Rheumatology
Canadian Rheumatology Association
Last updated: May 2025
-
ANA testing should not be used to screen people without specific symptoms (e.g., malar rash, symmetrical polyarthritis, etc.) or without a clinical evaluation that may lead to a presumptive diagnosis of SLE or other SARD (e.g. Sjögren’s disease, systemic sclerosis, idiopathic inflammatory myopathy), since ANA reactivity is present in many non-rheumatic conditions and even in “healthy” individuals (up to 20%). In a patient with low pre-test probability for ANA-associated rheumatic disease, positive ANA results can be misleading and may precipitate further unnecessary testing, erroneous diagnoses or even inappropriate therapy.
Sources:
BC Guidelines. Antinuclear antibody (ANA) testing protocol [Internet]. 2013 Jun [cited 2017 May 5].
Bonroy C, et al. Detection of antinuclear antibodies: recommendations from EFLM, EASI, and ICAP. Clin Chem Lab Med. 2023 Mar 29;61(7):1167-98. PMID: 36989417.
Kavanaugh A, et al. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med. 2000 Jan;124(1):71-81. PMID: 10629135.
Solomon DH, et al. Evidence-based guidelines for the use of immunologic tests: Antinuclear antibody testing. Arthritis Rheum. 2002 Aug;47(4):434-44. PMID: 12209492.
Tozzoli R, et al. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol. 2002 Feb;117(2):316-24. PMID: 11863229.
-
HLA-B27 testing is not useful as a single diagnostic test in a patient with low back pain without further spondyloarthritis (SpA) signs or symptoms (e.g., inflammatory back pain ≥3 months duration with age of onset <45 years, peripheral synovitis, enthesitis, dactylitis, psoriasis or uveitis) because the diagnosis of spondyloarthritis in these patients is of low probability. If HLA-B27 is used, at least two SpA signs or symptoms, or the presence of positive imaging findings, need to be present to classify a patient as having axial SpA. There is no clinical utility to ordering an HLA-B27 in the absence of positive imaging or the minimally required SpA signs or symptoms.
Sources:
Poddubnyy D, et al. Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis. Ann Rheum Dis. 2015 Aug;74(8):1483-7. PMID: 25990288.
Rostom S, et al. New tools for diagnosing spondyloarthropathy. Joint Bone Spine. 2010 Mar;77(2):108-14. PMID: 20153677.
Rudwaleit M, et al. How to diagnose axial spondyloarthritis early. Ann Rheum Dis. 2004 May;63(5):535-43. PMID: 15082484.
Rudwaleit M, et al. The development of assessment of SpondyloArthritis international society classification criteria for axial spondyloarthritis (part II): Validation and final selection. Ann Rheum Dis. 2009 Jun;68(6):777-83. PMID: 19297344.
Sidiropoulos PI, et al. Evidence-based recommendations for the management of ankylosing spondylitis: Systematic literature search of the 3E initiative in rheumatology involving a broad panel of experts and practising rheumatologists. Rheumatology (Oxford). 2008 Mar;47(3):355-61. PMID: 18276738.
-
The use of repeat DEXA scans at intervals of every 2-3 years is appropriate in most clinical settings, and is supported by several current osteoporosis guidelines. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in BMD. If bone mineral densities are stable and/or individuals are at low risk of fracture, then less frequent monitoring up to an interval of 5-10 years can be considered. Shorter or longer intervals between repeat DEXA scans may be appropriate based on expected rate of change in bone mineral density and fracture risk.
Sources:
Buckley L, et al. 2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol. 2017 Aug; 69 (8):15521-1537. PMID: 28585373.
Morin S, et al. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023 Oct 10; 195 (39):E1333-E1348. PMID: 37816527.
Schousboe JT, et al. Executive summary of the 2013 international society for clinical densitometry position development conference on bone densitometry. J Clin Densitom. 2013 Oct-Dec;16(4):455-66. PMID: 24183638.
U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2011 Mar 1;154(5):356-64. PMID: 21242341.
Related Resources:
Patient Pamphlet: Bone Density Tests: When you need them and when you don’t
-
There is no convincing evidence that anti-osteoporotic therapy in patients with osteopenia alone reduces fracture risk. The 2008 Cochrane Reviews for three bisphosphonates (Alendronate, Etidronate, Risedronate) found no statistically significant reductions for primary prevention of fracture in postmenopausal women. Fracture risk is determined using either the Canadian Association of Radiologists and Osteoporosis Canada risk assessment tool (CAROC) or FRAX®, a World Health Organization fracture risk assessment tool. Both are available as online calculators of fracture risk. Given the lack of proven efficacy, widespread use of anti-osteoporotic therapy in patients at low risk of fracture is not currently recommended.
Sources:
FRAX®. WHO fracture risk assessment tool [Internet]. 2011 Jun [cited 2017 May 5].
Morin S, et al. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023 Oct 10; 195 (39):E1333-E1348. PMID: 37816527.
Roux C. Osteopenia: Is it a problem? Int J Clin Rheumtol. 2009 Dec;4(6):651-5.
Wells GA, et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001155. PMID: 18253985.
Wells GA, et al. Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003376. PMID: 18254018.
Wells G, et al. Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004523. PMID: 18254053.
Related Resources:
Patient Pamphlet: Treating Rheumatoid Arthritis: “Non-biologic” drugs are a better first choice
Patient Decision Aid: Mayo Clinic’s Bone Health Choice Decision Aid
-
The diagnosis of peripheral and axial inflammatory arthritis can usually be made on the basis of an appropriate history, physical exam and basic investigations. Whole body bone scans, such as the Tc-99m MDP scintigraphy, lack specificity to diagnose inflammatory polyarthritis or spondyloarthritis and have limited clinical utility. This approach is cost-effective and reduces radiation exposure.
