Hunter was diagnosed with Juvenile Idiopathic Arthritis (JIA) at 5.5 years. JIA is the most common type of arthritis in children where the immune system mistakenly attacks the body’s tissues, causing inflammation in joints and potentially other areas of the body. Hunter experienced painful, swollen joints, with fevers and fatigue.
The first medicine his doctor prescribed was an anti-inflammatory. He took the anti-inflammatory drug every day, for 8 weeks with no change in the intensity of his pain or swelling. With poor results, his physician then prescribed another anti-inflammatory for 12 weeks. Again, with little change in his symptoms, his physician prescribed oral Methotrexate for 12 weeks. At the end of the 12 weeks, Hunter was still miserable, having difficulty attending school or getting any pain relief. His physician was concerned that Hunter’s pain was a sign of joint destruction. She decided he needed a more powerful and effective medication to control his JIA and prevent further progression of internal damage and joint erosion. His rheumatologist prescribed a biologic.
Hunter’s family insurance plan denied coverage stating Hunter had to "fail first" on injectable Methotrexate, and continue on it as his treatment for 6 months, before they would consider approving the much needed biologic. After 3 months on the prescribed injectable, there was still no improvement. Hunter’s physician persevered helping Hunter to receive the biologic by enrolling him in the manufacturer’s Patient Assistance Program. When he reached the insurance plan’s requirement of 6 months taking a medication that did not help, the insurer finally approved coverage for the biologic the rheumatologists originally prescribed.
"Following the insurance coverage requirement of ‘failing first’ on 4 medications caused a 14 months wait for Hunter to get on the biologic medicine he needed to place his JIA under control. During the months of waiting, Hunter missed months of school because he could not walk without severe pain. The right medication, the biologic, started to help Hunter within 2 months. If he had started the biologic 3 months earlier he would have had less damage to his knees," replied Hunter’s mother, Heather. Hunter has since had arthritis surgery on both knees to remove the damaged membranes.
Step therapy is causing kids with JIA to suffer in pain. While the medicines to treat progressive arthritis are expensive, so is the high cost of joint replacement surgery.