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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 IBD Day

Inflammatory bowel disease (IBD) describes both Crohn’s disease and ulcerative colitis. Both are chronic inflammatory diseases of the gut. People who have these diseases have symptoms that include but are not limited to, diarrhea, bleeding from the rectum, pain, and tiredness. Many patients find it difficult to leave the house because they always need access to restrooms due to the unpredictability of their disease. The point of treating IBD is to reduce symptoms in order to allow patients to resume their lives without interruption by their disease. 

World IBD Day takes place on May 19 of every year. Each year there are different events to raise awareness for these diseases. This year’s slogan is “IBD has no age” which emphasizes that elderly people still suffer from IBD. The World IBD Day website includes details about events in Brazil, France, Greece, India, Ireland, and New Zealand. Click here if you are in these places or if family members are there that wish to participate.

If you are in Canada and want to get involved in raising awareness and funding for IBD, you can participate in the Gutsy Walk, which is Canada’s largest fundraiser for IBD research and patient programs! 

If you wish to participate in the walk, the event takes place on June 5, 2022. The typical participant walks 5km, but anyone can do any distance they are comfortable with. You can sign up for different regions around Canada and there is even an “Ontario Virtual Walk” option for those who may not be able to come to the walk event areas. If you are unable to participate, you can consider sponsoring a team or individual who is! For more information on the walk, please visit the Gutsy Walk website.

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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Shingrix Awareness

Many health professionals will be selecting a week in May to promote the prevention of shingles through a Shingrix Awareness Week. Shingrix is a vaccine for the prevention of shingles (Herpes Zoster). It is given as a series of 2 doses, 2-6 months apart. The vaccine is now available without prescription and can be administered by your community pharmacist. It is available at no charge through Public Health supply to family physicians for adults aged 65-70, with a catch up this year to age 72, until December 2022. Many people beyond this age range will benefit from Shingrix and will choose to pay for the vaccine out-of-pocket or may have private insurance to cover the cost.

Shingles (Herpes Zoster) is a serious disease that commonly results in a very painful, blistering rash that occurs in one part of the body and can last for weeks. The pain can be severe, disabling, and interfere with your day-to-day activities9 in 10 Canadian adults carry the virus that causes shingles. Shingles that affect the eye (Herpes Zoster Ophthalmicus) can lead to blindness and must be treated immediately. The risk of shingles increases with age and is also increased in people with autoimmune conditions. Vaccination is our best protection, as anti-viral treatments can still leave people with symptoms, including postherpetic neuralgia (nerve pain) lasting weeks-months.

Although the recommendation for vaccination against shingles generally begins at age 50, it is now approved by Health Canada for adults 18 years old and older that have a deficient or suppressed immune system caused by known disease or therapy. As Shingrix is a non-live vaccine, it can be administered to people on advanced therapies for autoimmune conditions. The prior vaccine, Zostavax, is no longer available and its effectiveness is greatly diminished by 5 years. As a result, many adults have upgraded their protection with Shingrix. It is common for people to experience pain at the site of injection along with fatigue, aches, pains, and/or a low-grade fever for a day or two after the injection. Consult with your health care provider about vaccination against shingles.

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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Paxlovid© Information

Recently we have been receiving several questions from our patients about the new COVID medication Paxlovid©. Given that we are currently in the 6th COVID-19 wave, we thought it was important to clarify who qualifies and how to access Paxlovid© if it is needed. 

Paxlovid© consists of two medications, nirmatrelvir and ritonavir. The nirmatrelvir stops the virus from multiplying, while the ritonavir helps keep the levels of nirmatrelvir high so it can continue to work in the body for a longer time than without the ritonavir. 

Paxlovid© has been shown to reduce the risk of hospitalization for adult patients in the community with a positive COVID-19 test when taken within 5 days of symptom onset. In addition, it is prescribed for specific patients who would have a more difficult time fighting the virus. This would include those:

  • who are immunocompromised
  • with less than 3 COVID vaccines
  • who are pregnant
  • with other health risks 

Factors like the ones above in addition to your age will lead your doctor to decide whether Paxlovid© is right for you. 

