Rheumatology is a medical specialty that focuses on the diagnosis and treatment of autoimmune, inflammatory, and mechanical diseases most commonly affecting the musculoskeletal system, including joints, bones, muscles, and connective tissues.
Rheumatologists commonly treat conditions such as rheumatoid arthritis, osteoarthritis, lupus, gout, ankylosing spondylitis, and many other autoimmune and inflammatory disorders.
Symptoms can widely vary depending on the underlying condition. Common symptoms include joint pain with or without swelling, muscle pain, rashes, fatigue, dry eyes/dry mouth, mouth ulcers, fingers that turn pale (Raynaud’s), sun sensitivity, headaches, and many others.
Rheumatoid arthritis is a systemic autoimmune disorder that causes joint inflammation characterized by swollen, painful joints often made worse by rest; many modern treatments are available. Osteoarthritis is the result of the usual wear and tear of our joints over time, a disease characterized by painful joints often worse with activity like walking or making a fist; unfortunately, fewer treatments are available.
Diagnosis involves a combination of medical history, physical examination, laboratory tests, and imaging studies like X-ray and ultrasound. Rheumatologists may also extract fluid from joints to clarify a diagnosis (arthrocentesis).
Treatments vary depending on the specific condition but may include prescription medication, physical therapy, lifestyle modifications, joint or tendon injection, and in some cases, surgical interventions.
Yes! Diet and lifestyle modifications can play a role in managing symptoms and should also be considered. Maintaining a healthy weight, exercising regularly, and following an anti-inflammatory diet may be recommended.
While many rheumatic diseases (i.e. rheumatoid arthritis, lupus, etc) are autoimmune, some, like osteoarthritis, result from mechanical issues rather than an immune system malfunction. Treatments will vary accordingly on the cause.
Individuals who experience unexplained joint pain or swelling, chronic fatigue, unexplained rashes, frequent oral ulcers, hair loss, and/or have signs of systemic inflammation in lab testing should see a rheumatologist.
While some conditions can be effectively managed or go into remission with treatment, most rheumatic diseases are chronic and may require ongoing medical care to control symptoms and prevent complications. Cure is not always possible, but quality of life can often be significantly improved with modern treatment approaches.
Yes, many rheumatologists are able to help improve the often debilitating symptoms associated with COVID-19 infections such as chronic fatigue, brain fog, and muscle pain.
Fibromyalgia is a chronic pain disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and tenderness often all over the body without usual explanation. It is often associated with other symptoms like migraines, cognitive difficulties (commonly referred to as “brain fog”). tingling/numbness, gastrointestinal changes, and mood disorders.
The exact cause of fibromyalgia is not fully understood, but it is believed to arise from a combination of genetic, environmental, and psychological factors. Trauma (physical or psychological), too little or unrestful sleep, chronic diseases, and likely certain genetic predispositions may contribute to the development of fibromyalgia.
Diagnosing fibromyalgia can be challenging as there are not currently reliable laboratory tests or imaging studies for it. Diagnosis is typically based on a thorough medical history, a physical examination, occasionally testing to rule out related disorders, and the presence of widespread pain lasting for at least three months (many cases with pain for years or more).
Treatment for fibromyalgia often involves a multidisciplinary approach. Medications, such as pain relievers and neurologic medications, may be prescribed. Contributing factors are addressed and managed, like insomnia. Additionally, lifestyle changes, exercise, physical therapy, and stress management techniques are commonly recommended to improve symptoms.
Fibromyalgia is not solely a psychological disorder, but it does have psychological aspects. It is recognized as a real medical condition involving abnormal pain processing in the central nervous system. Emotional stress and mental health factors can contribute to symptom severity, and managing these aspects is often a part of the overall treatment plan.
Absolutely – the pain of fibromyalgia is invisible and shows nothing externally that others can see or perceived, even physicians. This makes it difficult for others to understand how debilitating the symptoms can be. Older thinking often labeled fibromyalgia as a fake diagnosis, a nonsense explanation for pain. On the contrary, in someone with fibromyalgia, we now what changes are happening on a molecular level. We can actually visualize the differences on certain types of MRIS used in research studies. There’s no doubt the disease is real and fortunately, options are available.
