New arthritis drugs effective but costly
Looking back 13 years, the events are still fresh in Cheryl Koehn’s mind. She was turning 30, one of those Vancouver fitness buffs who live to exercise and play competitive sports. When she first felt a pain in the ball of her foot, she dismissed it as too much work on the stair-climber. Three weeks later, the index finger on her right hand suddenly swelled so much she couldn’t bend it. Her family doctor did two blood tests just to make sure. The diagnosis was a shocker: rheumatoid arthritis.
“I was devastated,” Koehn recalls. “I went home and bawled my eyes out.” Within months, the disease had spread to 30 joints. Koehn, the athlete, was almost totally incapacitated.
Arthritis has many faces
Arguably, rheumatoid arthritis (RA), a runaway autoimmune disorder in which the body literally attacks its own joints instead of germs and disease, is the worst of a sometimes baffling spectrum of 100 different ailments all called arthritis and all related to joint and musculoskeletal deformity and excruciating pain. While RA may be the most painful and crippling, osteoarthritis (OA) is the most common. This form of arthritis, which usually hits us in our 40and on, is a degenerative disorder in which cartilage, the shock absorber that cushions the joints between the body’s 206 bones, begins to wear out, causing painful swelling in the joints. It usually affects the hips, knees, hands or spine.
Halifax rheumatologist Dianne Mosher, an associate professor of medicine at Dalhousie University and past president of the Canadian Rheumatology Association, says there are certain common denominators that link all forms of arthritis: no one knows exactly what causes it, the damage is irreversible and arthritis numbers are soaring. In October 2001, the Centers for Disease Control in Atlanta published the results of the first-ever American arthritis survey. It concluded that a full one-third of all adults in the United States have osteoarthritis. In Canada, four million people suffer from some form of arthritis. One in seven of us has osteoarthritis now. And as the baby boom generation enters old age, three million more will be diagnosed by the year 2031.
The price tag of treating arthritis is likewise swelling, faster than an arthritic knee joint, costing our economy some $17 billion every year. As the largest cause of disability in the country, arthritis is the third most common reason for prescription drug use. More troubling to those who suffer from it is that treatment can also be costly – especially if you don’t have a good drug plan.
Next page: New drugs work but cost the earth
New drugs work but cost the earth
Over the past decade, many new drugs that treat RA and other devastating forms of arthritis have become available in Canada. They work like nothing before. But because some provinces won’t pay for them, desperate individuals almost have to mortgage the house to afford the costs, which can soar as high as a whopping $15,000 to $25,000 a year.
Toronto resident Pauline Helferty has OA in her knee, ankle, neck, back and both hips. She sometimes uses a cane to walk. There are days she can’t even straighten up, much less do the things she loves to do – play the piano, act in little theatre and travel with her husband. Helferty is 59 and has suffered from OA for the past 20 years. Fortunately, Helferty is a retired teacher with a private health-care plan that covers her drugs (a cornucopia that has included Celebrex, Mexium, Tylenol 3, Mobicox, Miaculin, Vioxx, vitamin D, calcium, Motrin and cortisone shots).
For years, Helferty relied on a variety of treatments such as acupuncture, acu-pressure and chiropractic. Now, she says, “The drugs are maintaining me. I’d be a lot more crippled without them.” Celebrex, a so-called COX-2 inhibitor, works by keeping an aggressive enzyme that promotes inflammation at bay. But since its approval by Health Canada in 1999, it has been associated with side effects such as ulcers and criticized by some doctors as more expensive and no easier on the stomach than older, cheaper drugs. Helferty doesn’t care. “I hear a lot of discussion. All drugs have side effects. My motto is I will take whatever my doctor prescribes to maintain my quality of life.” With a good drug plan, she doesn’t need to worry about the cost.
