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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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COVID-19 Vaccine Guidance for Patients with Autoimmune Diseases

We have received many questions regarding the use of COVID-19 vaccines in patients with autoimmune diseases on a wide range of advanced therapies such as biologics. The first thing to be aware of, is that the studies done for these vaccines did not include patients with autoimmune diseases or those on treatments that may suppress the immune system.  Current advice about being vaccinated, is based on expert opinion knowing this is a non-live vaccine. The general opinion of specialists in the field is that the benefit of getting a COVID-19 vaccine far outweighs the risk. 

What you should know:

  • The COVID-19 vaccines currently available are non-live. They cannot cause COVID-19 when given to any patient.
  • The effectiveness of any vaccine given to people who have an autoimmune condition may be less effective than the public. This does not prevent you from receiving the vaccine as having a lesser effect is much better than no effect at all.
  • Most treatments for autoimmune conditions do not blunt the benefit of vaccines.  However, we do know that methotrexate can reduce the effectiveness of the standard dose influenza vaccine.  We do not know how methotrexate may reduce the effectiveness of the COVID-19 vaccines.  Some healthcare providers may suggest holding 2 doses of methotrexate after receiving this vaccine in patients who are not having a flare of their inflammatory disease.
  • We know that the infused medication rituximab can significantly blunt vaccine benefit.  The suggestion would be to wait until 5 – 5.5 months after your last dose of rituximab and receive your COVID-19 vaccine.  Then receive the second dose of the COVID-19 vaccine (in the case of the Pfizer vaccine this is 3 weeks later).  Then wait an additional 2 weeks, at which time you can resume rituximab treatment.  
  • Prednisone can blunt the benefit of vaccines when used in doses of 20mg per day or higher for more than 14 days.  If you are weaning off prednisone, waiting until your dose is less than 20mg/day would be advised for greater benefit.
  • The COVID-19 vaccines by Pfizer and Moderna are called mRNA vaccines.  When mRNA-based treatments have been given in the past, there was a potential for an inflammatory response.  These vaccines have made modifications to prevent this, but you should know that a short-term flare of your condition could happen.  This means that if possible, it would be best to be vaccinated when you are in good control.
  • Other vaccines such as Shingrix for Herpes Zoster (shingles) protection, were released onto the Canadian market with no studies in this population.  As this vaccine was non-live and had great benefit, we widely gave it to patients knowing that it may be less effective in this group of people and that there could be a short-term flare of their inflammatory condition.  As time passed,  we collected data on this group of patients and found that they had a 90% benefit vs over 97% in the general public. This is still a fabulous response. We also learned that about 5% of people had a flare of their inflammatory condition for 1-2 weeks. 
  • We have learned that anyone receiving this vaccine can experience about 24-48 hours of certain symptoms which include: fatigue, headache, sore arm, low-grade fever, and general achiness. 
  • A few people receiving the vaccine who had a background of anaphylactic reactions to foods such as shellfish, had an anaphylactic reaction to the COVID-19 vaccine.  This does not prevent people with food allergies receiving the vaccine but does suggest that anyone who carries an EpiPen and has high sensitives to allergens should have an EpiPen on hand for the vaccine administration.
  • Anyone with an allergy to polyethylene glycol should not receive the Pfizer or Moderna vaccines.
  • The COVID-19 vaccines have not been studied when given at the same time as other vaccines.  It is suggested to wait 28 days after the final COVID-19 vaccine injection before giving any other vaccines. (live or non-live)  If you have recently received another vaccine, wait at least 2 weeks before getting the COVID-19 vaccine.

The Canadian Rheumatology Association and Canadian Association of Gastroenterology  have recently published their guidelines regarding patients with autoimmune diseases, both in support of vaccination.  They can be found on these links: 

CRA_Position_Statement_on_COVID_19_Vaccination_Dec2020.pdf (albertarheumatology.com)

CAG-COVID-19-Vaccines-in-IBD-Patients.pdf (cag-acg.org)

As part of these statements,  they refer to the National Advisory Committee on Immunization (NACI) which has also stated that the COVID-19 vaccine may be offered to these individuals if a risk assessment deems that the benefits outweigh the potential risks.  They suggest that obtaining informed consent from a patient,  includes discussion about the absence of evidence of the use of this vaccine in these populations,  and that there is a potential for lower vaccine response in those immunosuppressed. It is important to note that depending on the public health unit in your community, you may be asked to sign a consent to receive this vaccine or indicate you have had a discussion with your physician.  The pre-vaccination questionnaire that you will be given by the healthcare provider giving the vaccine, identifies immunosuppressive agents and/or autoimmune disease as factors that require consent.  

