Recommendation 1.

Testing ANA and ENAs should be reserved for patients suspected to have a diagnosis of a connective tissue disease, e.g. lupus. Testing ANA and ENAs should be avoided in the investigation of widespread pain or fatigue alone. Repeat testing is not normally indicated unless the clinical picture changes significantly.

Evidence\guidance

Solomon DH, Kavanaugh AJ, Schur PH. Evidence-based guidelines for the use of immunologic tests: Antinuclear antibody testing. Arthritis Rheum 2002;47(4):434-44.

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(1):71–81.

American College of Rheumatology Ad Hoc Committee on Immunologic Testing. Guidelines for immunologic laboratory testing in the rheumatic diseases: an introduction. Guidelines..Arthritis Rheum. 2002 Aug; 47(4):429-33.

Tozzoli R, Bizzaro N, Tonutti E, Villalta D, Bassetti D, Manoni F, Piazza A, Pradella M, Rizzotti P. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 2002;117(2):316-24.

Yazdany J., Schmajuk G., Robbins M., et al. Choosing wisely: the American College of Rheumatology’s Top 5 list of things physicians and patients should question. Arthritis Care Res. (Hoboken) 2013;65:329–339

Fitch-Rogalsky C, Steber W, Mahler M, Lupton T, Martin L, Barr SG, et al. Clinical and serological features of patients referred through a rheumatology triage system because of positive antinuclear antibodies. PLoS One. 2014;9(4):e93812.

Gundín S, Irure-Ventura J, Asensio E, et al. Measurement of anti-DFS70 antibodies in patients with ANA-associated autoimmune rheumatic diseases suspicion is cost-effective. Auto-Immunity Highlights. 2016;7(1):10.

Lee AY, et al. The concordance of serial ANA tests in an Australian tertiary hospital pathology laboratory. Pathology. 2016;48(6):597-601.

Satoh M., Chan E.K., Ho L.A. Prevalence and sociodemographic correlates of antinuclear antibodies in the United States. Arthritis Rheum. 2012;64:2319–2327.

Sharp, CA, Bruce, IN, Efficiency in follow-up immunology testing for patients with connective tissue disease and vasculitis, Clinical Medicine, 2010;10(3):632-4

Tonutti E, Bizzaro N, Morozzi G, Radice A, Cinquanta L, Villalta D, et al. The ANA-reflex test as a model for improving clinical appropriateness in autoimmune diagnostics. Autoimmunity Highlights. 2016;7(1):9.

Wandstrat AE, Carr-Johnson F, Branch V, Gray H, Fairhurst A-M, Reimold A, et al. Autoantibody profiling to identify individuals at risk for systemic lupus erythematosus. Journal of autoimmunity. 2006;27(3):153-60

Patient information\decision aids

Arthritis Research UK: Lupus (2011)

LUPUS UK: Diagnosis (2015)

Recommendation 2

Patients with suspected inflammatory arthritis should be referred to Rheumatology without delay. Rheumatoid factor and CCP/ACPA are important, but should be avoided as screening tests. A negative result does not exclude rheumatoid arthritis, nor does a positive result equate to a diagnosis of rheumatoid arthritis. Repeat testing is not normally indicated.

Evidence\guidance

NICE clinical guideline CG79: rheumatoid arthritis in adults: management (2015) https://www.nice.org.uk/guidance/cg79

Burr. M. L., Viatte, S., Bukhari, M., Plant, D., Symmons, D. P., Thomson, W., & Barton A. 2012. Long-term stability of anti-cyclic citrullinated peptide antibody state in patients with early inflammatory polyarthritis. Arthritis research & therapy 2012; 14: R109

Sharp, CA, Bruce, IN, Eficiency in follow-up immunology testing for patients with connective tissue disease and vasculitis, Clinical Medicine, 2010, 10 (3): 632-4

Patient information\decision aids

Information for primary care physicians:

Royal College of General Physicians: Inflammatory arthritis toolkit (2017)

Arthritis Research UK: Rheumatoid Arthritis (2014)

National Rheumatoid Arthritis Society (NRAS): Getting an early diagnosis

NRAS: What is RA? (2014)

NRAS: Inflammatory Arthritis Patient Pathway

NRAS: Managing CVD risk in RA – Love your heart

NRAS: Have you got the S factor? (2011)

NRAS: Laboratory tests used in the diagnosis and monitoring of rheumatoid arthritis (2013)

Recommendation 3

Everyone should consider Vitamin D supplementation during winter.

People who have restricted access to sunlight (e.g. those living in institutions or who cover their skin), or have dark skin, should consider supplementation all year round. Vitamin D testing should be reserved for people at high risk from deficiency and avoided as part of routine investigation of widespread pain alone. Repeat testing is not normally indicated in those taking supplements.

