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Wise Words Wednesday Blog

This series features answers to some of the most frequently asked questions our pharmacists receive, as well as information on all the latest research surrounding biologics and the conditions they treat.

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World Hepatitis Day

World Hepatitis Day (WHD) takes place every year on July 28th, bringing the world together under a single theme to raise awareness of the global burden of viral hepatitis and to influence real change. In 2021 the theme is ‘Hepatitis Can’t Wait’.

With a person dying every 30 seconds from a hepatitis-related illness – even in the current COVID-19 crisis – we can’t wait to act on viral hepatitis.

People living with undiagnosed viral hepatitis can’t wait for testing
People living with hepatitis can’t wait for life-saving treatments
Expectant mothers can’t wait for hepatitis screening and treatment
Newborn babies can’t wait for birth dose vaccination
People affected by hepatitis can’t wait to end stigma and discrimination
Community organizations can’t wait for greater investment
Decision-makers can’t wait and must act now to make hepatitis elimination a reality through political will and funding.

Charlton Health, along with our Hepatology Team, continues to work hard to treat and eradicate Hepatitis C in our patient population.  We ask you to consider spreading the word and encourage those around you to be tested for Hepatitis C.  No one should suffer from the complications of this disease any longer!

If you or someone you know is living with Hepatitis C, referrals can be sent to Dr. Puglia here at Charlton Hepatology Program (Fax 905-522-7477.)

Source – https://www.worldhepatitisday.org/

Jennifer Heipel has approximately 14 years of experience working as a hepatology nurse/clinical research coordinator for several gastroenterologists, hepatologists, infectious diseases and addiction specialists. She is trained in the treatment of Hepatitis B and C therapies as well as general hepatology and pre/post liver transplant follow up. Jennifer serves as Charlton Health’s full-time Hepatology Nurse and manages the Hepatology Program. She has worked and continues to work with Dr. Puglia at McMaster University and other area Gastroenterologists to develop a comprehensive, in-house Hepatology program and Hepatitis C program here at Charlton Health.

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Infliximab Now Approved for Self Injection in Rheumatoid Arthritis

Infliximab was launched by Janssen over 20 years ago under the name Remicade.  It continues to be a biologic therapy given by infusion (IV) for many autoimmune conditions including rheumatoid arthritis, ankylosing spondylitis, psoriasis, Crohn’s, and ulcerative colitis.  In the last couple of years, a few biosimilars of infliximab have been approved by Health Canada (Inflectra, Renflexis, and Avsola).  Remsima is a biosimilar of infliximab that was launched in the United States and Europe a few years ago, and is produced by Celltrion. 

In May of this year, Celltrion launched Remsima in Canada with a newly approved dosing regimen for rheumatoid arthritis. The first 2 doses are given by infusion at week 0 and week 2, followed by self-administered injections using an auto-injector pen or syringe,  that begin at week 6 and continue every 2 weeks. This is an exciting option for rheumatoid arthritis patients.  Remsima is now listed on many private insurance plans but still is not listed as a benefit under government-based plans.

Carolyn Whiskin is the Pharmacy Manager for Charlton Health. Carolyn specializes in the treatment of autoimmune diseases, pharmaceutical compounding, women’s health, pain and smoking cessation. Carolyn has won provincial and national awards for her commitment to patient care and public service.

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Second Dose Imperative For Protection in Compromised Patients

We are all aware of the importance of completing both doses of Covid-19 vaccines to get the best protection.  In light of new variants, the push is on to get second doses as soon as possible. 

A recent independent study of mRNA vaccine response in patients with rheumatoid arthritis (RA) was just published on June 8, 2021, in Lancet Rheumatology.  This is a highly regarded and peer-reviewed journal.  The study included 53 patients with RA (9 received the Moderna vaccine and 44 received the Pfizer vaccine.) The study showed that compared to a control group without RA, the response after one vaccine was significantly less and a second dose was needed to offer strong levels of protection.

This is further proof that you should try to arrange for an earlier second vaccine as soon as you are able to, instead of leaving it to the larger interval that the Ontario government initially laid out. People with autoimmune conditions need to be vigilant in getting their appointments as soon as possible.  mRNA vaccines are arriving weekly at many community pharmacies.  You do not have to go to the same location for a second dose if an appointment elsewhere can be arranged sooner. If you are unsure of when you will become eligible for an accelerated second dose, have a look at our last blog!

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Second Covid-19 Vaccine Dose Eligibility

It is very exciting to share the news that many of you with high-risk health conditions, will be eligible to receive your second dose at an earlier time. Check with your local health department about the opportunity to have your second dose sooner than you may have already been scheduled. Keep in mind, that any other vaccines that you wish to update cannot be given within two weeks before a Covid shot or one month after.

Let’s all work together to ensure that not only ourselves but also those with who we are in close contact are vaccinated. Together we can have a huge impact on reducing the burden of this virus.

