Choosing Wisely Canada

Seven Things Physicians and Patients Should Question

• Don’t order ANA as a screening test in patients without specific signs or symptoms of systemic lupus erythematosus (SLE) or another connective tissue disease (CTD). ShowTopic 1

  ANA testing should not be used to screen subjects without specific symptoms (e.g., photosensitivity, malar rash, symmetrical polyarthritis, etc.) or without a clinical evaluation that may lead to a presumptive diagnosis of SLE or other CTD, since ANA reactivity is present in many non-rheumatic conditions and even in “healthy” control subjects (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 diagnosis or even inappropriate therapy.

   

  Sources:

  BC Guidelines. Antinuclear antibody (ANA) testing protocol [Internet]. 2013 Jun [cited 2017 May 5].

  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.

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• Don’t order an HLA-B27 unless spondyloarthritis is suspected based on specific signs or symptoms. ShowTopic 2

  HLA-B27 testing is not useful as a single diagnostic test in a patient with low back pain without further spondyloarthropathy (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 spondyloarthropathy 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:

  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.

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• Don’t repeat dual energy X-ray absorptiometry (DEXA) scans more often than every 2 years. ShowTopic 3

  The use of repeat DEXA scans at intervals of every 2 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:

  Papaioannou A, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: Summary. CMAJ. 2010 Nov 23;182(17):1864-73. PMID: 20940232.

  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

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• Don’t prescribe bisphosphonates for patients at low risk of fracture. ShowTopic 4

  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 bisphosphonates in patients at low risk of fracture is not currently recommended.

   

  Sources:

  FRAX®. WHO fracture risk assessment tool [Internet]. 2011 Jun [cited 20177 May 5].

  Osteoporosis Canada. Assessment of 10-year fracture risk – women and men [Internet]. 2010 [cited 2017 May 5].

  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

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• Don’t perform whole body bone scans (e.g., scintigraphy) for diagnostic screening for peripheral and axial arthritis in adults. ShowTopic 5

  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.

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• Don’t prescribe opioids for management of chronic rheumatic disease before optimizing the use of non-opioid approaches to pain management. ShowTopic 6

  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.

• Don’t delay or avoid palliative symptom management and advance care planning for a patient with life-limiting rheumatic disease because they are pursuing disease-directed treatment. ShowTopic 7

  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. Abstract retrieved from

  Saltman A. Palliative Care for the Rheumatologist: When Does the End Begin…And Why Does It Matter? CRAJ. 2019;29(2).

  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.

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• How the list was created ShowTopic 1

  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.