In the United States, those of us who work as healthcare providers often struggle with the realities of the “haves” vs. the “have nots.” The “haves” are the patients with good insurance, supportive families, and stable lives despite their disease. The “have nots” are at the other end of the spectrum, with sporadic or perhaps no insurance, a lack of
external support, and chronic unemployment.

Unfortunately, these realities often shape the nature of our discussions with patients diagnosed with rheumatoid arthritis (RA) and require us to be nimble in trying different
tactics to achieve of goals of disease remission or low disease activity. MM, a 56-year-old male, is one of those “have nots.” He came for his first appointment in March 2018, reporting an 8-year course of pain affecting his hands, feet, back, knees, and neck. He had worked for years in construction, spending hours every day on his hands and knees laying tile until the pain became unbearable. He subsequently took another job in maintenance at a local golf course, which is where he worked on a seasonal basis when we met.

MM had been a pack-a-day smoker for nearly 40 years and had a history of heavy drinking, although he said he had been sober for the last 14 years. He told me that he understood that delaying treatment for his symptoms had not been wise, but that he only recently had obtained health insurance through Medicaid and could not previously have afforded care.

An initial physical exam showed significant joint swelling throughout multiple proximal interphalangeal and metacarpophalangeal joints, with decreased range of motion in the hips, hands, neck, and lumber spine. There were also two spots of notable psoriasis on MM’s skin.

Lab results demonstrated a high rheumatoid factor and erythrocyte sedimentation rate. A multibiomarker disease activity test (Vectra) resulted in a score of 39, demonstrating active RA. Because of his years of smoking, poorlycontrolled disease, and concomitant psoriasis, it was clear that MM was at an increased risk for cardiovascular disease as well. Our treatment began conservatively with metrotrexate (MTX) 6 mg weekly, which we added to the over-the-counter diclofenac that

“Working with insurers is never easy, and there are certainly unique challenges for our patients insured through Medicaid.”

MM had been taking. Before initiating MTX, I did reiterate with MM the need to refrain from alcohol use, and he assured me that he was a regular participant in Alcoholics Anonymous meetings and had made a deal with God to never drink again. The MTX was a good initial choice due to the potential beneficial effects on both MM’s arthritis and cardiovascular risk.

Two months later, MM returned to my office for his initial follow-up. He reported modest improvement in his hand pain, but not as much as either of us had hoped for. We began to discuss other potential treatment options, and MM noted that he would prefer another oral medication as it was difficult for him to leave his house due to his extensive arthritis. We therefore opted for tofacitinib and filed a pre-authorization form with Medicaid for the medication.

The response we received a few days later was unfortunately not good—our request has been denied. We were informed that MM would need to start with a biosimilar first—infliximab-dyyb—at a modest 3 mg/kg dose before an additional biologic or biosimilar would be considered. After three infusions, MM’s symptoms again were modestly improved, but due to the years of built-up destruction and inflammation, the impact of these modest improvements on MM’s quality of life was minimal. He still was unable to leave his house on a regular basis.

MM asked our team once again if we could try to get use of tofacitinib authorized for him. Among other issues, he told us that it was difficult for the infusion nurse to insert the IV into his veins. This was not surprising—MM’s many years of smoking and drinking were likely a significant contributing factor. MM also said that he had recently been laid off from his seasonal job at the golf course and that, “If only my arthritis was better, I could make a better living.”

I hesitated in submitting a new request to Medicaid for a few reasons. First, because of our initial issues with tofacitinib authorization, I was skeptical that another request submitted so soon after initiating a biosimilar would be approved. Secondly, because we remain in the early stages of individualized medicine, there was no guarantee that tofactinib would be any more effective than infliximab-dyyb.

I therefore suggested to MM that we increase the dose of the biosimilar to 5 mg/kg Q8W for another two rounds to gauge any changes before considering further treatment adjustments. It’s been only a few days since this most recent conversation and MM is awaiting his next infusion, so we will have to wait and see how he responds to this latest dose escalation.

Working with insurers is never easy, and there are certainly unique challenges for our patients insured through Medicaid. I have generally found that approvals are easier to obtain for infusible biologics. I am usually OK when insurance mandates use of a biosimilar in these patients, unless there is a specific contraindication such as concomitant lupus or multiple sclerosis that would preclude use of a specific agent such as an anti-TNF biologic/ biosimilar. For our Medicaid patients, who make up a significant percentage of our schedule, I am often happy when we can get approval for ANY biologic agent.

Our patients come from many different backgrounds and have a variety of unique challenges that compound their struggles with rheumatic disease. Individualization of therapy often requires both a medical and social decision with a variety of factors to be weighed. It isn’t always enough to base our recommendation on which agent will be most likely to positively affect a patient’s symptoms—route of administration, cost, and insurance structures are all among the other factors that must often be considered.

Nonetheless, helping our RA patients—whether they are “haves” or “have nots”—achieve the goals of disease remission or low disease activity despite hurdles in their path must nonetheless always remain at the forefront of our thoughts.

AUTHOR PROFLE: Iris Zink, MSN, NP, RN-BC is a nurse practitioner at Lansing Rheumatology in Lansing, Michigan.