Sources:
Fisher BA, et al. Do tc-99m-diphosphonate bone scans have any place in the investigation of polyarthralgia? Rheumatology (Oxford). 2007 Jun;46(6):1036-7. PMID: 17449485.
Picano E, et al. Unnecessary radiation exposure from medical imaging in the rheumatology patient. Rheumatology (Oxford). 2011 Sep;50(9):1537-9. PMID: 21183451.
Song IH, et al. The diagnostic value of scintigraphy in assessing sacroiliitis in ankylosing spondylitis: A systematic literature research. Ann Rheum Dis. 2008 Nov;67(11):1535-40. PMID: 18230629.
Whallett A, et al. Isotope bone scans: An assessment of their diagnostic use in polyarticular pain of uncertain origin. Ann Rheum Dis. 2003 Aug;62(8):784-5. PMID: 12860741.
-
Opioids in chronic non-cancer pain are associated with substantial risks. Optimize non-opioid pharmacotherapy and non-pharmacologic therapy. Opioids are not superior to non-opioid medications for pain-related function over 12 months in moderate to severe hip or knee osteoarthritis, or mechanical back pain. Opioids should only be prescribed by physicians skilled in their use.
Sources:
Busse JW, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666. PMID: 28483845.
Krebs EE, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018; 319(9):872–882. PMID: 29509867.
-
A palliative approach to care alongside disease-specific treatment should be part of the continuum of care for patients with advanced rheumatic disease toward the end of life. This approach aims to improve quality of life for patients with life-limiting illnesses, through the prevention and relief of suffering, the control of symptoms, and the management of physical, psychosocial and spiritual distress. Such an approach is supported by a growing body of evidence that demonstrates improved patient satisfaction with care, decreased symptom burden and, in some cases, better survival, when a palliative approach to care is integrated early in a patient’s disease trajectory.
Sources:
Crosby V, Wilcock A. End-of-life care in rheumatolog: room for improvement. Rheumatology (Oxford). 2011 Jul;50(7):1187-8. PMID: 21097447.
Karpoff M, et al. 2019, November. Palliative Care Curriculum in Rheumatology: Teaching Serious Illness Conversations. Paper presented at the meeting of American College of Rheumatology, USA.
Saltman A. Palliative Care for the Rheumatologist: When Does the End Begin…And Why Does It Matter? CRAJ. 2019;29(2). [Internet].
Saltman A, et al. (2020, November). Rheumatologists’ Attitudes Toward Palliative Care and Medical Assistance in Dying. [Poster presentation]. American College of Rheumatology, Online (ACR Convergence).
Simon S, Schwarz-Eywill M, Bausewein C. Palliative care in rheumatic diseases: a first approach. J Palliat Care. Winter 2008;24(4):270-3. PMID: 19227019.
-
Patients on stable doses of non-biologic DMARDs (e.g., methotrexate, sulfasalazine) without specific comorbidities (e.g., obesity, diabetes mellitus, renal disease, liver disease, alcohol use, concomitant use of hepatotoxic or myelosuppressive medications) are at a low overall risk of toxicity. More frequent blood draws pose an unnecessary burden to patients. Patients new to treatment, on escalating doses, or with abnormal baseline labs typically require more frequent monitoring.
Sources:
Hideto Kameda, Takao Fujii, Ayako Nakajima, Ryuji Koike, Akira Sagawa, Katsuaki Kanbe, Tetsuya Tomita, Masayoshi Harigai, Yasuo Suzuki & Japan College of Rheumatology subcommittee on the guideline for the use of methotrexate in patients with rheumatoid arthritis (2019) Japan College of Rheumatology guideline for the use of methotrexate in patients with rheumatoid arthritis, Modern Rheumatology, 29:1, 31-40, DOI: 10.1080/14397595.2018.1472358. PMID: 29718746.
Jo Ledingham, Nicola Gullick, Katherine Irving, Rachel Gorodkin, Melissa Aris, Jean Burke, Patrick Gordon, Dimitrios Christidis, Sarah Galloway, Eranga Hayes, Andrew Jeffries, Scott Mercer, Janice Mooney, Sander van Leuven, James Galloway, on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs, Rheumatology, Volume 56, Issue 6, June 2017, Pages 865–868, https://doi.org/10.1093/rheumatology/kew479. PMID: 28339817.
Nakafero G, Grainge MJ, Card T, Mallen CD, Zhang W, Doherty M, Taal MW, Aithal GP, Abhishek A. What is the incidence of methotrexate or leflunomide discontinuation related to cytopenia, liver enzyme elevation or kidney function decline? Rheumatology (Oxford). 2021 Dec 1;60(12):5785-5794. doi: 10.1093/rheumatology/keab254. PMID: 33725120.
Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O’Dell J, King C, Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St Clair EW, Tindall E, Miller AS, McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2016 Jan;68(1):1-26. doi: 10.1002/art.39480. Epub 2015 Nov 6. PMID: 26545940.
Yazici, Y et al. “Long term safety of methotrexate in routine clinical care: discontinuation is unusual and rarely the result of laboratory abnormalities.” Annals of the rheumatic diseases vol. 64,2 (2005): 207-11. doi:10.1136/ard.2004.023408. PMID: 15208176.
