Of course, sometimes life gets in the way of taking a prescription drug perfectly: You forget to take a dose; a prescription runs out; or a perishable drug gets left in the car for a few days. And even if everything goes according to plan, you may still experience side effects from a drug that make you wonder if you should keep taking it. When it comes to ankylosing spondylitis medications, your pharmacist can be an invaluable resource to address any questions or concerns you may have. Pharmacists are generally knowledgeable about not just the dosing, effectiveness, and potential side effects of medications, but also practical concerns related to insurance coverage. “One of the big things in specialty pharmacy is managing insurance,” says Donald Miller, PharmD, a professor of pharmacy practice at the North Dakota State University School of Pharmacy in Fargo. “Pharmacists spend a lot of time trying to get prior authorizations.” Beyond that, says Dr. Miller, a pharmacist’s job involves “educating patients about what they can expect from the medication, the time frame for getting better, what kinds of adverse effects they might have — and answering any questions.” Here are some common questions you may have about your medications for ankylosing spondylitis, and how your pharmacist can help answer them.
1. What can I do if my insurance doesn’t cover my prescription?
This problem tends to arise only with biologics — highly effective but expensive drugs that are injected or infused — and specifically, a drug class called TNF inhibitors. There are five TNF inhibitors approved for ankylosing spondylitis and related diseases in the United States, according to the Spondylitis Association of America. Miller says many health insurance plans treat TNF inhibitors as interchangeable, so they don’t cover all of the meds. Insurance may have one or two preferred drugs based on negotiated prices and not cover any of the others under ordinary circumstances. “Whatever the insurance has as their first-line [treatment] tends to be what [you get],” says Miller. You can appeal your insurance company’s decision to deny coverage, but this process can be drawn out and difficult to navigate. “The path of least resistance, usually, is to go with the one your insurance company covers,” says Miller. If you’re just starting on a TNF inhibitor, he notes, there’s probably no good reason not to do this. But if you’ve already tried a TNF inhibitor that didn’t work for you, and now you’ve switched insurance plans and are being forced to go back to the old drug, an appeal may be worthwhile, Miller says — even though there’s no guarantee it will succeed.
2. My medication is too expensive. How can I pay for it?
If you’re having trouble affording deductibles or copayments even with insurance coverage, your pharmacist may be aware of coupons or other special programs or discounts offered by the manufacturer and can “fairly quickly determine which program is worth applying for,” says Miller. But most assistance programs, Miller notes, are for people without health insurance coverage. If you’re in this camp, you may have greater success than someone with insurance. “Generally, you can find a work-around” when costs are a concern, says Miller. “Still, it’s more difficult generally for people who have insurance but have huge deductibles.”
3. I’m running low on my medication and can’t reach my doctor’s office for a refill. What can I do?
How easily you can get your prescription urgently filled often depends on what drug you’re taking, says Miller. If you run out of a nonsteroidal anti-inflammatory drug (NSAID) — among the first drugs typically prescribed to control ankylosing spondylitis symptoms — your pharmacist may be able to give you a small amount to tide you over. But if you take a biologic drug, “You don’t want to think you’ll get a prescription from your doctor and get it filled the same day,” says Miller. Biologics usually require an extensive approval process from your insurance company. All of this means that when it comes to refills, “Patients do need to be proactive,” says Miller. “When they’re running out of the medicine, they need to talk to the pharmacy a couple of weeks in advance to ensure that there’s no break in their supply.”
4. I missed a dose of my medication — or took too much. What should I do?
If you take a drug daily — as is the case with NSAIDs and certain other drugs for ankylosing spondylitis, such as short-term courses of corticosteroids — then a missed dose can usually be taken within a few hours of your regular time. But if you don’t realize until the next day that you skipped a dose, simply resume your schedule. Don’t take more medication than you usually do. Injectable biologic drugs offer a bit more forgiveness, says Miller, since they’re typically taken every two weeks or once a month. “If you were due to take it yesterday, you can take it today or tomorrow.” On the other hand, “If you’re almost due for your next dose anyway, then just skip that dose you missed,” he advises. It’s rare to take too much of a biologic drug, but mistakes can happen, especially if you’re new to the medication. In this case, “The fortunate thing about biologics is, they’re very safe,” says Miller. “There’s probably a good margin for error. Watch for anything unusual, but you’re probably going to be just fine.” If you’re still unsure of what to do, ask your pharmacist for advice on your specific drug.
5. I’m worried my medication might cause unpleasant side effects. What should I do?
NSAIDs are known to cause potentially unpleasant or harmful side effects, which your pharmacist will explain, says Miller. “With NSAIDs, there’s always concern about gastrointestinal problems,” he notes. “Nausea and gastrointestinal bleeding are definitely issues.” Biologic drugs, on the other hand, tend to have fewer side effects in most people, along with almost no drug interactions, says Miller. Still, pay attention to the risks and precautions your doctor and pharmacist mention regarding these drugs. If your side effects are severe or interfere with your life in a significant way, contact your doctor to discuss alternatives to your current medication. If you can’t reach your doctor, your pharmacist may be able to advise you on whether you should stop taking the drug until your doctor responds.
6. My medication is expired or possibly spoiled. What should I do?
Expiration dates matter less if your medication has been stored properly, says Miller. For injected biologic drugs, this means keeping them refrigerated. Many drugs, Miller notes, are “potent well beyond the expiration date.” But if you haven’t been storing a biologic drug correctly, it can begin to break down long before the expiration date. If you know your medication hasn’t been stored properly for an extended period, “I would assume it’s probably not going to be effective and obtain a replacement dose,” says Miller. You can also ask your pharmacist for advice.
7. Why have my ankylosing spondylitis symptoms returned even though I’m taking my medication as directed?
First, double-check whether your medication may be spoiled because of improper storage or hasn’t been taken as directed. You should be able to get guidance on both from your pharmacist. Also pay attention to any recent changes in how you get your medication. If there are no easy explanations for your medication losing its effectiveness, it’s a good idea to talk with your doctor about your symptoms. They may ask about other changes in your life, such as increased stress, other health conditions you have, or new medications you’re taking. Miller urges people with ankylosing spondylitis not to ignore changes in their symptoms. “Our goal in ankylosing spondylitis, like any kind of inflammatory arthritis, is to achieve remission, or as close to remission as we can,” he says. “And patients should be striving for that.”
8. I don’t feel comfortable coming into the pharmacy. Are there other ways to get my medication?
Most specialty pharmacies, such as those that dispense biologics, offer mail delivery directly to your home or doctor’s office, Miller notes. If you aren’t sure what options are available, call your pharmacist or your insurance company. Especially with the ongoing spread of COVID-19, it’s understandable that people may want to avoid physically visiting a pharmacy. But many locations also offer easy pickup options, such as drive-through, that let you ask questions and get instructions from your pharmacist without much, if any, physical contact. So, don’t sell your pharmacist short. Whether it’s on the phone or in person, pharmacists are there to answer your questions and make sure you’re getting all the help you need with your medications.
