Abortion bans affect arthritis med access
Popular treatment can cause miscarriages
Denise Johnston stood in line at the pharmacy to pick up her monthly prescription of methotrexate, which she takes to relieve pain from her psoriatic arthritis.
A month earlier, Johnston, 49, picked up her new prescription with no problems. But this time, she was stopped at the counter of her CVS pharmacy outside San Antonio, Texas, and asked about her “birth control plan.”
She was stunned and embarrassed. Not only was she at an age when women typically begin menopause, she had a total hysterectomy about 20 years ago, ending her ability to get pregnant.
She explained that to the pharmacist in front of a line of waiting customers but was told her insurance wouldn’t cover the medication, which has the potential to cause miscarriages and birth defects.
“It was just like a slap in the face,” Johnston said. “I was very angry. I just wanted my meds.”
Experts say Johnston’s story is becoming more common in abortion-restrictive states after the Supreme Court’s decision overturning Roe v. Wade, the 1973 landmark case that made abortion a constitutional right.
“We’re hearing scattered reports about people having limited access to (methotrexate),” said Dr. Kenneth Saag, president of the American College of Rheumatology. “Doctors and pharmacies are uncertain about their legal situation in prescribing or dispensing the medicine.”
Methotrexate is an immunosuppressive drug used to treat rheumatoid, psoriatic and juvenile idiopathic arthritis and vasculitis, said Dr. Mehret Birru Talabi, assistant professor of medicine at the University of Pittsburgh School of Medicine.
It’s a “cornerstone therapy in rheumatology,” she said. The Arthritis Foundation calls it “one of the most effective and widely used medications for treating inflammatory types of arthritis.”
But its contraindication in pregnancy is what’s making providers hesitant to prescribe or refill prescriptions for women of childbearing age in states with anti-abortion laws.
“It is an abortifacient medication … and has the potential to cause birth defects,” Birru Talabi said. “It’s being lumped into medication that can facilitate abortion, and even though it’s an incredible therapeutic for patients, it can be used for abortion purposes, and that’s leading to some restriction over its use.”
Fills for methotrexate were relatively flat between April and July, increasing by only 5%, according to data from SingleCare, a free prescriptions savings service. But experts worry that may change amid reports of women struggling to access the arthritis treatment.
More than 1.3 million people in the U.S. have rheumatoid arthritis, according to the Cleveland Clinic. The Arthritis Foundation estimates about 90% of rheumatoid arthritis patients have taken methotrexate at some point.
Methotrexate is also widely used outside rheumatology. It originally was developed to treat blood, bone, lung, breast, head and neck cancers at high doses. It’s also used in gynecology, dermatology and sometimes gastroenterology, Birru Talabi said.
“Methotrexate has been around since the ‘80s,” Saag said. “It’s taken exceptionally well and tolerable, quite safe and relatively low-cost.”
The only alternative to methotrexate are biologic response modifiers that work by disrupting the inflammation process that leads to joint pain.
Biologic therapies are “perfectly safe to use during pregnancy,” Birru Talabi said, but they cost $10,000 to $60,000 a year, depending on the medication. Methotrexate costs about $50 a month.
It’s unrealistic to expect insurance companies to cover biologic medications for every patient living in an abortion-restrictive state who has a uterus and the potential to get pregnant in the next 20 years, she said.
“Defensive prescribing for some of these medications is going to lead to downstream effects,” Birru Talabi said. “I don’t know if the health care system can bear those costs.”
Johnston ended up paying for her 28day supply of methotrexate out-ofpocket. But she acknowledged not everyone has the financial flexibility to do that.
“I am very fortunate that I am in a position to pay for it,” she said. “It’s not delusional, however, that $50 a month – especially in this economy that we’re in right now – could make or break someone.”
After reaching out to CVS Caremark, she was told the generic drug should be covered and was offered reimbursement.
In a statement sent to USA TODAY, CVS said its policy in certain states, including Texas, is to validate the drug’s indication with the patient’s provider.
“Laws in certain states restrict the dispensing of medications for the purpose of inducing an abortion,” a CVS spokesperson said. “These laws, some of which include criminal penalties, have forced us to require pharmacists in these states to validate that the intended indication is not to terminate a pregnancy before they can fill a prescription for methotrexate or misoprostol.”
The company’s policy does not state pharmacists or pharmacy employees can ask patients directly about their birth control plan or intended use of the drug if the diagnosis is not included on the prescription.
Saag said pharmacists and doctors have expressed concern about the possible legal ramifications of prescribing and dispensing methotrexate after the Supreme Court decision. In response, the American College of Rheumatology formed a task force to address these issues, create clear messages to health care providers and offer tools to improve access.
Johnston hopes the effort creates more stability for women navigating the health care system in a post-Roe world beyond reproductive health.
To see “women’s rights set back so far with this is just devastating,” she said. “I just don’t know if these long-reaching effects were thought through.”
(Methotrexate) is an abortifacient medication … being lumped into medication that can facilitate abortion, and even though it’s an incredible therapeutic for patients, it can be used for abortion purposes, and that’s leading to some restriction over its use.” Dr. Mehret Birru Talabi Assistant professor of medicine, University of Pittsburgh School of Medicine