-
Avoid ordering these autoantibodies in patients with arthralgia (joint pain) but who do not meet the CSA criteria or have arthritis (>one swollen joint) on physical exam. EULAR defines CSA at risk for developing Rheumatoid Arthritis (RA) as having 3 or more parameters including new joint symptoms <1 year, symptoms located in metacarpophalangeal (MCP) joints, morning stiffness >60 min, most severe symptoms in the morning, 1st degree relative with RA, and difficulty making a fist and positive MCP squeeze test on physical exam. Even in CSA with positive RF and ACPA, more than 30%-60% of patients will not develop RA over the next two years. Most musculoskeletal pain causing global disability is not related to rheumatoid arthritis. Inappropriate testing of RF serology in patients with low likelihood of RA is associated with low positive predictive value (PPV) and increased cost.
Sources:
Ahrari A, Barrett SS, Basharat P, Rohekar S, Pope JE: Appropriateness of laboratory tests in the diagnosis of inflammatory rheumatic diseases among patients newly referred to rheumatologists. Joint Bone Spine 2020, 87(6):588-595. PMID: 32522598.
Bos WH, Wolbink GJ, Boers M, Tijhuis GJ, de Vries N, van der Horst-Bruinsma IE, Tak PP, van de Stadt RJ, van der Laken CJ, Dijkmans BA et al: Arthritis development in patients with arthralgia is strongly associated with anti-citrullinated protein antibody status: a prospective cohort study. Ann Rheum Dis 2010, 69(3):490-494. PMID: 19363023.
Briggs AM, Woolf AD, Dreinhöfer K, Homb N, Hoy DG, Kopansky-Giles D, Åkesson K, March L: Reducing the global burden of musculoskeletal conditions. Bull World Health Organ 2018, 96(5):366-368. PMID: 29875522.
Ruta S, Prado ES, Chichande JT, Ruta A, Salvatori F, Magri S, Salinas RG: EULAR definition of “arthralgia suspicious for progression to rheumatoid arthritis” in a large cohort of patients included in a program for rapid diagnosis: role of auto-antibodies and ultrasound. Clinical Rheumatology 2020, 39(5):1493-1499. PMID: 31933033.
Ten Brinck RM, van Steenbergen HW, van Delft MAM, Verheul MK, Toes REM, Trouw LA, van der Helm-van Mil AHM: The risk of individual autoantibodies, autoantibody combinations and levels for arthritis development in clinically suspect arthralgia. Rheumatology (Oxford) 2017, 56(12):2145-2153. PMID: 28968865.
-
In addition to increasing healthcare costs and blood draws from patients, redundant diagnostic testing for rheumatic disease adds carbon emissions through sample procurement, equipment, and processing. Beyond the tests themselves, patient transport to/from facilities and sample transport (including, for some tests, across institutions, provinces, or countries) adds to the carbon footprint. Ordering providers need to consider the reliability and validity of prior results, as well as the patients’ clinical evolution, when deciding whether repeat testing could be justified.
Because repeat testing may occur if test results performed elsewhere are not readily available, integrating electronic medical records across systems to facilitate rapid retrieval of external test results may curb redundant testing without contributing to providers’ administrative burden. Within a single health system, testing algorithms could prevent inadvertent repeat testing.
Sources:
Lake S, Yao Z, Gakhal N, et al. Frequency of repeat antinuclear antibody testing in Ontario: a population-based descriptive study. CMAJ Open (2020) 8(1):E184-190. PMID: 32184282.
Man A, Shojania J, Phoon C, et al. An evaluation of autoimmune antibody testing patterns in a Canadian health region and an evaluation of a laboratory algorithm aimed at reducing unnecessary testing. Clin Rheumatol (2013) 32:601-608. PMID: 23292519.
-
Joint aspirations and injections create biohazardous and non-biohazardous waste. Since biohazardous waste is incinerated before going to the landfill, it generates higher greenhouse gas emissions than other types of waste disposal. Avoid placing regular, non-biohazardous waste in biohazard/sharps containers to reduce unnecessary incineration and associated emissions.
Sources:
Jakik-Karpinska E, Brancaleoni R, Niemcewicz M, et al. Healthcare waste- a serious problem for global health. Healthcare (Basel). 2023, 11 (2) 242. PMID: 36673610.
Yves Chartier, Jorge Emmanuel, Ute Pieper, Annette Prüss, Philip Rushbrook, Ruth Stringer, William Townend, Susan Wilburn and Raki Zghondi, Eds. Safe management of wastes from health-care activities, 2nd Ed. World Health Organization, June 2014, WHO World Press, Geneva, Switzerland.
-
Recommendations 1 – 5
The Canadian Rheumatology Association (CRA) established its Choosing Wisely Canada Top 5 recommendations using a multistage process combining consensus methodology and literature reviews. A steering committee solicited a group of practicing rheumatologists from across the country from diverse clinical settings and an allied health professional to form the CRA Choosing Wisely Canada committee. This group generated candidate recommendations using the Delphi method. Recommendations with high content agreement and perceived prevalence advanced to a survey of CRA members. CRA members ranked these top items based on content agreement, impact and item ranking. A methodology subcommittee discussed the items in light of their relevance to rheumatology, potential impact on patients and the member survey results. The Top 5 candidate items were selected to advance for literature review. The list was approved by the CRA Board of Directors and has been reviewed by a group of patient collaborators with rheumatic diseases. Patient collaborators also worked with the CRA to ensure the CRA Choosing Wisely Canada statements were translated into lay-language and made accessible to patients and the public.
Recommendations 6 & 7
Recommendation 6 was approved by the CRA board in September, 2019. The statement was created by the CRA Choosing Wisely subcommittee and was selected for having good evidence and for being frequently encountered by rheumatologists. The statement was then adjudicated by the CRA Guidelines committee and the CRA Board, and the statement was further modified for language by the group.
