Less may be more

Do you ever wonder how doctors make decisions related to your care in areas such as ordering tests, making a diagnosis, or prescribing a drug? Fortunately for today’s doctors and patients, years of accumulated medical knowledge inform the work of doctors and other health-care professionals as they work to diagnose and treat health conditions. Doctors also gain valuable experience during their years of practice. When individual experience is combined with best-practice standards established by medical organizations, knowledge gained from reading scientific studies, and other information supplied by medical organizations and drug companies, doctors can deliver care that is both personal and based on the collective wisdom of the medical profession.

For rheumatologists and other doctors who treat the over 120 types of arthritis, best-practice standards related to arthritis are outlined by the American College of Rheumatology (ACR). Headquartered in Atlanta, Georgia, the ACR is an international organization representing approximately 9,000 rheumatologists. The mission of the ACR is to improve the practice of rheumatology and help doctors successfully treat people who have problems with their joints, muscles, and bones.

The ACR is one of more than 30 medical societies that have contributed to the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign, an effort to improve health care and contain health-care costs by spreading the word about medical tests and treatments that may be unnecessary or even harmful. Each participating organization was asked to create a list of five things that should be questioned or avoided in their specialty; participating groups represented everyone from allergists to vascular surgeons. The ACR’s task team for this project compiled reviews of scientific data and sent questionnaires to 1,052 members of the ACR to find out what topics medical professionals felt should be addressed. The resulting list is not a specific prescription that needs to be followed. Instead, the “Five Things” list is intended to provoke discussion between doctors and patients about why, sometimes, a simpler test or treatment—or no test or treatment at all—may be the best course of action. Additional follow-up items that didn’t make the “Five Things” list, including items related to pediatric rheumatology and other common care issues, will be forthcoming from the ACR.

The ACR’s “Five Things Physicians and Patients Should Question” was published in the March 2013 edition of the ACR’s journal, Arthritis Care & Research, and is also available at www.ChoosingWisely.org. This article breaks down the ACR’s list, explaining the group’s recommendations for what to avoid in the areas of diagnostic tests, Lyme disease, MRIs of joints, drugs for rheumatoid arthritis, and bone density scans for osteoporosis.

Diagnostic tests

Here is the first of the ACR’s “Five Things”: Don’t test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease.

When a doctor is making a diagnosis, he may suspect that the patient has an autoimmune disorder such as rheumatoid arthritis or lupus. In an autoimmune disorder, the immune system mistakenly attacks healthy cells in the body. One way to broadly test for the presence of an autoimmune disorder is with an antinuclear antibody (ANA) test. Antibodies are proteins produced by the immune system that normally help to fight infection. In an autoimmune disorder, the immune system produces antibodies that target the nucleus of cells in the body. These antinuclear antibodies, if detected using the ANA test, don’t tell doctors much about your specific autoimmune disorder—only that you may have one. Since up to 15% of completely healthy people test positive for ANA, doctors should only order the test when a patient’s symptoms suggest an autoimmune disorder.

There are, however, other antibodies that doctors can test for to help pinpoint the specific autoimmune disorder that a patient may have. These antibodies, known as subserologies of ANA, have names such as double-stranded DNA, Smith, RNP, SSA, SSB, Scl-70, and centromere antibodies. The ACR’s recommendation states that tests for these additional antibodies should only be done when the first test, for ANA, comes back positive. This is because if someone tests negative for ANA, he will almost certainly test negative with the more specific antibody tests. There are a couple of exceptions to this rule: If a doctor thinks that someone is showing signs of myositis (muscle inflammation), an antibody test called anti-Jo1 may come back positive even if an ANA test was negative. If a patient is showing signs of lupus or Sjögren syndrome, a test for SSA antibodies may come back positive after a negative ANA test result. Lupus is characterized by a rash, sun sensitivity, fatigue, and joint pain and inflammation. Sjögren syndrome is another autoimmune rheumatic disease, in which glands that produce tears and saliva are destroyed, leading to dry mouth and eyes.

Whether an ANA test comes back positive or negative, the ACR recommends that any further testing for antibodies should be based on the specific disease or problem that a doctor suspects based on the patient’s symptoms, as opposed to casting a wide net and ordering multiple tests for antibodies. This rule can help both doctors and patients avoid unnecessary tests and their associated costs while arriving at a diagnosis in an orderly, efficient way.