Please note the general guidance provided by this statement does not replace individual advice given to you by your specialist and healthcare team. 

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Charlton Health Launches Educational Video Series: Inflammatory Arthritis & Its Treatments

Charlton Health would like to wish everyone all the best of health in 2021.  We are pleased to share the following series of educational videos which we have just launched for the New Year. At a time when virtual education has become a necessity, this became an important project for us. Back in May, our pharmacist, Carolyn Whiskin had been asked to fly to Thunder Bay to present an educational program for patients. Of course, this was not possible during a pandemic and this is what sparked the production of the series.  We appreciate the Thunder Bay Rheumatology Program’s initiative and encouragement in developing this program. The series covers different aspects of both understanding types of inflammatory arthritis as well as the various treatments available.  All modules were written and presented by our clinical pharmacist Carolyn Whiskin.  We suggest you watch these in order of the modules, from 1-5.  The modules vary in length with some being close to 30 minutes, so you may want to watch these over a couple of sessions and can of course replay them at your convenience.  It is also a great series to share with family members wanting to better understand your condition.  Keep in mind that this information is only intended to supplement the advice and care you receive from your rheumatologist and healthcare team.  Simply click on the module and you will be taken directly to the video. We hope you enjoy the series. 

Module 1: What is an Autoimmune Disease?

Module 2: Differentiating Types of Inflammatory Arthritis

Module 3: Holistic and Conventional Treatments

Module 4: Advanced Therapies 

Module 5: Vaccination

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The Power of Human Connection

A couple of years ago, we brought you a blog post called “The Health Benefits of Singing,” where we discussed how singing and other types of social activities can help with loneliness, stress, and depression. Of course, this holiday season, things are different – we certainly can’t sing together, nor can we be connected in so many of the ways that we are used to doing. We know that for so many, this lack of human connection, especially for those living on their own or in long term care, can have negative impacts on our health, such as a failure to thrive and mental health struggles.

Connecting with others is such a beautiful thing – it gives us a sense of belonging and of purpose – it builds community, and there is no question that all of these things can positively impact our mental health (and in turn, our physical health too!) We’ve come up with such innovative ways of connecting with one another throughout the pandemic – primarily we’ve seen a huge rise in video chats on Zoom or Skype, which is such a wonderful way of keeping in touch with others. With that said, we’ve also heard about ‘Zoom fatigue’ and know that through a screen, while helpful, isn’t always the best way of connecting to one another. 

So what do we do? How do we find human connection when we’re confined to our own households? This holiday season, we encourage you to make human connections in any way you can (providing it’s COVID-friendly). Some ideas we would love to share is by connecting with people outside, while masked and 6 feet apart; or visiting with someone from below while they’re on a balcony; or even by just saying hello to people at the grocery store. While limits on travelling may make it difficult to physically be with our loved ones, many of us still have neighbours we can have a safe, distanced conversation with. We encourage you to make that small effort to connect, even if it’s not with your family or close friends. Get outside and say hello – you might make someone’s day. 

This year has been a challenging one for all of us, and on behalf of all of us at Charlton Health, we would like to wish you the best during this trying time. We hope you have a very Happy Holiday season and a Happy New Year. 

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Looking for help to better manage your Arthritis… online?

The Arthritis Society provides care through the Arthritis Rehabilitation and Education Program (AREP) to Ontario residents with a valid health card. The Arthritis Society offers one-on-one consultations, as well as group education classes led by physiotherapists, occupational therapists or social workers.

Throughout the pandemic, the Arthritis society has done a great job of transition educational arthritis groups to virtual classes. All first visits are virtual utilizing secure telephone, email, and video conferencing.  