Recommendation 7 was approved by the CRA board in February, 2021. This statement was created by the CRA Choosing Wisely subcommittee in response to the Choosing Wisely Canada campaign about serious illness conversations entitled “Time to Talk.” The subcommittee liaised with a palliative care doctor on the wording of the statement, given the scarcity of evidence in this area to date in rheumatology.
Recommendations 8 & 9
Recommendations 8 and 9 were approved by the CRA board in June, 2022. These items were identified from the paediatric rheumatology Choosing Wisely list as being frequently encountered problems by adult rheumatologists. A working group of the CRA Choosing Wisely subcommittee was formed, and they completed an updated literature review of the topic and developed their own statement. The statement was then adjudicated by the CRA Choosing Wisely subcommittee, the CRA Quality Care committee, and then the CRA Board of Directors. Modifications were made as needed.
-
Choosing Wisely Canada’s climate-conscious recommendations are developed by clinician societies to improve planetary health without compromising patient care. These recommendations highlight everyday practices we can reduce or eliminate to minimize environmental harm. Visit our climate page to explore all the recommendations and learn more.
Sources:
BC Guidelines. Antinuclear antibody (ANA) testing protocol [Internet]. 2013 Jun [cited 2017 May 5].
Bonroy C, et al. Detection of antinuclear antibodies: recommendations from EFLM, EASI, and ICAP. Clin Chem Lab Med. 2023 Mar 29;61(7):1167-98. PMID: 36989417.
Kavanaugh A, et al. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med. 2000 Jan;124(1):71-81. PMID: 10629135.
Solomon DH, et al. Evidence-based guidelines for the use of immunologic tests: Antinuclear antibody testing. Arthritis Rheum. 2002 Aug;47(4):434-44. PMID: 12209492.
Tozzoli R, et al. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol. 2002 Feb;117(2):316-24. PMID: 11863229.
Poddubnyy D, et al. Development of an ASAS-endorsed recommendation for the early referral of patients with a suspicion of axial spondyloarthritis. Ann Rheum Dis. 2015 Aug;74(8):1483-7. PMID: 25990288.
Rostom S, et al. New tools for diagnosing spondyloarthropathy. Joint Bone Spine. 2010 Mar;77(2):108-14. PMID: 20153677.
Rudwaleit M, et al. How to diagnose axial spondyloarthritis early. Ann Rheum Dis. 2004 May;63(5):535-43. PMID: 15082484.
Rudwaleit M, et al. The development of assessment of SpondyloArthritis international society classification criteria for axial spondyloarthritis (part II): Validation and final selection. Ann Rheum Dis. 2009 Jun;68(6):777-83. PMID: 19297344.
Sidiropoulos PI, et al. Evidence-based recommendations for the management of ankylosing spondylitis: Systematic literature search of the 3E initiative in rheumatology involving a broad panel of experts and practising rheumatologists. Rheumatology (Oxford). 2008 Mar;47(3):355-61. PMID: 18276738.
Buckley L, et al. 2017 American College of Rheumatology Guideline for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis. Arthritis Rheumatol. 2017 Aug; 69 (8):15521-1537. PMID: 28585373.
Morin S, et al. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023 Oct 10; 195 (39):E1333-E1348. PMID: 37816527.
Schousboe JT, et al. Executive summary of the 2013 international society for clinical densitometry position development conference on bone densitometry. J Clin Densitom. 2013 Oct-Dec;16(4):455-66. PMID: 24183638.
U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med. 2011 Mar 1;154(5):356-64. PMID: 21242341.
Related Resources:
Patient Pamphlet: Bone Density Tests: When you need them and when you don’t
FRAX®. WHO fracture risk assessment tool [Internet]. 2011 Jun [cited 2017 May 5].
Morin S, et al. Clinical practice guideline for management of osteoporosis and fracture prevention in Canada: 2023 update. CMAJ. 2023 Oct 10; 195 (39):E1333-E1348. PMID: 37816527.
Roux C. Osteopenia: Is it a problem? Int J Clin Rheumtol. 2009 Dec;4(6):651-5.
Wells GA, et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001155. PMID: 18253985.
Wells GA, et al. Etidronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003376. PMID: 18254018.
Wells G, et al. Risedronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD004523. PMID: 18254053.
Related Resources:
Patient Pamphlet: Treating Rheumatoid Arthritis: “Non-biologic” drugs are a better first choice
Patient Decision Aid: Mayo Clinic’s Bone Health Choice Decision Aid
Fisher BA, et al. Do tc-99m-diphosphonate bone scans have any place in the investigation of polyarthralgia? Rheumatology (Oxford). 2007 Jun;46(6):1036-7. PMID: 17449485.
Picano E, et al. Unnecessary radiation exposure from medical imaging in the rheumatology patient. Rheumatology (Oxford). 2011 Sep;50(9):1537-9. PMID: 21183451.
Song IH, et al. The diagnostic value of scintigraphy in assessing sacroiliitis in ankylosing spondylitis: A systematic literature research. Ann Rheum Dis. 2008 Nov;67(11):1535-40. PMID: 18230629.
Whallett A, et al. Isotope bone scans: An assessment of their diagnostic use in polyarticular pain of uncertain origin. Ann Rheum Dis. 2003 Aug;62(8):784-5. PMID: 12860741.
Busse JW, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189(18):E659-E666. PMID: 28483845.
Krebs EE, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018; 319(9):872–882. PMID: 29509867.
