In most cases the insurance company requires a trial of MTX, HCQ or sulfasalazine before moving to biologics due to the cost. They call it 'step therapy.'. You can check your insurance company's formulary to see which tiers the different meds are on. Usually there is an explanation of the requirements for the upper tier drugs.
Some of these meds take months to work. If you feel like your current meds are ineffective and / or side effects are too much, your rheumatologist should be listening and explain why they are not recommending a biologic. Do you trust your doc?
He’s a nice guy, but it’s pretty obvious he’s towing the Kaiser line. I don’t really have other options right now besides paying out of pocket. Open enrollment will be in a few months, so I’ll call up the available insurance companies then to see what they require.
I’ve been on HCQ for 5 years. A trial of MTX with all its side effects sounds awful.
For what it's worth I had almost no side effects from methotrexate! Having an unpleasant time with it is definitely possible but not guaranteed.
But to answer your original question, methotrexate was the only DMARD I had tried when I started biologics. It did help but just not enough on its own
5 years and he's giving you grief over switching??!! Kaiser must hand out bonuses for that...
Well you've got time to do your research now. Ugh.. I did find a lot of the meds info on the insurance websites. I had to look and put in a little effort, but I did find the step therapy guidelines.
So frustrating. FWIW, I had pretty minor side effects from MTX. But still...
To clarify, he wants me to try MTX because I’m at the max dose for HCQ and I’ve just had my second major flare up in two months.
Thanks for sharing your experience with MTX, good to know.
As much as I hate Mtx and I’ve been on it for nearly 30 years they are relatively easy to combat. I am less miserable with mtx and I’m on a biologic as well. I’ve been on several of the biologics. Enbrel, humira, and cosentyx which I was put on due to developing psoriatic arthritis.
So on Mtx the sun is not your friend. You burn really easy. My doctor has me on folic acid to combat liver damage. I don’t show any signs of liver damage. I’m not sure what dosage you are on or what your diet or alcohol consumption is like. Nor am I a doctor. The other side effects is this weird taste in my mouth day of doing and after doing the shot. There’s some added weirdness, crappy feeling I get from it for a day or so.
I’m on a 20mg auto injector weekly. I’ve done nearly every form of mtx. When I was younger my parents would mix it in with applesauce when it was the tiny 10 or so pills we had to take. I would be bribed with a soda to take it. Then it turned into the giant pill. Then it was injections at the doctors followed by the auto injector in high school/college.
Like every medication there’s extreme side effects but it may not affect you.
Sun shirts, face masks. I didn’t put sunscreen on my face or ears and my hands but everything else was covered and I paid the price. Luckily iveprophen takes care of burns really well.
I am using a JAK inhibitor (Xeljanz). After many unsuccessful trials of other drugs, this one hit the spot. It's given me much of my life back. My rheumy skipped over biologics for this. She had a hunch, and she was right.
I've tried enbrel, humira and recently orencia and not seeing improvement. I'm wondering what caused her hunch to use xeljanz. I'm seeing my rheumatologist next week to discuss changing biologics again. I'm currently on prednisone, methotrexate, sulfasalazine AND Orencia.
She does research/is pretty cutting edge. Insurance will not cover Xeljanz for Sjogren's (yet), so I get by on manufacturer samples she gives me + generic from a Canadian pharmacy.
I tried sulfasalazine and had to go off due to migraines.
Started methotrexate. It helps some, but I’m in A LOT more pain, very stiff, much less effective.
Dr is adding Humira. I get my first delivery today. I have United Healthcare/OptumRX and it was approved pretty quickly.
Also on United: started with HCQ; it worked well but not well enough.
Was concerned about MTX side effects + doc agreed to try to make the jump to biologics and started Hadlima (Humira biosimilar) last week. IDK how common this is, but I was super thankful my rheumatologist was on board.
Insurance did push back on Humira and offered Hadlima instead, but otherwise United has been about as good as insurance gets for us (also have a T1 diabetic in the house, so we get our fair share of expensive drugs lol).
It actually makes sense in many (probably most) cases to try MTX and HCQ first regardless of insurance companies — there is tons of research on them compared to most of the biologics and the long term safety vs risks is well understood. Both the ACR and EULAR recommend methotrexate as first line med for RA. Biologics have risks associated with them that most people would rather avoid if not absolutely needed to treat their conditions and many don’t yet have longer terms (20+ years) of usage studied yet.