Biologics are a class of medications derived from living cells or organisms. In rheumatology, they are often used to treat autoimmune diseases and inflammatory conditions by targeting very specific components of the immune system involved in the disease process.
Biologics target specific molecules in the immune system, such as cytokines or immune cells, to reduce inflammation and modify the underlying disease process. They aim to restore balance to the immune system in conditions like rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis.
Biologics are frequently used to treat autoimmune and inflammatory rheumatic conditions, including rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and certain types of lupus.
Biologics are typically administered through injections, either subcutaneously (under the skin) or intravenously (into a vein). The method of administration depends on the specific biologic and the condition being treated.
When used in the correct way, absolutely! While each medication has its own potential side effects, the fact that these therapies target only a single molecule (in contrast to usual medications that may have different effects in different parts of the body), side effects tend to be infrequent.
While biologics are generally well-tolerated, they can have side effects. Common side effects include injection site reactions, mild infections, and, in some cases, an increased risk of certain infections. Serious side effects are uncommon but may include allergic reactions and reactivation of latent infections.
The onset of action can vary among individuals and depends on the specific biologic and the condition being treated. Some people may experience symptom relief within a few days, while for others, it may take several months.
In many cases, biologics are prescribed in combination with other medications, such as disease-modifying antirheumatic drugs (DMARDs), to enhance their effectiveness or manage symptoms more comprehensively.
The duration of biologic treatment varies and is often determined by the response to therapy. Some individuals may need ongoing treatment, while others may achieve remission and eventually discontinue the biologic under the guidance of their rheumatologist.
The safety of biologics during pregnancy and breastfeeding varies among different medications. There are options that are considered fully pregnancy compatible. It is essential for individuals to discuss their specific situation with their rheumatologist to weigh the potential risks and benefits.
Yes, there are alternative medications, including conventional DMARDs (like methotrexate or sulfasalazine) and nonsteroidal anti-inflammatory drugs (NSAIDs), which may be considered based on the individual’s condition, preferences, and response to treatment. The choice of therapy is tailored to each patient’s unique circumstances.
Coverage will always vary by plan and year-to-year, however most insurers will offer partial coverage for at least one or more medication of each biologic type. Even with coverage, however, nearly all patients will need to be enrolled with the drug manufacturer’s copay support program. These are free programs that will often lower out-of-pocket costs for biologics to an extremely reasonable cost, usually $5-10 per month.
Infusion therapies in rheumatology involve the administration of medications directly into the bloodstream through an intravenous (IV) line. These medications can include biologics, disease-modifying antirheumatic drugs (DMARDs), and other therapies to manage autoimmune and inflammatory conditions.
Infusion therapies are often used to treat conditions such as rheumatoid arthritis, lupus, vasculitis, ankylosing spondylitis, and psoriatic arthritis.
The frequency of infusion therapy varies depending on the specific medication and the individual’s response to treatment. Some infusions may be given every few weeks, while others may be administered less frequently.
The duration of an infusion session can vary but usually ranges from 45 minutes to half a day, depending on the medication. Patients often receive infusions in an outpatient infusion center or a hospital setting.
Side effects can vary based on the medication but may include mild reactions such as headache, nausea, or fatigue. Severe allergic reactions are rare but can occur. The infusion is administered under medical supervision to monitor and manage any potential side effects.
Most infusion sessions allow patients to eat and drink. However, it’s essential to follow any specific instructions provided by the healthcare team, as certain medications may have dietary restrictions during infusion.
Yes, there are alternative forms of medications, such as oral or injectable options. The choice between infusion and other methods depends on factors like
the specific condition being treated, the patient’s preferences, and the efficacy of the medication.
The selection of infusion therapy is based on factors such as the type and severity of the rheumatic condition, the patient’s medical history, and their response to previous treatments. The rheumatologist works closely with the patient to make an informed decision.
While some medications can be self-administered at home, most infusion therapies are typically administered in a healthcare setting under the supervision of trained medical professionals. Home administration is only considered, and possible, in specific cases.
Many individuals resume their normal activities after an infusion session, but it’s advisable to listen to your body. Some people may experience mild fatigue or other side effects, so planning for rest or lighter activities on infusion days may be beneficial. Always follow the guidance provided by your physician.
