CHOOSING WISELY CANADA
and patients should question
3
Don’t repeat dual energy X-ray absorpti- ing for peripheral and axial arthritis in the
ometry (DEXA) scans more often than ev- adults.
The diagnosis of peripheral and axial inflammatory arthritis
ery 2 years.
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 limita
tions 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.
4
Don’t prescribe bisphosphonates for patients at low risk of fracture.
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.
5
Don’t perform whole body bone scans
(e.g., scintigraphy) for diagnostic screen-
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. The equivalent of radiation
exposure of a total whole body bone scan is reported as
over 40 routine chest X-rays, thus posing risk.
How the list was created
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.
* Full physician list with references is available at ChoosingWiselyCanada.org
SMA NEWS DIGEST | SUMMER 2014
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