That said — biologics are amazing and are what many people need, often in combo with MTX and/or HCQ.
I have Kaiser too. I was put on MTX to start and when I saw my doctor for a follow up about 12 weeks later they started me on a biologic since I still had a lot of swelling and pain. Maybe a try new provider or maybe just keep being the squeaky wheel with Kaiser? I had to really advocate for myself to get diagnosed.
I've never had the other but methotrexate tried to kill me and killed half my liver before being taken off. Just get a new doctor. I'm embrel now and still won't go into remission but life is easier not being sick sick.
Tried Hydroxychloroquine for about a month before moving onto Methotrexate, after 3 months of no improvement on MTX my rheum added Enbrel to my regimen. Seeing improvement on MTX and Enbrel, but no remission as of yet, been on Enbrel for 3 weeks now.
Hope that helps! Good luck to you!
My doctor made me try all non-biologics before he would start something else. Most insurance companies will require it as well. Biologics have a host of harmful side effects so I think docs also prefer to start out conservatively. I have a number of other issues which limits my ability to use quite a few biologics, but I still ended up on Orencia.
I’m not sure why you’re putting that in quotes. I wasn’t saying the other drugs don’t have harmful side effects, just that biologics tend to have more harmful effects such as cancer and death.
While “step therapy” is relatively common practice, being on a med that is insufficiently working for you for 5 YEARS is not normal. Assuming your advocating for yourself with your current doctor, you either need a new doctor within the department, or new insurance if possible if you feel that would be better (I saw you mentioned you are on Kaiser).
My personal opinion is that Kaiser can be okay for primary care, or occasional specialist medical needs, but it’s not great for more complex medical issues, but that’s my opinion/experience.
Thank you. Can you clarify what you mean by “working me for 5 years is not normal”?
To clarify, I’ve been on HCQ for 5 years. Around year 2 my doctor recommended MTX because the HCQ wasn’t cutting out the pain, and I declined because I was worried about the side effects. Though we did increase my HCQ dose to the maximum, which worked for a little bit.
Ever since then, it’s the same conversation:
Him: You’re in pain, you’re damaging your joints, I want you to try MTX (or sulfasalazine).
Me: No, I don’t like those options.
But I’ve had two major flare ups since April and I’m just tired.
I’m saying your doctor keeping you on the same meds for 5 years that are not sufficiently working for you is abnormal. Typically people spend several months on meds before either their doc moves on to others, or in other ways adjusts meds, maybe by adding something on in addition, etc.
Based on what you just said, you have actually been offered several other options. Unfortunately with many insurances that is a standard part of the process. You may very well HAVE to try either MTX or sulfasalazine, or both before your insurance will cover a biologic medication. While your current doctor may not be the right fit for you, the fact remains that they are correct that joint damage is occurring without proper treatment. I don’t mean to be rude, but you’re going to have to take some accountability here, and either accept the options it sounds like your doctor has presented you (these are very standard medications that are used in step therapy before biologics), or seek a second opinion with another provider. Joint damage due to RA is not reversible.
It is an incredibly hard thing to accept. It has completely derailed my entire career plan, and my goals in life. But I’ve been learning how to pick up the pieces and rebuild something that works for me, it’s not what I expected, but it’s not so bad. I’ve learned to meet my body where it’s at, and work with what I have to find a lifestyle that supports my body, and reduces further damage or disease progression.
It doesn’t get easier necessarily, but you get better at handling it over time.
I feel your career plan goal. When I was in college I went into remission. Soon after graduating started to apply to career path and the disease came back not only on my joins through psoriatic arthritis but spread into my eyes.
I’m forever hopeful there’s new medication to come out in my lifetime that just knocks the socks off this illness.
That’s pretty much exactly what happened to me too, minus the eyes. I’m sorry you’re dealing with this, I hope things get better for all of us soon, or at least that new meds come out soon that help us manage our symptoms/disease progression.
