Australian Rheumatology Association
Recommendations from the Australian Rheumatology Association on arthroscopy, ANA testing, imaging, ultrasound and anti-dsDNA antibodies. The ARA supports and educates members and other practitioners in the musculoskeletal field to enable provision of best possible management for patients. It fosters excellence in the diagnosis and management of musculoskeletal and inflammatory conditions through training, professional development, research and advocacy.
Do not order antinuclear antibody (ANA) testing without symptoms and/or signs suggestive of a systemic rheumatic disease.
Antinuclear antibodies (ANAs) are present in healthy individuals and ANA testing is only useful in patients with symptoms and/or signs of a rheumatic disease where it can aid in the confirmation or exclusion of systemic connective tissues diseases. ANA testing has a very high negative predictive value for excluding connective tissue diseases as a cause for patients’ symptoms. However, a positive ANA result does not have a high positive predictive value for diagnosing these conditions in isolation, and further sub-serology testing is needed to accurately diagnose and classify these conditions.
- Agmon-Levin N, Damoiseaux J, Kallenberg C, et al. International recommendations for the assessment of autoantibodies to cellular antigens referred to as anti-nuclear antibodies. Ann Rheum Dis 2014; 73:17-23.
- British Columbia Guidelines: Antinuclear Antibody (ANA) Testing for Connective Tissue Disease [homepage on the Internet] British Columbia: Ministry of Health [updated 1 June 2013; cited 18 Sept 2017]. Available at: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bcguidelines/ana-testing.
- Solomon DH, Kavanaugh AJ, Schur PH. Evidence-based guidelines for the use of immunologic tests: antinuclear antibody testing. Arthritis Rheum 2002; 47:434-44.
An ARA Evolve working group comprising 19 rheumatologists and 3 advanced rheumatology trainees was established after a call for interest. The group agreed that items should be included if they were either primarily a rheumatologist issue or an issue that rheumatologists should advocate for on behalf of their patients.
A preliminary list of low-value clinical practices was created based upon the working group’s clinical experiences, as well as consideration of potentially relevant items identified from a review of other lists generated. This list was refined into 12 items and small teams for each topic were formed to review the evidence pertaining to these items and their relevance to Australian healthcare.
Brief summaries of the evidence were written based on NHMRC evidence review standards. An anonymous online survey was created based on these summaries and all ordinary (356 rheumatologists) and associate (72 rheumatology trainees) ARA members were invited to participate. Survey participants were asked to select the five recommendations for which they considered the evidence to be the strongest. The survey attracted a 50% response rate and based on its results, the ARA top five recommendations were formulated.
- 1 Do not perform arthroscopy with lavage and/or debridement or partial meniscectomy for patients with symptomatic osteoarthritis of the knee and/or degenerate meniscal tear.
- 2 Do not order antinuclear antibody (ANA) testing without symptoms and/or signs suggestive of a systemic rheumatic disease.
- 3 Do not undertake imaging for low back pain in patients without indications of a serious underlying condition.
- 4 Do not use ultrasound guidance to perform injections into the subacromial space as it provides no additional benefit in comparison to landmark-guided injection.
- 5 Do not order anti-double stranded (ds) DNA antibodies in ANA negative patients unless clinical suspicion of systemic lupus erythematosus (SLE) remains high.