Crosby V, Wilcock A. End-of-life care in rheumatolog: room for improvement. Rheumatology (Oxford). 2011 Jul;50(7):1187-8. PMID: 21097447.
Karpoff M, et al. 2019, November. Palliative Care Curriculum in Rheumatology: Teaching Serious Illness Conversations. Paper presented at the meeting of American College of Rheumatology, USA.
Saltman A. Palliative Care for the Rheumatologist: When Does the End Begin…And Why Does It Matter? CRAJ. 2019;29(2). [Internet].
Saltman A, et al. (2020, November). Rheumatologists’ Attitudes Toward Palliative Care and Medical Assistance in Dying. [Poster presentation]. American College of Rheumatology, Online (ACR Convergence).
Simon S, Schwarz-Eywill M, Bausewein C. Palliative care in rheumatic diseases: a first approach. J Palliat Care. Winter 2008;24(4):270-3. PMID: 19227019.
Hideto Kameda, Takao Fujii, Ayako Nakajima, Ryuji Koike, Akira Sagawa, Katsuaki Kanbe, Tetsuya Tomita, Masayoshi Harigai, Yasuo Suzuki & Japan College of Rheumatology subcommittee on the guideline for the use of methotrexate in patients with rheumatoid arthritis (2019) Japan College of Rheumatology guideline for the use of methotrexate in patients with rheumatoid arthritis, Modern Rheumatology, 29:1, 31-40, DOI: 10.1080/14397595.2018.1472358. PMID: 29718746.
Jo Ledingham, Nicola Gullick, Katherine Irving, Rachel Gorodkin, Melissa Aris, Jean Burke, Patrick Gordon, Dimitrios Christidis, Sarah Galloway, Eranga Hayes, Andrew Jeffries, Scott Mercer, Janice Mooney, Sander van Leuven, James Galloway, on behalf of the BSR and BHPR Standards, Guidelines and Audit Working Group, BSR and BHPR guideline for the prescription and monitoring of non-biologic disease-modifying anti-rheumatic drugs, Rheumatology, Volume 56, Issue 6, June 2017, Pages 865–868, https://doi.org/10.1093/rheumatology/kew479. PMID: 28339817.
Nakafero G, Grainge MJ, Card T, Mallen CD, Zhang W, Doherty M, Taal MW, Aithal GP, Abhishek A. What is the incidence of methotrexate or leflunomide discontinuation related to cytopenia, liver enzyme elevation or kidney function decline? Rheumatology (Oxford). 2021 Dec 1;60(12):5785-5794. doi: 10.1093/rheumatology/keab254. PMID: 33725120.
Singh JA, Saag KG, Bridges SL Jr, Akl EA, Bannuru RR, Sullivan MC, Vaysbrot E, McNaughton C, Osani M, Shmerling RH, Curtis JR, Furst DE, Parks D, Kavanaugh A, O’Dell J, King C, Leong A, Matteson EL, Schousboe JT, Drevlow B, Ginsberg S, Grober J, St Clair EW, Tindall E, Miller AS, McAlindon T. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Rheumatol. 2016 Jan;68(1):1-26. doi: 10.1002/art.39480. Epub 2015 Nov 6. PMID: 26545940.
Yazici, Y et al. “Long term safety of methotrexate in routine clinical care: discontinuation is unusual and rarely the result of laboratory abnormalities.” Annals of the rheumatic diseases vol. 64,2 (2005): 207-11. doi:10.1136/ard.2004.023408. PMID: 15208176.
Ahrari A, Barrett SS, Basharat P, Rohekar S, Pope JE: Appropriateness of laboratory tests in the diagnosis of inflammatory rheumatic diseases among patients newly referred to rheumatologists. Joint Bone Spine 2020, 87(6):588-595. PMID: 32522598.
Bos WH, Wolbink GJ, Boers M, Tijhuis GJ, de Vries N, van der Horst-Bruinsma IE, Tak PP, van de Stadt RJ, van der Laken CJ, Dijkmans BA et al: Arthritis development in patients with arthralgia is strongly associated with anti-citrullinated protein antibody status: a prospective cohort study. Ann Rheum Dis 2010, 69(3):490-494. PMID: 19363023.
Briggs AM, Woolf AD, Dreinhöfer K, Homb N, Hoy DG, Kopansky-Giles D, Åkesson K, March L: Reducing the global burden of musculoskeletal conditions. Bull World Health Organ 2018, 96(5):366-368. PMID: 29875522.
Ruta S, Prado ES, Chichande JT, Ruta A, Salvatori F, Magri S, Salinas RG: EULAR definition of “arthralgia suspicious for progression to rheumatoid arthritis” in a large cohort of patients included in a program for rapid diagnosis: role of auto-antibodies and ultrasound. Clinical Rheumatology 2020, 39(5):1493-1499. PMID: 31933033.
Ten Brinck RM, van Steenbergen HW, van Delft MAM, Verheul MK, Toes REM, Trouw LA, van der Helm-van Mil AHM: The risk of individual autoantibodies, autoantibody combinations and levels for arthritis development in clinically suspect arthralgia. Rheumatology (Oxford) 2017, 56(12):2145-2153. PMID: 28968865.
Lake S, Yao Z, Gakhal N, et al. Frequency of repeat antinuclear antibody testing in Ontario: a population-based descriptive study. CMAJ Open (2020) 8(1):E184-190. PMID: 32184282.
Man A, Shojania J, Phoon C, et al. An evaluation of autoimmune antibody testing patterns in a Canadian health region and an evaluation of a laboratory algorithm aimed at reducing unnecessary testing. Clin Rheumatol (2013) 32:601-608. PMID: 23292519.