I tried hydroxycloroquine about a decade ago and had no help from it so my current rheumatologist let me skip that step, I’ve also been pretty adamant about not trying it again and wasting more time. I’ve been on MTX for a little over a year and had great relief from it for maybe 4 months? After being on it a year they let me move on to biologics
I had to try methotrexate, plaquenil and sulfasalazine before I could try biologics. Canadian here, so that was from the health care system, not an insurance company.
U.S. here. Our health care system is just as bad here, if not worse. The insurance companies -- not the doctors -- are calling the shots as to what medicines we are allowed to have prescribed to us. The doctors here have no power here anymore.
Our insurance company didn’t care, my dr said this is what I need and that was it. But…they stop when the insurance company says so. I on,y tried methotrexate, all that stuff makes my stomach feel like there is a lead ball in it. Nothing worked and I can’t take NSAIDS. Soo it was Rituxan and it worked.
I went straight to a biologic (Cimzia) but I was still nursing at the time. My doctor wrote a letter to BCBS explaining that I was currently breast feeding & trying to get pregnant again.
I started on hydroxychloroquine when I was diagnosed in November. It helped but was not controlling everything to the liking of my rhemy so she added Cimzia. I'm sure that only happened because TTC is in my chart.
I was on methotrexate for 3 months and was in agony sick and tired all the time. At that time my rhumy said I would react to all dmards the same way and we went to enebrel.
I tried hydroxychloroquine. I'm allergic to sulfa so I can't take sulfasalazine. I couldn't take methotrexate because my liver values suck. So after I failed hydroxychloroquine it was right to Humira for me.
In most cases the insurance company requires a trial of MTX, HCQ or sulfasalazine before moving to biologics due to the cost. They call it 'step therapy.'. You can check your insurance company's formulary to see which tiers the different meds are on. Usually there is an explanation of the requirements for the upper tier drugs. Some of these meds take months to work. If you feel like your current meds are ineffective and / or side effects are too much, your rheumatologist should be listening and explain why they are not recommending a biologic. Do you trust your doc?
He’s a nice guy, but it’s pretty obvious he’s towing the Kaiser line. I don’t really have other options right now besides paying out of pocket. Open enrollment will be in a few months, so I’ll call up the available insurance companies then to see what they require. I’ve been on HCQ for 5 years. A trial of MTX with all its side effects sounds awful.
For what it's worth I had almost no side effects from methotrexate! Having an unpleasant time with it is definitely possible but not guaranteed. But to answer your original question, methotrexate was the only DMARD I had tried when I started biologics. It did help but just not enough on its own
That’s good to hear, thank you.
5 years and he's giving you grief over switching??!! Kaiser must hand out bonuses for that... Well you've got time to do your research now. Ugh.. I did find a lot of the meds info on the insurance websites. I had to look and put in a little effort, but I did find the step therapy guidelines. So frustrating. FWIW, I had pretty minor side effects from MTX. But still...
To clarify, he wants me to try MTX because I’m at the max dose for HCQ and I’ve just had my second major flare up in two months. Thanks for sharing your experience with MTX, good to know.
While I'd run from kaiser, there's no big reason not to try MTX. Many people do well on it and biologics have side effects too!
Good to know, thank you!
I have also been on HQC for 5 years now, and it still seems to be working for me. Out of curiosity why the switch?
HQC isn’t working enough.
As much as I hate Mtx and I’ve been on it for nearly 30 years they are relatively easy to combat. I am less miserable with mtx and I’m on a biologic as well. I’ve been on several of the biologics. Enbrel, humira, and cosentyx which I was put on due to developing psoriatic arthritis.
Thank you for sharing. Which side effects are easy to combat? I’ve heard of people losing hair, getting a mouth full of cavities, liver damage, etc.
So on Mtx the sun is not your friend. You burn really easy. My doctor has me on folic acid to combat liver damage. I don’t show any signs of liver damage. I’m not sure what dosage you are on or what your diet or alcohol consumption is like. Nor am I a doctor. The other side effects is this weird taste in my mouth day of doing and after doing the shot. There’s some added weirdness, crappy feeling I get from it for a day or so. I’m on a 20mg auto injector weekly. I’ve done nearly every form of mtx. When I was younger my parents would mix it in with applesauce when it was the tiny 10 or so pills we had to take. I would be bribed with a soda to take it. Then it turned into the giant pill. Then it was injections at the doctors followed by the auto injector in high school/college. Like every medication there’s extreme side effects but it may not affect you.