Education classes:

  • Stay Active – Managing Osteoarthritis Pain of the Hips and Knees
  • Osteoarthritis of the Hand
  • Osteoarthritis of the Neck and Back
  • Taking Charge of Your Rheumatoid Arthritis
  • Taking Charge of Your Fibromyalgia
  • Moving Forward With Your Feet –Workshop for Managing Your Foot Arthritis
  • An Introduction to Mindfulness Meditation
  • How to Get Better Sleep with Arthritis

For more information or to book a free appointment:

www.arthritis.ca/arep

Or call

1 800 321 1433 extension 3307

Online Resources https://arthritis.ca/support-education/resources

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New Treatment Approved For Psoriatic Arthritis

We are pleased to share that a new biologic treatment has been approved for the treatment of psoriatic arthritis. People who have this condition can suffer from inflammation in joints of  the hands and feet as well as larger joints such as the elbows, shoulders, hips, knees and lower back.  There is also inflammation in the tendons and ligaments that attach to these joints.  Some people also suffer with a significant amount of psoriasis where others may only have a family history of psoriasis or have limited areas on the scalp and nails. The ideal treatment will reduce inflammation in all areas to reduce pain, stiffness and areas of skin involvement.

Tremfya (guselkumab) is a large protein based treatment known as a biologic. It binds to a substance called Interleukin-23 (IL-23) to prevent excess signalling to the immune system. This results in a reduction of inflammation in all areas affected by psoriatic arthritis. It is given by injection by either a pre-filled syringe or a patient-controlled autoinjector called a One-Press. After the initial injection, a second dose is given 4 weeks later and then every 8 weeks as a maintenance dose. Tremfya was initially approved for psoriasis, but it is very exciting to see the proven benefits it has on the joints as well!

Important Update to our Blog…

We have very much enjoyed bringing you this weekly blog for the past few years. As of this month, we will be publishing blogs on a bi-weekly basis. However, if there is critical information that needs to be shared, we will post more often. We also bring you content over on our Facebook and Twitter pages, so you can always tune in there if you miss having us in your inbox as frequently!

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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Influenza Vaccine Distribution

We have received many calls with concern that their community pharmacy has already run out of the influenza vaccine.  I want to reassure you that although  there was a preliminary distribution of influenza vaccine around October 7-9th from public health, the actual launch date of full distribution to pharmacies is not until October 26th.  Pharmacies will be able to order from this date onward through their standard wholesaler under the direction of public health.  Both the standard dose and high dose vaccines will be available.  The high dose has four times the amount of inactivated influenza vaccine and has shown to illicit a greater immune response (more antibodies) against the flu for people who age 65 or older.  This does not mean that the standard dose will not work for a person over 65 but if you can access the high dose and you are age 65, it is suggested .  In provinces other than Ontario, the high dose is only being distributed to long term care homes.  We are fortunate in Ontario to have extra doses that are being distributed to family physicians and pharmacies.  The best protection however is for everyone around you, including yourself, to be vaccinated as this is what reduces spread the most. 

For those who are taking advanced therapies for their autoimmune disease, such as biologic treatments, it is safe to get either influenza vaccine as they are both inactivated.  There is no need to hold or delay a dose of your biologic to receive any non-live vaccine. If there is a perfect time to get your influenza vaccine when the effectiveness could be a littler greater, it would be 2 weeks before your next biologic dose when the level of drug is lowering. The vaccine takes 2 weeks to process. For people doing a weekly or every other week dose, take the vaccine half way between your doses.

The National Advisory Committee on Immunization (NACI) is suggesting when booking an appointment for the influenza vaccine, that you consider what other vaccines you are in need of.  This could include the pneumonia vaccines (Prevnar 13 first followed by Pneumovax 8 weeks later), the shingles vaccine (Shingrix given as 2 doses, 2-6 months apart) and others including the tetanus shot given every 10 years.  Multiple vaccines can be given at the same time.

Important Update to our Blog…

We have very much enjoyed bringing you this weekly blog for the past few years. As of this month, we will be publishing blogs on a bi-weekly basis. However, if there is critical information that needs to be shared, we will post more often. We also bring you content over on our Facebook and Twitter pages, so you can always tune in there if you miss having us in your inbox as frequently!

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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When can a person on rituximab receive the flu shot?

Question:
When can a person on rituximab receive the flu shot?

Answer:
Let me first speak about our biologic treatments for autoimmune conditions in general, where it is fine to get the flu shot as it is not a ‘live’ vaccine and we do not need to interrupt the biologic treatment. If we could pick an ideal time when a person might get a little bit more immune response, it would be 2 weeks before the next biologic dose, as vaccines take 2 weeks to process and this is when the biologic is at its lowest level.

However, people waiting for a ‘perfect’ time often miss the window and never get the vaccine.  So we don’t want to make a person feel a specific time is necessary.