Jakik-Karpinska E, Brancaleoni R, Niemcewicz M, et al. Healthcare waste- a serious problem for global health. Healthcare (Basel). 2023, 11 (2) 242. PMID: 36673610.
Yves Chartier, Jorge Emmanuel, Ute Pieper, Annette Prüss, Philip Rushbrook, Ruth Stringer, William Townend, Susan Wilburn and Raki Zghondi, Eds. Safe management of wastes from health-care activities, 2nd Ed. World Health Organization, June 2014, WHO World Press, Geneva, Switzerland.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Canadian Rheumatology Association
Last updated: May 2025
-
Anti-nuclear antibody (ANA) should not be used as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus or other systemic autoimmune rheumatic disease (e.g. inflammatory arthritis, malar rash, photosensitivity, etc.) since ANA positivity may occur in non-rheumatic conditions and in “healthy” populations (up to 20%). In consideration of juvenile idiopathic arthritis (JIA), a positive ANA indicates increased risk of uveitis, but is not a useful screening test for the diagnosis of JIA. Inappropriate ANA testing may be misleading, precipitate further unnecessary testing, and lead to patient anxiety.
Sources:
Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med 2000;124:71-81. PMID: 10629135.
Solomon DH, Kavanaugh AJ, Schur PH. American College of Rheumatology Ad Hoc Committee on Immunologic Testing Guidelines. Evidence-based guidelines for the use of immunologic tests: antinuclear antibody testing. Arthritis Rheum 2002;47:434-44. PMID: 12209492.
Tozzoli R, Bizzaro N, Tonutti E, et al. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 2002;117:316-24. PMID: 11863229.
-
Pediatric patients on stable doses of non-biologic disease modifying anti-rheumatic drugs (DMARDs) (e.g. methotrexate, sulfasalazine) without specific risk factors (e.g. obesity, diabetes mellitus, renal disease, alcohol use, concomitant use of hepatotoxic or myelosuppressive medications) are at a low overall risk of toxicity. More frequent blood draws pose an unnecessary burden to pediatric patients and the health-care system. Patients new to treatment, on escalating doses, or with abnormal baseline labs typically require more frequent monitoring.
Sources:
Karlsson Sundbaum J, Eriksson N, Hallberg P, Lehto N, Wadelius M, Baecklund E. Methotrexate treatment in rheumatoid arthritis and elevated liver enzymes: A long-term follow-up of predictors, surveillance, and outcome in clinical practice. Int J Rheum Dis. 2019 Jul;22(7):1226-1232. PMID: 31012257.
Ledingham J, Gullick N, Irving K, et al. BSR and BHPR Standards, Guidelines and Audit Working Group. Rheumatology (Oxford). 2017 Jun 1;56(6):865-868. PMID: 28339817.
Zajc Avramovič M, Dolžan V, Toplak N, Accetto M, Lusa L, Avčin T. Relationship Between Polymorphisms in Methotrexate Pathway Genes and Outcome of Methotrexate Treatment in a Cohort of 119 Patients with Juvenile Idiopathic Arthritis. J Rheumatol. 2017 Aug;44(8):1216-1223. PMID: 28572465.
-
Back pain is a common symptom relative to the incidence of spondyloarthropathy (SpA) in children. In addition, the prevalence of HLA-B27 is 2-8% in the general population, and individuals with a positive HLA-B27 have a low probability of developing SpA. As such, HLA-B27 testing is not useful as a single diagnostic test in a patient with low back pain without specific signs or symptoms of SpA (e.g., inflammatory back pain, peripheral arthritis, enthesitis, or acute anterior uveitis) or suggestive findings on MRI. Of note, patients with confirmed Juvenile Idiopathic Arthritis (JIA) may have HLA-B27 testing in order to classify their JIA subtype.
Sources:
Gran JT, Husby G. HLA-B27 and spondyloarthropathy: value for early diagnosis? J Med Genet. 1995;32(7):497-501. PMID: 7562959.
Reveille JD. Epidemiology of spondyloarthritis in North America. Am J Med Sci. 2011;341(4):284-6. PMID: 21430444.
Reveille JD, Hirsch R, Dillon CF, Carroll MD, Weisman MH. The prevalence of HLA-B27 in the US: data from the US National Health and Nutrition Examination Survey, 2009. Arthritis Rheum. 2012;64(5):1407-11. PMID: 22139851.
-
In children, the vast majority of musculoskeletal (MSK) pain is non-inflammatory (97%) and is rarely secondary to a rheumatic disease. For patients with arthralgia (joint pain) but no arthritis on physical exam (defined as presence of joint effusion or ≥2 of warmth, tenderness, stress pain, reduced range of motion), testing rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP) is not clinically useful and has low diagnostic utility. For example, a positive RF may result from various infections. Performing such tests without clinical relevance may result in unnecessary additional testing and anxiety.
Sources:
Hermosillo-Villafranca, J.A., et al., Role of rheumatoid factor isotypes and anti-citrullinated peptide antibodies in the differential diagnosis of non-selected patients with inflammatory arthralgia. Reumatol Clin. 2021. 17(1): p. 12-15. PMID: 31399351.
Wang, Y., et al., Meta-analysis: diagnostic accuracy of anti-cyclic citrullinated peptide antibody for juvenile idiopathic arthritis. J Immunol Res. 2015. 2015: p. 915276. PMID: 25789331.
