Step ther­apy not al­ways the best course of action

Albuquerque Journal - - OP-ED -

TWO RE­CENT let­ters have been pub­lished re­gard­ing step ther­apy, one from a rheuma­tol­o­gist and one from an in­sur­ance com­pany rep­re­sen­ta­tive. Step ther­apy is a prac­tice whereby in­sur­ance com­pa­nies force pa­tients to use more cost-ef­fec­tive med­i­ca­tions be­fore ap­prov­ing more ex­pen­sive ones. Most pa­tients cer­tainly un­der­stand the in­sur­ance com­pa­nies’ fi­nan­cial mo­ti­va­tion for step ther­apy; how­ever, some per­spec­tive from a pa­tient like me clearly demon­strates why this rigid prac­tice is not ap­pro­pri­ate for many pa­tient sit­u­a­tions here in New Mex­ico.

I have se­vere rheuma­toid arthri­tis (RA), which is a chronic, in­cur­able au­toim­mune dis­ease that af­fects joints and or­gans. When I was di­ag­nosed nine years ago at the age of 32, the sever­ity of my dis­ease ac­tiv­ity prompted my rheuma­tol­o­gist to rec­om­mend that I start im­me­di­ately on an ex­pen­sive but ef­fec­tive bi­o­logic med­i­ca­tion. How­ever, be­cause of the lim­i­ta­tions of step ther­apy, I was forced to first take an older, less ex­pen­sive, non-bi­o­logic med­i­ca­tion that she was con­fi­dent would not pro­duce the de­sired re­lief. Fol­low­ing this un­suc­cess­ful trial, dur­ing which I was in ex­treme pain while car­ing for a new­born, I was al­lowed to start the new med­i­ca­tion, and I fi­nally be­gan to ex­pe­ri­ence re­lief sev­eral months later. This med­i­ca­tion re­mained ef­fec­tive for me for sev­eral years un­til I de­vel­oped an im­mu­nity and had to change med­i­ca­tions— a com­mon oc­cur­rence for au­toim­mune pa­tients.

Once again, I was forced to suf­fer need­lessly while com­plet­ing the step ther­apy to change to a new med­i­ca­tion. In­stead of be­ing able to start the med­i­ca­tion that my rheuma­tol­o­gist wanted me to go on, I had to try two other med­i­ca­tions first, in be­tween which I had to “wash out,” mean­ing that the med­i­ca­tions needed a month to be gone from my body. Ad­di­tion­ally, many spe­cialty med­i­ca­tions take months to be­come ef­fec­tive. In to­tal, it was al­most a year be­fore I be­gan to ex­pe­ri­ence any re­lief. In the mean­time, I had to take pred­nisone, a steroid, to mit­i­gate my ex­cru­ci­at­ing pain, and I now have per­ma­nent joint dam­age in my hands along with lin­ger­ing side ef­fects from the pred­nisone.

At least nine months of de­bil­i­tat­ing pain and ex­treme fa­tigue, as well as per­ma­nent joint dam­age, could have been avoided if I would have been able to start on the med­i­ca­tion my doc­tor orig­i­nally wanted for me at the time I be­gan to have is­sues . But be­cause of step ther­apy, I was forced to suf­fer. I fail to see how that is “ap­pro­pri­ate care.” SHANNA JAR­RETT Albuquerqu­e

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