Here is the current plan (click on the image to enlarge):

Carolyn Whiskin is the Pharmacy Manager for Charlton Health. Carolyn specializes in the treatment of autoimmune diseases, pharmaceutical compounding, women’s health, pain and smoking cessation. Carolyn has won provincial and national awards for her commitment to patient care and public service.

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Eat Smart for Arthritis

Charlton Health is always on the lookout for great educational resources to share with our patients. We love sharing the work that the Arthritis Society does as their programming is abundant and readily accessible. Tonight the Arthritis Society is hosting a seminar focussing on nutrition for patients living with arthritis as part of their Arthritis Talks series.

From their website…

“Featuring registered dietitian Lalitha Taylor, this Arthritis Talks will cover common questions about nutrition:

• Why is having a balanced diet so important for people living with arthritis?
• Should people living with arthritis go gluten-free or avoid nightshade vegetables?
• What small changes can people make that will make a big difference in their overall health and arthritis management?”

Register here.

Carolyn Whiskin is the Pharmacy Manager for Charlton Health. Carolyn specializes in the treatment of autoimmune diseases, pharmaceutical compounding, women’s health, pain and smoking cessation. Carolyn has won provincial and national awards for her commitment to patient care and public service.


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COVID-19 Vaccination Weekly Forum

This week we are happy to share a great learning opportunity. COVID Discussions is a weekly meeting where a group of Canadian health professionals with expertise in vaccination offer weekly information sessions to answer questions from both the public and health professionals on COVID vaccination.  These health professionals volunteer their time for this excellent public service opportunity. The aim is to “provide a safe space for everyone to bring their questions about the science and social aspects of the COVID-19 pandemic.”1 The group meets from 8-10 EST on Mondays, Thursdays, and Saturdays.

Learn more and join the discussions here.

Carolyn Whiskin is the Pharmacy Manager for Charlton Health. Carolyn specializes in the treatment of autoimmune diseases, pharmaceutical compounding, women’s health, pain and smoking cessation. Carolyn has won provincial and national awards for her commitment to patient care and public service.

1 Fong, Bensun. “COVID Discussions”. COVID-19 Resources Canada, 2021, https://covid19resources.ca/public/discussions/.

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Can we measure TNF (Tumour Necrosis Factor)?

Recently I was asked if a person’s TNF level could be measured to know if a biologic that lowers TNF is a good treatment for them. I wish it was that easy! Although we can do blood tests for markers of inflammation, such as CRP (C-Reactive Protein) or ESR (Erythrocyte Sedimentation Rate), these tests do not tell which specific inflammatory substance is elevated.
We are very hopeful that pharmacogenetic testing will determine which type of advanced therapies are best suited to an individual in the future.  Currently,  it is often trial and error to find which type of therapy will offer the best result.  It is not unusual for a treatment that has been successful in a close family member to also be successful in their relative with the same autoimmune condition.

Carolyn Whiskin is the Pharmacy Manager for Charlton Health. Carolyn specializes in the treatment of autoimmune diseases, pharmaceutical compounding, women’s health, pain and smoking cessation. Carolyn has won provincial and national awards for her commitment to patient care and public service.

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COVID-19 Vaccination Phase 2 Includes Compromised Patients

In writing this blog, we are all aware that the vaccine distribution continues to be updated.  Phase 2 of vaccine distribution is to include patients who have compromising conditions or treatments that suppress the immune system,  regardless of the person’s age.  The intention is for this to begin in April and in some health units, this has already happened.  This may be an opportunity for you to be vaccinated before your age group is eligible.  The question is, what information will be required when booking in order to receive a vaccine under this ‘at risk’ category.  Many patients have been asking for a note from their specialist at their most recent visit confirming to confirm their condition and that they are a person of increased risk.  I recently heard from an individual whom public health had reached out to directly,  based on a list public health received from a local family physician listing their “at-risk” patients.   Each public health unit may be implementing Phase 2 differently. What we do know is that when being vaccinated you will be asked if you are immunocompromised and you must be able to confirm that you have had a conversation with a health professional in your care about any alterations in your medications that may be needed when receiving the COVID-19 vaccine. Ensure you are prepared to answer such questions to avoid being turned away for vaccine administration.

Carolyn Whiskin is the Pharmacy Manager for Charlton Health. Carolyn specializes in the treatment of autoimmune diseases, pharmaceutical compounding, women’s health, pain and smoking cessation. Carolyn has won provincial and national awards for her commitment to patient care and public service.

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First Canadian dose of Biosimilar Adalimumab (Amgevita) administered at Charlton Health!

Charlton Health is proud to announce that the first dose in Canada of the biosimilar adalimumab, known as Amgevita (produced by Amgen), was injected at Charlton Health on February 22, 2021.

Five biosimilars of adalimumab were released onto the Canadian market in February.  In alphabetical order they are: Amgevita (Amgen), Hadlima (Merck), Hyrimoz (Sandoz), Hulio (Viatris), Idacio (Fresenius Kabi), and there are still more to come.   Humira (Abbvie) is the name of the originator adalimumab, and has had the biggest distribution of any biologic in the world. 