Wong, K.O., et al., Antinuclear Antibody, Rheumatoid Factor, and Cyclic-Citrullinated Peptide Tests for Evaluating Musculoskeletal Complaints in Children. Comparative Effectiveness Review No. 50 (Prepared by the University of Alberta Evidence-based Practice Center under Contract No. HHSA 290 2007 10021 I). 2012, Agency for Healthcare Research and Quality: Rockville (MD). PMID: 22514802.
-
Lyme disease is most likely to occur if an individual resides in or visits an endemic area. The most common musculoskeletal (MSK) manifestation of Lyme disease is persistent or intermittent arthritis in at least one joint (typically the knee) which develops within weeks to months after a tick bite. Chronic diffuse arthralgias, myalgias or fibromyalgia alone are not criteria for MSK Lyme disease. Because both standard and modified two-tiered testing approaches cannot distinguish recent from remote infection, testing should be limited to children with characteristic clinical signs and exposure risk to avoid false positive tests and unnecessary treatment.
Sources:
Government of Canada, Surveillance of Lyme Disease. [Internet].
Hatchette T, et al. Modified two-tiered testing algorithm for Lyme disease serology: The Canadian context. Can Commun Dis Resp 2020; 46(5):125-31. PMID: 32558809.
Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Arthritis Rheum. 2021;73(1):12-20. PMID: 33251700.
Lipsett SC, Nigrovic LE. Diagnosis of Lyme disease in the pediatric acute care setting. Curr Opin Pediatr. 2016;28(3):287-293. PMID: 27138805.
-
Pediatric patients with juvenile idiopathic arthritis (JIA) often benefit from treatment with intra-articular corticosteroid injections, especially when arthritis is impacting activities of daily living. However, in patients with polyarticular JIA (≥5 affected joints) the probability of a short-lived or poor response to corticosteroid injections is increased when compared to those with oligoarticular JIA (≤4 affected joints). Lack of concomitant initiation of a disease modifying anti-rheumatic drug (DMARD) in polyarticular disease is also a risk factor for suboptimal response to joint injections. In addition, repeating joint injections in the same joint (e.g. >2-3 times/year) has a lower probability of achieving disease control compared to initiating a DMARD and may be a risk factor for the development of osteochondritis dissecans. Multiple or recurrent intra-articular corticosteroid injections may be considered as an adjunctive therapy while awaiting the effect of an escalation in systemic therapy.
Sources:
Heidt C, Grueberger N, Grisch D, Righini-Grunder F, Rueger M, Ramseier L. The assessment of steroid injections as a potential risk factor for osteochondral lesions in children with juvenile idiopathic arthritis. Cartilage. 2020 Sep:1947603520961173. PMID: 32985233.
Lanni S, Bertamino M, Consolaro A, et al. Outcome and predicting factors of single and multiple intra-articular corticosteroid injections in children with juvenile idiopathic arthritis. Rheumatology (Oxford). 2011 Sep;50(9):1627-1634. PMID: 21561981.
Ringold S, Angeles-Han ST, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis: therapeutic approaches for non-systemic polyarthritis, sacroiliitis, and enthesitis. Arthritis Care Res (Hoboken). 2019 Jun;71(6):717-734. PMID: 31021516.
-
Periodic fever, aphthous stomatitis, pharyngitis, adenitis (PFAPA) syndrome is a clinical diagnosis, and currently, no genetic mutations have been identified for this condition. Periodic fever genetic panel in patients with classic features of PFAPA—without any features of another periodic fever syndrome—rarely yields an alternate diagnosis and as such is costly and has no clinical benefit. However, genetic testing may be warranted if patients have atypical features at presentation, don’t respond to treatment as expected, or develop concerning features over time.
Sources:
Berkun Y, Levy R, Hurwitz A, et al. The familial Mediterranean fever gene as a modifier of periodic fever, aphthous stomatitis, pharyngitis, and adenopathy syndrome. Semin Arthritis Rheum. 2011 Apr;40(5):467-72. PMID: 20828792.
Dagan E, Gershoni-Baruch R, Khatib I, Mori A, Brik R. MEFV, TNF1rA, CARD15 and NLRP3 mutation analysis in PFAPA. Rheumatol Int. 2010 Mar;30(5):633-6. PMID: 19579027.
Gattorno M, Caorsi R, Meini A, et al. Differentiating PFAPA syndrome from monogenic periodic fevers. Pediatrics. 2009 Oct;124(4):e721-8. PMID: 19786432.
-
The Canadian Rheumatology Association (CRA) Pediatrics Committee established its Choosing Wisely Canada Top 7 recommendations in a multistage process combining consensus methodology and literature review. A Choosing Wisely working group was formed including pediatric rheumatologists from across the country from diverse clinical settings, an allied health professional, a parent and a patient. This group generated candidate recommendations using a series of Delphi surveys. Recommendations with high content agreement and perceived prevalence advanced to a survey of all CRA members who practice pediatric rheumatology. CRA members ranked these top items based on content agreement, impact and item ranking. A methodology subcommittee discussed the items in light of their relevance to pediatric rheumatology, potential impact on patients and the member survey results. The Top 7 items were selected to advance for literature review. The list was reviewed by all pediatric committee members and patient partners, and has been approved by the CRA Board of Directors.
Sources:
Kavanaugh A, Tomar R, Reveille J, Solomon DH, Homburger HA. Guidelines for clinical use of the antinuclear antibody test and tests for specific autoantibodies to nuclear antigens. American College of Pathologists. Arch Pathol Lab Med 2000;124:71-81. PMID: 10629135.
