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Dose Escalation: Paying More to Get Less

The first move is often to increase the dose or frequency of
the biologic therapy. If the drug isn’t working, maybe you
just need more of it, more often. On paper, this seems
rational. But in practice, it often does little more than delay
the inevitable—while dramatically increasing costs and
side effects.

• Patients on anti-TNF therapies like Humira may go
from biweekly to weekly injections.
• Infusions like Stelara may be scheduled every 4
weeks instead of every 8.
• The total annual cost of therapy may double or
triple—without a proportional clinical benefit.

This is the equivalent of turning up the volume on a broken
speaker. You’re amplifying noise, not clarity. Dose
escalation is simply kicking the ball down the road, but the
road doesn’t go on forever.

Immunosuppressant Add-Ons: Blunting the
Immune System to Save the Drug

When dose escalation fails—or is contraindicated—the
next move is often to add an immunosuppressant. Drugs
like methotrexate or azathioprine are introduced to
suppress the immune system’s production of anti-drug
antibodies, theoretically restoring the biologic’s effect.

But this introduces a dangerous trade-off:

• Increased risk of infection and malignancy.
• Additional monitoring and toxicity management.

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