The magic of biologics
After trying a variety of medications, Cheryl Koehn began to take a biologic, a new medication that targets a specific cell that’s creating the arthritis, while leaving the rest of the immune system intact. Biologics are seen as a new weapon; conventional arthritis drugs only treated symptoms such as pain and inflammation. Within 12 hours, the overwhelming pain and disabling swelling was gone. “This drug was magic,” Koehn says. Dr. Mosher won’t go that far but she has about 80 patients on biologics now and she does agree that they are “vastly superior.” Like Helferty, Koehn has an insurance plan, but the high cost of her treatment means she has to pay an $8,000 deductible every year.
That’s a price many people, including Alex Harvey, can’t afford. The former mining supervisor from Peterborough, Ont., was diagnosed with RA in 1974 when he was 54. Over the years, he had tried many drugs and for a while, each one worked to help the pain and swelling in his hands, knees, feet and shoulders. In March 2001, Harvey got into a drug trial for a biologic called Remicade. He had three infusions intravenously. Then the trial was cancelled. Then he got two more treatments. Then the trial was cancelled again. After a letter-writing campaign that included every level of government, Harvey, a Second World War vet, appealed to Veterans Affairs. They agreed to assume the costs of his treatments: $3,253.43 every eight weeks.
Next page: Formularies and red tape
Formularies and red tape
In brief, this is how the provincial drug plans work: in all provinces except P.E.I. and Newfoundland and Labrador, two biologics are listed on formularies, which means that a patient following a certain set of criteria (failure to respond to other drugs, poverty and age) may get them fully or partially covered. A third biologic is newer, so it is only listed on the Ontario and Manitoba formularies.
This situation makes Dennis Morrice, president of the Canadian Arthritis Association, mad. He feels drug costs continue to rise because each province insists on testing each drug before it is listed on a formulary. “We are not suggesting that they give up safety. We are suggesting that they stop running the same studies,” he says. “These drugs are not candies. They are prescribed by doctors.” Morrice and other advocates are now working on a Common Drug Review plan that centralizes drug studies and cuts down on much of the red tape.
A spectrum of health care
Besides the uneven drug coverage, many patients say the quality of diagnosis and medical care is dictated by location. “There is a spectrum of care in this country,” says Pauline Helferty. “It depends on where you live.” And expect to wait in line. There are only 270 rheumatologists (arthritis specialists) in Canada.
In light of this, Dr. Safiq Quaadri, a Toronto physician, health columnist and lecturer, says that the best advice for patients is to aggressively push their doctors for early diagnosis and treatment. “Bone health is massively under appreciated in Canada. People just let bone pain go on too long. If you have pain after four weeks – eight at most – go and see a doctor. After blood tests and a run of anti-inflammatories, seek out a rheumatologist.”
Arthritis risk factors
• Heredity is a clear factor in osteoarthritis due to substandard cartilage and improper joint formation. In rheumatoid arthritis, if one family member has it, another is three to four times more likely to get it.
• Women get RA and lupus more often than men. Men get gout and ankylosing spondylitis more than women.
• If you’re carrying extra weight, it can put extra stress on joints, causing arthritis.
• Staying fit can help lower the risk.
• Like every ailment, alcohol, caffeine and cigarettes are risk factors.
• Injuries such as falls, particularly falls that damage a joint, can set up premature OA.
• Overuse of the same joints can cause OA.
• Diabetes and low thyroid problems predispose to early OA.
Arthritis fact and fiction
• Habitually wearing high heels can contribute to OA of the knees.
• Stress – the teeth-grinding variety – can cause OA of the jaw.
• Cracking your knuckles does not predispose you to OA of the fingers.
• Hair dyes and perms do not cause or aggravate lupus.
• X-rays show that damage to finger joints in RA is less in fingers that bear a gold ring. Go figure.
• Copper bracelets won’t do any harm. Neither is there enough proof to say they do any good.
• Some four billion people around the world use herbs for medicinal purposes. On average, Canadians spend $622 each annually on herbal remedies. Most of them do nothing useful for arthritis, with certain exceptions including glucosamine and condroitin sulphate, which can ease swelling, stiffness, pain and tenderness.
Adapted from Living Well with Arthritis: A Sourcebook for Understanding and Managing Your Arthritis by doctors Dianne Mosher, Howard Stein and Gunnar Kraag (Penguin, 2002) $29.