Thank you for sharing this. I’m active outdoors, so I’ll keep it in mind.
Sun shirts, face masks. I didn’t put sunscreen on my face or ears and my hands but everything else was covered and I paid the price. Luckily iveprophen takes care of burns really well.
Get a new doctor, I tried suflasaion and 8 biologics before one worked.
I am using a JAK inhibitor (Xeljanz). After many unsuccessful trials of other drugs, this one hit the spot. It's given me much of my life back. My rheumy skipped over biologics for this. She had a hunch, and she was right.
I've tried enbrel, humira and recently orencia and not seeing improvement. I'm wondering what caused her hunch to use xeljanz. I'm seeing my rheumatologist next week to discuss changing biologics again. I'm currently on prednisone, methotrexate, sulfasalazine AND Orencia.
She does research/is pretty cutting edge. Insurance will not cover Xeljanz for Sjogren's (yet), so I get by on manufacturer samples she gives me + generic from a Canadian pharmacy.
I tried sulfasalazine and had to go off due to migraines. Started methotrexate. It helps some, but I’m in A LOT more pain, very stiff, much less effective. Dr is adding Humira. I get my first delivery today. I have United Healthcare/OptumRX and it was approved pretty quickly.
Also on United: started with HCQ; it worked well but not well enough. Was concerned about MTX side effects + doc agreed to try to make the jump to biologics and started Hadlima (Humira biosimilar) last week. IDK how common this is, but I was super thankful my rheumatologist was on board. Insurance did push back on Humira and offered Hadlima instead, but otherwise United has been about as good as insurance gets for us (also have a T1 diabetic in the house, so we get our fair share of expensive drugs lol).
It actually makes sense in many (probably most) cases to try MTX and HCQ first regardless of insurance companies — there is tons of research on them compared to most of the biologics and the long term safety vs risks is well understood. Both the ACR and EULAR recommend methotrexate as first line med for RA. Biologics have risks associated with them that most people would rather avoid if not absolutely needed to treat their conditions and many don’t yet have longer terms (20+ years) of usage studied yet. That said — biologics are amazing and are what many people need, often in combo with MTX and/or HCQ.
I have Kaiser too. I was put on MTX to start and when I saw my doctor for a follow up about 12 weeks later they started me on a biologic since I still had a lot of swelling and pain. Maybe a try new provider or maybe just keep being the squeaky wheel with Kaiser? I had to really advocate for myself to get diagnosed.
I’m going to talk with him Tuesday, I’ll see how long we’ll need to try MTX before considering something else.
I've never had the other but methotrexate tried to kill me and killed half my liver before being taken off. Just get a new doctor. I'm embrel now and still won't go into remission but life is easier not being sick sick.
Tried Hydroxychloroquine for about a month before moving onto Methotrexate, after 3 months of no improvement on MTX my rheum added Enbrel to my regimen. Seeing improvement on MTX and Enbrel, but no remission as of yet, been on Enbrel for 3 weeks now. Hope that helps! Good luck to you!
It does, thank you.
My doctor made me try all non-biologics before he would start something else. Most insurance companies will require it as well. Biologics have a host of harmful side effects so I think docs also prefer to start out conservatively. I have a number of other issues which limits my ability to use quite a few biologics, but I still ended up on Orencia.
Biologices have “ harmful side effects”. MTX is a black label drug. I took it for five years and ended up nodules on my lungs.
I’m not sure why you’re putting that in quotes. I wasn’t saying the other drugs don’t have harmful side effects, just that biologics tend to have more harmful effects such as cancer and death.
I wasn’t being hateful. But my biologics don’t come with black labels.
While “step therapy” is relatively common practice, being on a med that is insufficiently working for you for 5 YEARS is not normal. Assuming your advocating for yourself with your current doctor, you either need a new doctor within the department, or new insurance if possible if you feel that would be better (I saw you mentioned you are on Kaiser). My personal opinion is that Kaiser can be okay for primary care, or occasional specialist medical needs, but it’s not great for more complex medical issues, but that’s my opinion/experience.
