless a patient has an inadequate response to methotrexate during a three-month trial.

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“Do not routinely repeat Dual-energy X-ray Absorptiometry (DXA) scans more often than once every two years.”

DXA scans performed more frequently than every two years is unnecessary because “changes in bone density over short intervals are often smaller than the measurement error of most DXA scanners.”

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“Do not test anti-nuclear antibody (ANA) sub-serologies without a positive ANA and clinical suspicion of immune-mediated disease.”

If the ANA test is negative, the results of the ANA sub-serologies are also negative. The choice of autoantibodies should depend on the specific disease under consideration.

ACR says that these guidelines do not serve as a “prescriptive set of rules” but as reminder for the rheumatology community to discuss the best and cost-effective treatments for patients. Although clinical autonomy is important, the choice of treatment agreed by the rheumatologist and the patient must be based on the patient’s clinical needs, values, and preferences.

This blog of Dr. Kinga Vereczkey-Porter tackles multiple concepts in rheumatology and internal medicine.