Solomon DH, Kavanaugh AJ, Schur PH. American College of Rheumatology Ad Hoc Committee on Immunologic Testing Guidelines. Evidence-based guidelines for the use of immunologic tests: antinuclear antibody testing. Arthritis Rheum 2002;47:434-44. PMID: 12209492.
Tozzoli R, Bizzaro N, Tonutti E, et al. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 2002;117:316-24. PMID: 11863229.
Karlsson Sundbaum J, Eriksson N, Hallberg P, Lehto N, Wadelius M, Baecklund E. Methotrexate treatment in rheumatoid arthritis and elevated liver enzymes: A long-term follow-up of predictors, surveillance, and outcome in clinical practice. Int J Rheum Dis. 2019 Jul;22(7):1226-1232. PMID: 31012257.
Ledingham J, Gullick N, Irving K, et al. BSR and BHPR Standards, Guidelines and Audit Working Group. Rheumatology (Oxford). 2017 Jun 1;56(6):865-868. PMID: 28339817.
Zajc Avramovič M, Dolžan V, Toplak N, Accetto M, Lusa L, Avčin T. Relationship Between Polymorphisms in Methotrexate Pathway Genes and Outcome of Methotrexate Treatment in a Cohort of 119 Patients with Juvenile Idiopathic Arthritis. J Rheumatol. 2017 Aug;44(8):1216-1223. PMID: 28572465.
Gran JT, Husby G. HLA-B27 and spondyloarthropathy: value for early diagnosis? J Med Genet. 1995;32(7):497-501. PMID: 7562959.
Reveille JD. Epidemiology of spondyloarthritis in North America. Am J Med Sci. 2011;341(4):284-6. PMID: 21430444.
Reveille JD, Hirsch R, Dillon CF, Carroll MD, Weisman MH. The prevalence of HLA-B27 in the US: data from the US National Health and Nutrition Examination Survey, 2009. Arthritis Rheum. 2012;64(5):1407-11. PMID: 22139851.
Hermosillo-Villafranca, J.A., et al., Role of rheumatoid factor isotypes and anti-citrullinated peptide antibodies in the differential diagnosis of non-selected patients with inflammatory arthralgia. Reumatol Clin. 2021. 17(1): p. 12-15. PMID: 31399351.
Wang, Y., et al., Meta-analysis: diagnostic accuracy of anti-cyclic citrullinated peptide antibody for juvenile idiopathic arthritis. J Immunol Res. 2015. 2015: p. 915276. PMID: 25789331.
Wong, K.O., et al., Antinuclear Antibody, Rheumatoid Factor, and Cyclic-Citrullinated Peptide Tests for Evaluating Musculoskeletal Complaints in Children. Comparative Effectiveness Review No. 50 (Prepared by the University of Alberta Evidence-based Practice Center under Contract No. HHSA 290 2007 10021 I). 2012, Agency for Healthcare Research and Quality: Rockville (MD). PMID: 22514802.
Government of Canada, Surveillance of Lyme Disease. [Internet].
Hatchette T, et al. Modified two-tiered testing algorithm for Lyme disease serology: The Canadian context. Can Commun Dis Resp 2020; 46(5):125-31. PMID: 32558809.
Lantos PM, Rumbaugh J, Bockenstedt LK, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis, and Treatment of Lyme Disease. Arthritis Rheum. 2021;73(1):12-20. PMID: 33251700.
Lipsett SC, Nigrovic LE. Diagnosis of Lyme disease in the pediatric acute care setting. Curr Opin Pediatr. 2016;28(3):287-293. PMID: 27138805.
Heidt C, Grueberger N, Grisch D, Righini-Grunder F, Rueger M, Ramseier L. The assessment of steroid injections as a potential risk factor for osteochondral lesions in children with juvenile idiopathic arthritis. Cartilage. 2020 Sep:1947603520961173. PMID: 32985233.
Lanni S, Bertamino M, Consolaro A, et al. Outcome and predicting factors of single and multiple intra-articular corticosteroid injections in children with juvenile idiopathic arthritis. Rheumatology (Oxford). 2011 Sep;50(9):1627-1634. PMID: 21561981.
Ringold S, Angeles-Han ST, Beukelman T, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis: therapeutic approaches for non-systemic polyarthritis, sacroiliitis, and enthesitis. Arthritis Care Res (Hoboken). 2019 Jun;71(6):717-734. PMID: 31021516.
Berkun Y, Levy R, Hurwitz A, et al. The familial Mediterranean fever gene as a modifier of periodic fever, aphthous stomatitis, pharyngitis, and adenopathy syndrome. Semin Arthritis Rheum. 2011 Apr;40(5):467-72. PMID: 20828792.
Dagan E, Gershoni-Baruch R, Khatib I, Mori A, Brik R. MEFV, TNF1rA, CARD15 and NLRP3 mutation analysis in PFAPA. Rheumatol Int. 2010 Mar;30(5):633-6. PMID: 19579027.
Gattorno M, Caorsi R, Meini A, et al. Differentiating PFAPA syndrome from monogenic periodic fevers. Pediatrics. 2009 Oct;124(4):e721-8. PMID: 19786432.
About Choosing Wisely Canada
Choosing Wisely Canada is the national voice for reducing unnecessary tests and treatments in health care. One of its important functions is to help clinicians and patients engage in conversations that lead to smart and effective care choices.
Web: choosingwiselycanada.org
Email: info@choosingwiselycanada.org
Twitter: @ChooseWiselyCA
Facebook: /ChoosingWiselyCanada
Patient Decision Aid: Mayo Clinic’s Bone Health Choice Decision Aid
Bone Density Tests
When you need them and when you don’t.