Usually – this always depends on your insurer and may change every year. Commercial insurers will often cover a partial amount leaving the rest the patient’s responsibility (this includes Medicare Advantage plans). Medicare Part B patients are always covered at 80% of the cost per infusion for an approved, appropriate infusion – Medicare supplements (“Medigap” plans) will cover 0-20% of the remaining amount but very frequently the full amount. Therefore infusions are often an excellent, and preferred, option for Medicare Part B patients with usually no cost out-of-pocket.
Often, the older medications in use such as methotrexate, sulfasalazine, azathioprine, and many others are covered well by insurers at lower copay tiers. Patients should always ask their physician and their pharmacist if they have concerns their insurance is charging them too much for these medications – unfortunately, this does often occur.
All patients are encouraged to discuss prescription costs with their physician. There are excellent options for obtaining many medications via cash (and side-stepping insurance) that allow patients to obtain medications often for much less than usual insurance copays for the same. For example, CostPlusDrugs is a mail-order pharmacy with transparent pricing that sells drugs at wholesale cost with slight markup. Free savings programs exist that allow one to purchase their usual medications from their local pharmacy at a negotiated rate sometimes far lower than insurance copays.
Unfortunately, commercial insurers do not often act in good faith in covering these medications. Many plans will offer coverage for one or more medications of each type of biologic however usually at an unrealistic copay ($600-2000/mo). Drug manufacturers for rheumatologic therapies will virtually always provide free copay assistance plans that rheumatologists strongly recommend patients enroll in at time of prescription. These programs allow patients to receive their medication at a very low copay, usually $5-10 a month as long as they have commercial insurance. Ask your physician about
these programs.
At-home injectable therapies are covered variably by Part D plans, it is best to check with your individual plan to determine coverage. Copay assistance programs are not available for Medicare patients, thus copays are unfortunately often high. Infusion therapies are covered extremely well with Medicare, however, covering 80% of the infusion cost without question as long as given for an approved indication. Medicare supplement (“Medigap”) plans often cover the remaining 20% leaving patients with no out-of-pocket cost after Part B deductible is met. Therefore, Medicare patients are often recommended infusion therapies over home injectables.
Unfortunately, as of 2024, coverage for these medications are often poor and offered in bad faith by the insurance plans. While coverage varies from plan-to-plan, Part C plans often “cover” a specialty medication like a biologic but force the patient to pay an unreasonable copay monthly, often $600-$1000 or more. For this reason and others, Advantage plans are generally not recommended by many physicians.
PBMs are entities that help design and manage an insurer’s list of covered medications (their formulary) by negotiating prices with drug manufacturers. While these companies used to be independent, in 2024 these are nearly universally owned by insurers and additionally often have their own mail-order and/or specialty pharmacy arms all within one large organization (for example, United Healthcare and OptumRx, CVS and CVS Caremark, Cigna and Express Scripts).
Kickbacks in the PBM industry were specifically, and unethically, permitted and allowed since the 1990s and allow an insurer, through their PBM, to force you to use their own pharmacy or specialty pharmacy by dramatically increasing your out-of-pocket price if you choose a competing pharmacy. Since many rheumatologic medications are specialty medications, you will often be locked into receiving your medication from a single specialty pharmacy designated (or often owned) by your insurers. These specialty pharmacies therefore act without market competition and subsequently often provide a poor patient experience. If you have difficulty with your specialty pharmacy, always discuss this with your physician who may be able to assist.
This is a particular rule variation within an insurance plan applicable to those who use copay assistance programs from drug manufacturers for specialty medications. Where typically copay assistance is applied towards your deductible, copay accumulator plans intentionally do not apply it towards the deductible. Therefore, insurance plans will often exhaust the limited copay assistance funds early in the year and suddenly begin asking for large, monthly copays (often exceeding $1000) until your deductible is met. These plans are anti-consumer and have been made illegal in many states, but unfortunately are still legal in California as of early 2024.
You may call your insurer and ask. When on a specialty medication with copay assistance from the drug manufacturer, patients will often be told by the specialty pharmacy that their copay assistance is exhausted and a large out-of-pocket copay is suddenly required. This often occurs by Spring or Summer in
most cases.
Call your physician’s office for advice. Many manufacturers have developed stop-gap solutions for these situations to ensure you remain on the medication
you need, your physician can help direct you to these or provide alternative solutions.
