Page 66 - Binder2

The answer is often tolerization but here’s the paradox:
most clinicians don’t test for it. ADA testing is
inconsistent, expensive, and frequently not covered by
insurance. The results are often ambiguous. There’s no
clear threshold that tells a provider whether to persist or
pivot. So many don’t order the test at all. They rely instead
on clinical judgment, patient-reported symptoms, and
inflammatory markers—tools that can suggest failure but
can’t explain it.

This leaves patients stuck in a cycle of managed
uncertainty.

When one biologic fails, they’re handed another. When that
fails, they’re told “we’ll try something else.” Each new
therapy comes with hope, side effects, and paperwork.
Each failure is treated as a personal quirk of the disease, not
part of a broader pattern of immune rejection.

From the patient’s perspective, this feels less like precision
medicine and more like a controlled burn: every flare is
tolerated, every setback rationalized. The language of
progress—“treatment journey,” “step therapy,” “ongoing
management”—masks what’s really happening: the
immune system is saying no, and no one’s listening.

From the clinician’s perspective, it’s not indifference—it’s
survival within the system. With limited tools, limited
time, and mounting pressures from insurers and regulators,
physicians have adapted to failure instead of challenging its
root cause. They’ve become fluent in cycling therapies
rather than solving the incompatibility driving the cycle in
the first place.

The result is a clinical culture where tolerization is
absorbed rather than interrogated. Where “secondary loss

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