Evidence\guidance

NICE: Clinical Knowledge Summary – Vitamin D deficiency in adults – treatment and prevention (2013)

Scientific Advisory Committee on Nutrition – Vitamin D and Health. Scientific Advisory Committee on Nutrition (2016)

National Osteoporosis Society: Vitamin D and bone health – A practical clinical guideline for patient management (2013)

Patient information\decision aids

National Osteoporosis Society patient leaflet – Vitamin D supplements and tests (2016)

Public Health England: Health England: Vitamin D- All you need to know (2014)

NHS Choices: Vitamin D

Recommendation 4

Bisphosphonate therapy should be reviewed with every patient after 3-5 years, and a treatment holiday considered. This should follow a shared-decision making conversation which includes the risks and benefits of continued treatment.

Evidence\guidance

Osteoporosis Guideline Group: Clinical Guideline for the Prevention and Treatment of Osteoporosis(2017)

NICE technology appraisal guidance 464: Bisphosphonates for treating osteoporosis (2017)

Vitamin D and bone health: A practical clinical guideline for patient management (2013)

Patient information\decision aids

National Osteoporosis Society

Recommendation 5

The use of intra-articular and soft-tissue steroid injections for non-inflammatory musculoskeletal conditions should be preceded by consideration of non-invasive alternatives such as exercise and physical therapy. Consent to any invasive procedure such as this must arise from a shared-decision making conversation with every patient, which includes assessment of the risks and benefits.

Evidence\guidance

NICE Guideline CG177 (2014) Osteoarthritis: Care and Management https://www.nice.org.uk/guidance/cg177

National Safety Standards for Invasive Procedures (NatSSIPS) (2015)

https://improvement.nhs.uk/uploads/documents/natssips-safety-standards.pdf

American College of Rheumatology, Guidelines on use of pharmacologic and non-pharmacologic therapies in osteoarthritis of the hand, knee and hip 2012; Arthritis Care & Research, 2012; 64(4): 465-74

Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. Fleckenstein J, editor. PLoS One 2017;12(6):e0178621

Brennan KL. J Orthop Sports Phys Ther. 2017;47(4):232-239

Jüni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, et al. Intra-articular corticosteroid for knee osteoarthritis. In: da Costa BR, editor. Cochrane Database of Systematic Reviews Chichester, UK: John Wiley & Sons, Ltd; 201

Kim et al. Pain Physician. 2013;16(6):557-68

Manchikanti et al. Pain Physician. 2014;17(4):E489-501

Mandel S, Schilling J, Peterson E, Rao DS, Sanders W. A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections. J Bone Jt Surg 2013;95(11):961–4.

Mardani-Kivi et al. Arch Orthop Trauma Surg. 2013;133(6):757-63

Mohamadi A, et al. Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis. Clin Orthop Relat Res. 2017;475(1):232-243

Nguyen C et al. Intradiscal Glucocorticoid Injection for Patients With Chronic Low Back Pain Associated With Active Discopathy. A Randomized Trial. Ann Intern Med. 2017;18;166(8):547-556

Scott A, Khan KM. Corticosteroids: short-term gain for long-term pain? Lancet. 2010;376(9754):1714–5.

Steuri R, Sattelmayer M, Elsig S, Kolly C, Tal A, Taeymans J, et al. Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs. Br J Sports Med. 2017;51(18):1340–7

Wang W, Shi M, Zhou C, Shi Z, Cai X, Lin T, et al. Effectiveness of corticosteroid injections in adhesive capsulitis of shoulder. Medicine. 2017;96(28):e7529

Patient information\decision aids

NHS Right Care – Shared Decision Making: Osteoarthritis of the knee (2017)

Recommendation 6

C3, C4 and dsDNA are important tests to help in the diagnosis and assessment of disease activity in lupus. They should be reserved for specialist monitoring of disease activity and should be avoided as screening tests.

Evidence\guidance

Gordon, C., et al for the British Society for Rheumatology Standards, Audit and Guidelines Working Group (2018) The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology. 2018;57(1) e1-e45.

Bertsias G, Ioannidis JP, Boletis J, Bombardieri S, Cervera R, Dostal C, et al. EULAR recommendations for the management of systemic lupus erythematosus: report of a task force of the EULAR Standing Committee for international clinical studies including therapeutics. Ann Rheum Dis 2008;67:195–205

López-Hoyos M, et al. Clinical disease activity and titers of anti-dsDNA antibodies measured by an automated immunofluorescence assay in patients with systemic lupus erythematosus. Lupus. 2005;14(7):505-9.

Nasiri S, Karimifar M, Bonakdar ZS, Salesi M. Correlation of ESR, C3, C4, anti-DNA and lupus activity based on British Isles Lupus Assessment Group Index in patients of rheumatology clinic. Rheumatol Int. 2010;30(12):1605-9

Tozzoli R, Bizzaro N, Tonutti E, Villalta D, Bassetti D, Manoni F, Piazza A, Pradella M, Rizzotti P. Guidelines for the laboratory use of autoantibody tests in the diagnosis and monitoring of autoimmune rheumatic diseases. Am J Clin Pathol 2002;117(2):316-24.

Patient information\decision aids

Arthritis Research UK: Lupus (2016)

LUPUS UK: Diagnosis (2015)