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2.4 – Clinical Normalization: The

Algorithm of Abandonment

By the time a patient starts their second biologic therapy,
something deeply counterintuitive has already happened:
what was once a medical red flag—the failure of a high-
cost, highly engineered therapy—has been transformed into
a routine next step. There’s a protocol. A guideline. A
clinical pathway. The failure is no longer a surprise. It’s
expected.

Welcome to the algorithm of abandonment.

In many specialties—rheumatology, gastroenterology,
dermatology, neurology—the use of biologics follows a
familiar, almost ritualized pattern:

• Start with a first-line biologic (often an anti-TNF
agent).
• If the patient fails, escalate the dose or shorten the
interval.
• If that fails, switch to another drug—often in the
same class.
• If that fails, add an immunosuppressant.
• If that fails, rotate again.

Each of these steps is backed by consensus guidelines.
There are decision trees. Billing codes. Prior authorization
forms. What’s missing is the one question that should come
first:

Why did the drug stop working in the first place?

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