For rituximab, it is a different story.  As B cells are depleted by this treatment, which we need to make antibodies when receiving a vaccine, there will be almost no benefit to getting any vaccine for about 5 – 5 ½ months after a rituximab dose.  It will do a person no harm to receive the vaccine, it just won’t have the benefit. So once the flu shot is available, receiving it  2 weeks prior to the next rituximab dose would be highly suggested.  If you have missed this opportunity, then the best thing a person can do is to ensure all those in close contact with them are vaccinated. We expect the flu vaccine to be available within the first two weeks of October.

Important Update to our Blog…

We have very much enjoyed bringing you this weekly blog for the past few years. As of this month, we will be publishing blogs on a bi-weekly basis. However, if there is critical information that needs to be shared, we will post more often. We also bring you content over on our Facebook and Twitter pages, so you can always tune in there if you miss having us in your inbox as frequently!

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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Importance of Blood Monitoring

We are often asked if it is necessary to have ongoing blood work while on disease modifying treatments for autoimmune conditions. 

Blood work is one part of understanding how well your condition is being managed, as well as watching for any changes that may be due to your treatment. Blood work alone of course, never tells the full story, as your symptoms along with an examination of your joints in the case of arthritic conditions or a scope in the case of inflammatory bowel diseases is needed to understand the full picture.

The reason why we need the blood work on a regular basis (often every 1-3 months) is that there may be changes in your liver or kidney function, white or red blood cells etc., that you cannot feel and by spotting these changes early in your blood work, changes in your treatment can be made before any damage is caused. 

We also use blood work before starting treatments to see if you have any underlying infections that you were unaware of, such as, hepatitis or HIV.  There is even a blood test (Quantiferon Gold) for detecting tuberculosis.  Disease modifying medications, such as biologics do not cause these infections, but if you already unknowingly were infected, they could make these infections worse.  These blood tests are called screening tests and in some patients they may be repeated on an annual basis.

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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ReBlog: Community Based Resources for Adults with Arthritis

In honour of Arthritis Awareness Month, we thought we would share one of our most popular past blogs on arthritis. In April 2019, we brought you this list of helpful resources. If you didn’t see it then, we hope you enjoy it now.

The original post is as follows…

150 minutes per week of exercise is important for all Canadians. Although some individuals with arthritis may find it hard to find modified activities. At Charlton Health we have compiled a list of community resources and on-line programs for individuals with arthritis to help you to achieve 150 minutes of exercise per week.

ResourceWhat it is?LocationContact information / Website
Arthritis Society – Arthritis Rehabilitation and Education programHelps facilitate access to physiotherapists, occupational therapists and social workersVarious – Click here for more information1-800-321-1433 ext. 1301
INMOTIONWeekly education sessions by a physiotherapist for individuals with chronic bone and joint health problems such as osteoporosis and arthritis. This program allows participants to access; GentleFit, hydrotherapy and Walkfit classes along with individualized exercise plansLes Chater Family YMCA (356 Rymal Road East, Hamilton, ON)    Phone: 905-667-1515   https://www.ymcahbb.ca/Programs/LiveWell/InMotion
Your Exercise SolutionProgram by the arthritis foundation that helps individuals find exercises that will work for themOnlinehttps://www.arthritis.org/living-with-arthritis/tools-resources/your-exercise-solution/
From Soup to Tomatoes (exercise program)Online exercise videos that are for individuals with mobility impairment, all exercises are done with the support of a chair.OnlineFrom Soup to Tomatoes YouTube
GLA:D exercise programThis is a standardized education and exercise program, that is twice a week for 6 weeks. 2 sessions are education and the rest of the sessions are exercise with a trainer.   Referrals to this clinic need to be accessed via the Rapid Access Clinic (RAC) ask your physician if you would qualify.Wilson Medical Centre (130 Wilson St lower level Hamilton, ON, L8R 1E2    Phone:  905-526-6250   https://gladcanada.ca/index.php/what-is-glad-canada/

To view the entire post in full, click here.

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When is the flu shot coming?

As we have seen in Australia, there is a definite expectation that Canadians will want to be protected against any vaccine preventable infection possible, including influenza. It is known that getting influenza changes the airway lining, increasing the risk of also getting pneumonia and with Covid-19 numbers rising this adds even greater concern. The National Advisory Committee on Immunization is suggesting that when receiving the flu shot this year, other vaccines should be updated at the same time.  There is a large emphasis on the pneumonia vaccines and shingles vaccines being updated; especially in the most vulnerable populations.

Pharmacists anticipate that they will receive the flu vaccine by mid-October. Now could be a good time to consult with them and your family physician about other vaccines that you may require.

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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