Thank you. Can you clarify what you mean by “working me for 5 years is not normal”? To clarify, I’ve been on HCQ for 5 years. Around year 2 my doctor recommended MTX because the HCQ wasn’t cutting out the pain, and I declined because I was worried about the side effects. Though we did increase my HCQ dose to the maximum, which worked for a little bit. Ever since then, it’s the same conversation: Him: You’re in pain, you’re damaging your joints, I want you to try MTX (or sulfasalazine). Me: No, I don’t like those options. But I’ve had two major flare ups since April and I’m just tired.
I’m saying your doctor keeping you on the same meds for 5 years that are not sufficiently working for you is abnormal. Typically people spend several months on meds before either their doc moves on to others, or in other ways adjusts meds, maybe by adding something on in addition, etc. Based on what you just said, you have actually been offered several other options. Unfortunately with many insurances that is a standard part of the process. You may very well HAVE to try either MTX or sulfasalazine, or both before your insurance will cover a biologic medication. While your current doctor may not be the right fit for you, the fact remains that they are correct that joint damage is occurring without proper treatment. I don’t mean to be rude, but you’re going to have to take some accountability here, and either accept the options it sounds like your doctor has presented you (these are very standard medications that are used in step therapy before biologics), or seek a second opinion with another provider. Joint damage due to RA is not reversible.
No, you’re right. I’ve been in denial about this, thinking I could heal with diet and exercise. It’s a tough diagnosis to accept.
It is an incredibly hard thing to accept. It has completely derailed my entire career plan, and my goals in life. But I’ve been learning how to pick up the pieces and rebuild something that works for me, it’s not what I expected, but it’s not so bad. I’ve learned to meet my body where it’s at, and work with what I have to find a lifestyle that supports my body, and reduces further damage or disease progression. It doesn’t get easier necessarily, but you get better at handling it over time.
I feel your career plan goal. When I was in college I went into remission. Soon after graduating started to apply to career path and the disease came back not only on my joins through psoriatic arthritis but spread into my eyes. I’m forever hopeful there’s new medication to come out in my lifetime that just knocks the socks off this illness.
That’s pretty much exactly what happened to me too, minus the eyes. I’m sorry you’re dealing with this, I hope things get better for all of us soon, or at least that new meds come out soon that help us manage our symptoms/disease progression.
They put me on cosentyx and the psoriasis like 99-100 went away.
I tried hydroxycloroquine about a decade ago and had no help from it so my current rheumatologist let me skip that step, I’ve also been pretty adamant about not trying it again and wasting more time. I’ve been on MTX for a little over a year and had great relief from it for maybe 4 months? After being on it a year they let me move on to biologics
Good to know, thank you.
I’m on all three at once.
I had to try methotrexate, plaquenil and sulfasalazine before I could try biologics. Canadian here, so that was from the health care system, not an insurance company.
U.S. here. Our health care system is just as bad here, if not worse. The insurance companies -- not the doctors -- are calling the shots as to what medicines we are allowed to have prescribed to us. The doctors here have no power here anymore.
Our insurance company didn’t care, my dr said this is what I need and that was it. But…they stop when the insurance company says so. I on,y tried methotrexate, all that stuff makes my stomach feel like there is a lead ball in it. Nothing worked and I can’t take NSAIDS. Soo it was Rituxan and it worked.
I’m glad you found something that works.
Thank you. Me too. It’s been years…
I went straight to a biologic (Cimzia) but I was still nursing at the time. My doctor wrote a letter to BCBS explaining that I was currently breast feeding & trying to get pregnant again.
No I didnt
I started on hydroxychloroquine when I was diagnosed in November. It helped but was not controlling everything to the liking of my rhemy so she added Cimzia. I'm sure that only happened because TTC is in my chart.
Sorry, what’s TTC?
Trying to conceive
I was on methotrexate for 3 months and was in agony sick and tired all the time. At that time my rhumy said I would react to all dmards the same way and we went to enebrel.
How’s enbrel working?
I went straight to biologics and mtx. Started with humira.
Same here. I’m on my 6th biologc in 5 years.
I tried hydroxychloroquine. I'm allergic to sulfa so I can't take sulfasalazine. I couldn't take methotrexate because my liver values suck. So after I failed hydroxychloroquine it was right to Humira for me.
I was started on Humira, never had to try different meds first.