When I was first diagnosed in 2020 for #nrAxSpa, the 2019 College of Rheumatology strongly recommended treatment using TNFi (high level of evidence), and only conditionally recommended OSMs.

Check out numbers 55 and 56
https://rheumatology.org/Portals/0/Files/AxialSpA-Guideline-2019.pdf

Not to mention, OSMs have had very little evidence of providing relief from axial (spine) symptoms

See
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5557185/#section3-1759720X17706454title

I wasn't sold. I had been playing for years and years, and I was used to the normal aches and pains. This was different.

My pain levels caused me to completely stop playing, but my pain didn't go away. I had to become my own advocate, so I started to research my symptoms.

Through my research, and talking with to family members, I realized we have a family history of #PsA, so I asked the student health center for a rheumatology referral (which was met with reluctance due to only slightly elevated blood inflammation levels, tho on NSAIDS).

I finally got to my appointment, and my rheumatologist agreed that this was not normal for a 22 year old. I shouldn't be feeling like this.

So he dx'd #nrAxSpA, and prescribed Cimzia in line with FDA and College of Rheumatology recommendations.

For about a year, Cimzia worked! But after the year mark, things began to get worse. The immunocompromising effects began to add up and I started getting infections for which I had to start and stop treatment, which can reduce efficacy of the treatment.

My psoriasis lesions got worse, and new ones began popping up. Peripheral involvement got worse (new pain in achilles, elbows, knees, and new dactylitis). Previous SI and lumbar pain returned, at even worse levels.

I brought this up to my (new) rheumatologist, and we tried everything to get my existing Cimzia treatment to work. We changed dosage, and delivery method (from 2 shots a month to 1 shot every two weeks). Nothing worked.

She decided that Cimzia was no longer working for me, and recommend we look into Remicade (Avsola) and Orencia. We decided that since Avsola is approved for RA, PsA, PO, and SpA (AS), it would likely have the best results for me and my symptom set.

We've done everything by the book in regards to my treatment, so to have United Healthcare deny my prior auth simply because they don't want to cover the expensive drug is ridiculous, and so typical of insurance.

"Only you and your doctor can decide what medical care you need."

It's almost as if they don't believe cost (especially of biologics) is a barrier to treatment. Take a look at the average prices for Avsola with GoodRX

https://www.goodrx.com/avsola

Side note, some may ask why we decided to go to another TNFi instead of added Methotrexate to begin with. Due to previously mentioned increase in axial symptoms, we decided we'd have better results if we got that back under control first, and could add MTX if needed.

All this brings me back to my original thoughts about MTX, which start with

• Has low evidence for relief of axial symptoms
• Is no longer recommended as first treatment for PsA or SpA

...

• Can be used to induce abortion for ectopic pregnancies

and most importantly to insurance

• is much cheaper than biologics.

No wonder my prior auth was denied!

My main concern regards my 3rd point. I live in Virginia, where there are reports of patients already struggling to get access to MTX.

https://www.cnn.com/2022/07/22/health/abortion-law-medications-methotrexate

Virginia has even introduced a potential bill that would further limit access to drugs that could induce abortion.

https://lis.virginia.gov/cgi-bin/legp604.exe?221+ful+SB710

So then my question becomes what happens in a scenario where patients can't get access to drugs required in step-therapy by their insurance providers?

Am I stuck on a treatment that is no longer working?

Do I pay thousands out of pocket for a treatment that has been standard of care for almost 3 years?

We knew the Roe v. Wade reversal would have detrimental effects on Women's healthcare. Many didn't consider the ripple effects outside of abortion care.

I have no doubt that my rheum will go to bat for me against UHC. Any good doctor would (doesn't mean they should have to).

But the barriers of access to care for rheumatological conditions (which more often affect women than men) have been increased in a post-roe world.