Fall 2022 (Volume 32, Number 3)

Survey Results:
CRA Choosing Wisely — Ordering RF & ACPA Tests and Monitoring DMARDs

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This issue’s Joint Count survey, in collaboration with the CRA Choosing Wisely submcommittee, aimed to better understand when rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) tests are ordered, and how disease-modifying anti-rheumatic drugs (DMARDs) are monitored. The CRA Choosing Wisely subcommittee (at the time of this writing) plans to publish new statements regarding the ordering of RF and ACPA tests, as well as the monitoring of DMARDs this fall (these statements are shown in the box below). The survey was sent to members of the CRA (603 members), and a total of 68 responses were received.

The first question of the survey queried members about how often they monitored lab work in a stable patient with inflammatory arthritis on non-biologic disease-modifying anti-rheumatic drug therapy. Most (approximately 70%) indicated every three months, while 18% said every 2 months; 9% said less often than every 3 months; and only 3% said every month. One respondent commented that the question was too vague, and that patients’ comorbidities would also need to be taken into account.

The next question asked members about what tests they monitor for patients on methotrexate therapy. Responses are shown in Chart 1. A complete blood count (CBC) and alanine aminotransferase (ALT) were almost universal. Overall, there seems to be a lot of variability in what tests are ordered and how often. It should be noted that some provinces, such as Ontario, limit the ordering of aspartate aminotransferase (AST) to GI specialists. As well, with the current health human resources crisis affecting laboratory medicine, physicians have been requested to review their routine lab ordering protocols, especially for non-specific tests such as ESR.

For the next question, only 26% of survey respondents were aware that the symptoms located in the metatarsophalangeal (MTP) joints are not part of the EULAR definition of clinically suspicious arthralgia (CSA) at risk of developing rheumatoid arthritis (RA). The EULAR definition of CSA includes symptoms of new joint pain, pain in metacarpophalangeal (MCP) joints, morning stiffness >60 minutes, most severe symptoms in the morning, presence of 1st-degree relative with RA, difficulty making a fist and positive MCP squeeze test.

Regarding the last question, the results reflected that only about a quarter of respondents were aware that among individuals with clinically significant arthralgia with positive RF and ACPA, 30-60% will never develop RA (for more information visit

The CRA would love to hear your reflections. For any feedback on the survey, please reach out to Mona Bosinceanu at For further information, visit or

Two New Choosing Wisely Statements:
RF & ACPA Tests:
Do not order Rheumatoid Factor (RF) and Anti-Citrullinated Protein Antibody (ACPA) tests unless patients have clinically suspicious arthralgia (CSA*) or arthritis on exam.

DMARD Monitoring: Do not order labs for drug toxicity monitoring (i.e., CBC, liver enzymes, creatinine) more often than every 8-12 weeks for patients on a stable dose of non-biologic disease modifying anti-rheumatic drugs (DMARDs), in patients without comorbidities or (baseline) lab abnormalities.

*EULAR defined characteristics defining Clinically Suspect Arthralgia at risk for RA

The CRA Choosing Wisely Subcommittee would like to thank
the CW working group: Maryam Obaidalla (Ontario);
Bindu Nair (Saskatchewan); Nicole Beckett (Nova Scotia)
Nicolas Richard (Quebec); Zachary Shaff (Nova Scotia)
Nadia Lucia (Alberta); and Shirley Lake (Ontario)


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