Table 1.

The American College of Rheumatology’s Top 5 list^*

Do not test ANA subserologies without a positive ANA and clinical suspicion of immune-mediated disease.
Tests for ANA subserologies (including antibodies to double-stranded DNA, Sm, RNP, SSA, SSB, Scl-70, and centromere) are usually negative if the ANA is negative. Exceptions include anti–Jo-1, which can be positive in some forms of myositis, or occasionally, anti-SSA in the setting of lupus or Sjogren's syndrome. Broad testing of autoantibodies should be avoided; instead, the choice of autoantibodies should be guided by the specific disease under consideration.
Do not test for Lyme disease as a cause of musculoskeletal symptoms without an exposure history and appropriate examination findings.
The musculoskeletal manifestations of Lyme disease include brief attacks of arthralgia or intermittent or persistent episodes of arthritis in 1 or a few large joints at a time, especially the knee. Lyme testing in the absence of these features increases the likelihood of false-positive results and may lead to unnecessary followup and therapy. Diffuse arthralgias, myalgias, or fibromyalgia alone are not criteria for musculoskeletal Lyme disease.
Do not perform MRI of the peripheral joints to routinely monitor inflammatory arthritis.
Data evaluating MRI for the diagnosis and prognosis of RA are currently inadequate to justify widespread use of this technology for these purposes in clinical practice. Although bone edema assessed by MRI on a single occasion may be predictive of progression in certain RA populations, using MRI routinely is not cost effective compared with the current standard of care, which includes clinical disease activity assessments and plain film radiography.
Do not prescribe biologic agents for RA before a trial of methotrexate (or other conventional nonbiologic DMARD).
High-quality evidence suggests that methotrexate and other conventional nonbiologic DMARDs are effective in many patients with RA. Initial therapy for RA should be a conventional nonbiologic DMARD unless these are contraindicated. If a patient has had an inadequate response to methotrexate with or without other nonbiologic DMARDs during an initial 3-month trial, then biologic therapy can be considered. Exceptions include patients with high disease activity AND poor prognostic features (functional limitations, disease outside the joints, seropositivity, or bony damage), where biologic therapy may be appropriate first-line treatment.
Do not routinely repeat DXA scans more often than once every 2 years.
Initial screening for osteoporosis should be performed according to National Osteoporosis Foundation recommendations. The optimal interval for repeating DXA scans is uncertain, but because changes in bone density over short intervals are often smaller than the measurement error of most DXA scanners, frequent testing (e.g., <2 years) is unnecessary in most patients. Even in high-risk patients receiving drug therapy for osteoporosis, DXA changes do not always correlate with the probability of fracture. Therefore, DXA scans should only be repeated if the result will influence clinical management or if rapid changes in bone density are expected. Recent evidence also suggests that healthy women ages ≥67 years with normal bone mass may not need additional DXA testing for up to ten years provided osteoporosis risk factors do not significantly change.

^*ANA = antinuclear antibody; MRI = magnetic resonance imaging; RA = rheumatoid arthritis; DMARD = disease-modifying antirheumatic drug; DXA = dual x-ray bone absorptiometry.