Biosimilars are very different from generic medications.  When a traditional synthetically made medication loses its patent, another manufacturer is able to copy the chemical structure to make a generic product.  Studies are done in a lab setting to ensure the product has the same chemical properties and dissolves in the same manner as the original product in order to be approved by Health Canada.   When a biologic medication loses its patent, the process for a second manufacturer to be approved by Heath Canada is quite different.  Biologics are not synthetically produced  chemical structures; they are made by programming living cells to produce a protein.  Even batch to batch, the protein structure can have slight differences. Therefore any manufacturer wanting to replicate a biologic, must develop their own cell line to produce a protein that is as similar as possible to the original product. This biosimilar, must be studied in patients in the same way the original product was researched.  The biosimilar must show the same level of safety and efficacy to the originator to be approved. 

Biosimilars offer support programs just as the originator biologic, to ensure patients are not limited to medication access  due to the cost of the medication.  Many biosimilars are produced by innovative companies who have produced originator biologics as well; in fact Amgen, who produced the biosimilar recently injected in our clinic, also produces the originator biologic for etanercept, known as Enbrel.  There has been extensive use of biosimilars in Europe.  As an example, Amgen’s biosimilar (Amgevita) has been in Europe for over 2 ½ years.  Each biosimilar will have its own patented autoinjector device.  As devices can each have their own nuances, it is important to have training before starting.  Some of the adalimumab biosimilars also have citrate-free formulations, such as the Amgen product. This can make a difference on the comfort of the injection.

There have  been several studies based on people switching from an originator product to a biosimilar showing excellent results.  It is due to this, that last year, the province of British Columbia has mandated patients on existing biologics for which there is a Health Canada approved biosimilar, make a switch.  This has  provided significant cost savings.  We anticipate this will eventually happen in Ontario.  When this is announced, a new prescription must be written by your specialist as this cannot be automatically substituted when a medication is refilled.  There will also be time given for such a transition to allow time for a medical visit.  We will keep you informed as details are released.

Carolyn Whiskin is the Pharmacy Manager for Charlton Health. Carolyn specializes in the treatment of autoimmune diseases, pharmaceutical compounding, women’s health, pain and smoking cessation. Carolyn has won provincial and national awards for her commitment to patient care and public service.

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American College of Rheumatology Announces COVID-19 Clinical Guidance Summary

The American College of Rheumatology (ACR) is a prominent organization that provides expert guidance on the diagnosis and treatment of rheumatic conditions.  Their annual meeting has over 15,000 clinicians from around the world in attendance. This week they held a town hall virtual meeting to discuss their recommendations regarding COVID-19 vaccination and how it should be managed in patients who have rheumatic diseases. 

As stated in previous blog posts, the main message is that although patients who have autoimmune diseases and are on medications that may suppress the immune system, and as such, may have somewhat less of a response to the COVID-19 vaccines or even have a short-term flare of their inflammatory condition, getting the vaccine is highly suggested and is of less risk to patients than not being vaccinated. 

Their summary document can be found here.

In Table 3 of this document, there are suggestions as to which treatments could be held for a short period of time after the vaccine to help increase the vaccine benefit. Holding any dose of medication when getting a vaccine is only suggested for patients who are stable and not flaring. 

Here are some of the highlights of this guidance:

  • Methotrexate – consider holding one dose the week after each of the COVID-19 vaccines.
  • JAK inhibitors includes: Xeljanz (tofacitinib), Olumiant (Baricitinib) and Rinvoq (upadacitinib)- hold tablets for 1 week after each vaccine dose. 
  • Abatacept (Orencia) is given by weekly injection or an infusion.  If you receive the injection, hold the dose the week before and the week after the first dose of COVID vaccine but not for the second vaccine dose.  For those on IV Orencia, when your next dose is due at 4 weeks, receive the first COVID vaccine, wait 1 week and then resume treatment (no holding of dose for the second vaccine).
  • Rituximab (Rituxan, Ruxience, Riximyo, Truxima) can significantly blunt vaccine benefit in general.  Ideally wait until 4 weeks before your next rituximab dose to get your first vaccine and then wait 2-4 weeks after the second vaccine before resuming rituximab treatment.
  • NO holding of any doses is required for the majority of treatments, including: sulfasalazine, leflunomide, hydroxychloroquine, prednisone under 20mg/day, azathioprine, IVIG, mycophenolate, belimumab, cyclophosphamide tablets and the following biologic groups of medications: (anti-TNF, anti-IL-6R, anti- IL-12/23, anti-IL-23, anti-IL-1) do not require any doses to be held at the time of receiving the COVID vaccines

As always, these suggestions are based on expert opinion and do not replace the individual advice of your specialist.

Carolyn Whiskin is the Pharmacy Manager for Charlton Health. Carolyn specializes in the treatment of autoimmune diseases, pharmaceutical compounding, women’s health, pain and smoking cessation. Carolyn has won provincial and national awards for her commitment to patient care and public service.

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