Lyme disease

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

Lyme disease, a rheumatic disease, is transmitted to humans through the bite of a deer tick. Not all deer ticks are infected by the bacterium that causes Lyme disease. Symptoms of Lyme disease include fatigue, fever, and pain and inflammation in one or more joints—usually involving a large joint, especially the knee joint. A blood test for antibodies to the bacterium that causes it is used to diagnose Lyme disease, along with signs and symptoms of the disease, which usually include a bull’s-eye rash following a tick bite. Because the joint and muscle pains caused by Lyme disease are often similar to those caused by other types of arthritis (such as fibromyalgia), the blood test can help doctors arrive at the correct diagnosis. Unfortunately, though, the blood test for Lyme disease is not entirely reliable, sometimes giving a false positive result when the person does not actually have Lyme disease. The ACR recommends testing for Lyme disease only when a person’s symptoms are consistent with those of Lyme disease. General aches and pains alone are not enough to justify a test for the disease.

MRIs for monitoring

The ACR recommends: Don’t perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.

Magnetic resonance imaging (MRI) has been used to look at all parts of the body in great detail for about 25 years. In this process, protons located in hydrogen atoms in the water in the body are made to move by magnets in the imaging machine. Radio waves are then directed at the portion of the body being examined to create a picture of the movement of the protons, resulting in a clear picture of the tissues and bones. While useful, MRIs are still very expensive, and in rheumatoid arthritis and other types of inflammatory arthritis, the ACR recommends that they not be used for regular, ongoing monitoring of the condition.

When MRIs are used to view inflammation in the joints of people with arthritis, the degree of bone edema (swelling of the bone due to inflammation) seen may predict future joint damage and deterioration. However, there is no compelling evidence that MRIs lead to better treatment of arthritis for most people than the current standard of care, which is using traditional x-rays and clinical examinations to assess the level of inflammation in joints. Since MRIs are so expensive, they should be used in arthritis only when there is a special, compelling reason to do so.

Drugs for rheumatoid arthritis

The ACR recommends: Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional, nonbiologic DMARDs).

Methotrexate, a drug developed in the early 1980’s to treat cancer, has become the standard first-line drug treatment for rheumatoid arthritis. Prescribed in much lower doses than are used for cancer, the drug has been shown to control inflammation and help reduce joint damage. Its safety record is also excellent, with many people taking methotrexate for many years with few or no negative side effects.

Occasionally, there are reasons that someone should not take methotrexate or other disease-modifying antirheumatic drugs (DMARDs). However, the ACR recommends that for most people with rheumatoid arthritis, methotrexate and/or other DMARDs should be tried for at least three months before newer biologic drugs are considered. According to the ACR, biologics should be considered as a first-line treatment only if methotrexate is contraindicated (not advisable because it may harm the person) or if the person’s arthritis is already at an advanced stage, resulting in limitations in function, disease that reaches beyond the joints, seropositivity (testing positive for certain proteins in a blood test), or bone damage.

If methotrexate and/or other DMARDs have been tried for three months and both doctor and patient agree that inflammation is not under control, biologics can be started. It is important to remember that biologics are newer drugs with a shorter track record when it comes to safety and effectiveness, and they are not without the risk of side effects. This is why the ACR recommends trying what is generally considered the safest, best-tested, and least-costly drug before moving on to other options.

DXA scans

The ACR recommends: Don’t routinely repeat DXA scans more often than once every two years.
People thought to be at risk for osteoporosis should be screened according to the recommendations of the National Osteoporosis Foundation, using dual-energy x-ray absorptiometry (DXA) scans to measure bone density. Even in people who are taking drugs for osteoporosis, changes in bone density are usually slow to occur. The ACR generally recommends that after an initial DXA scan, follow-up scans should be done no more often than every two years. Scans should be done more frequently only if the course of treatment is expected to change because of the DXA results, or if rapid changes in bone density are expected as a result of an aggressive treatment plan. Studies have also demonstrated that in healthy women ages 67 or above whose DXA scans show normal bone density, follow-up scans may not be needed for up to 10 years, as long as there are no major changes in risk factors for osteoporosis. Although the DXA scan is a relatively simple procedure, the ACR’s guidelines can help doctors and patients avoid a needless test, saving money, time, and effort.

Talk to your doctor

Like all medical guidelines, the ACR’s “Five Things” are intended as recommendations for most people, not absolute rules for everyone. If you are concerned that your doctor is calling for tests or treatments that run counter to these recommendations, ask about it. There is probably a reason your doctor’s recommendation for care is different.

According to the ACR, the final decision on how to proceed with a patient’s care should be based on the doctor’s clinical judgment and the patient’s preferences. The goal of its “Five Things” list is to help doctors and patients make decisions that take cost-effectiveness and the waste of unnecessary tests and treatments into account. Ultimately, an approach that considers the needs, values, and preferences of patients, while still grounded in guidelines from groups like the ACR, will lead to the best care and best outcomes for people with arthritis.

Wendy McBrair spent 30 years as a health-care professional in the fields of rheumatology and orthopedics, where she specialized in patient and community service, patient education, and advocacy.

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