Your doctor may consider other treatments for those patients who are not in the hospital and may not be ideal candidates for Paxlovid©. This may include patients with impaired kidney function; depending on the degree of impairment, a dose reduction in the Paxlovid© may be needed.

Given that the medication needs to be started within 5-days of symptom onset, it is important that your pharmacy is able to dispense the medication in a timely manner. Apart from the prescription and being within the 5-day window, you must also have a positive COVID test. The best way to make sure you get Paxlovid© promptly is to get a prescription and put it on HOLD at your local pharmacy. This way, if you get a positive COVID test, you can show the proof of the test to the pharmacy and get the Paxlovid© quickly.  Keep in mind, that physicians and pharmacies are overwhelmed with calls regarding Paxlovid© at this time. Please be patient as they are trying their best to prioritize their patients at the greatest risk. 

Paxlovid© has many drug interactions, so it is very important you disclose all medications you are taking to your pharmacy. This includes prescription medications, over-the-counter medications, and natural health products. Please also inform your pharmacist if you have impaired kidney function. Your pharmacist will help your doctor make a plan regarding any interacting drugs to ensure the Paxlovid© works as effectively and safely as possible. 

Marija Ilic is a Pharmacy Student from the University of Waterloo currently doing a rotation at Charlton Health as part of her final year of studies. Through Marija’s education, she has gained experience in both hospital and community pharmacy settings and hopes to find a specialized pharmacy role when she graduates.

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Celebrating International Pompe Day

International Pompe Day is April 15. We would like to celebrate this day by raising more awareness for those who are living with Pompe Disease and help others understand the challenges they face.  It is also a very exciting time as the newest treatment, avalglucosidase alfa (NEXVIAZYME™) has recently been approved by Health Canada. 

Pompe is a genetic disease. People who have Pompe Disease have insufficient functioning of an enzyme called acid alfa glucosidase (GAA) which breaks down glycogen, in the body. Glycogen is how our body stores glucose, a type of sugar that our body uses for energy. Without this enzyme, there is a build-up of glycogen in lysosomes which are in many human cells. Lysosomes function to help rid cells of unwanted cellular debris and waste. The build-up of glycogen in lysosomes can cause symptoms such as muscle weakness, trouble breathing, enlarged heart, and more. 

Pompe Disease is broken down into two forms, infantile and late-onset. The Infantile-form presents in the first few months of life and usually involves an enlarged heart whereas late-onset Pompe can present at any time in life and does not involve the heart. 

For many years, alglucosidase alfa (MYOZYME™) has been the only drug used in Pompe Disease. Myozyme is an enzyme replacement therapy of the GAA enzyme that is deficient in patients with Pompe Disease. It can be used in both infantile Pompe Disease as well as late-onset Pompe.  Patients receive an infusion of this enzyme every 2 weeks lifelong.  However, as of late 2021, Health Canada has approved the use of a new enzyme replacement therapy for late-onset Pompe Disease. 

As Charlton Health was the first centre to offer home infusions of Myozyme in Canada, our nursing team and pharmacists are very excited to be able to offer Nexviazyme as patients become eligible to receive this therapy. 

Nexviazyme has been designed to be absorbed more efficiently into the muscle cells than Myozyme. The studies look very promising for this medication and have even shown to work as well as Myozyme for most assessments, but actually showed it was better than Myozyme when looking at the 6-minute walk test (6MWT). The 6-minute walk test evaluates how much distance a person can walk in 6-minutes and is used to assess their endurance and exercise tolerance. We look forward to helping patients that will be starting this new therapy.  

If you want more information on Pompe Disease, refer to the Canadian Association of Pompe.

Marija Ilic is a Pharmacy Student from the University of Waterloo currently doing a rotation at Charlton Health as part of her final year of studies. Through Marija’s education, she has gained experience in both hospital and community pharmacy settings and hopes to find a specialized pharmacy role when she graduates.

References:

  • Diaz-Manera J, Kishnani PS, Kushlaf H, et al. Safety and efficacy of avalglucosidase alfa versus alglucosidase alfa in patients with late-onset Pompe disease (COMET): a phase 3, randomised, multicentre trial [published correction appears in Lancet Neurol. 2022 Apr;21(4):e4]. Lancet Neurol. 2021;20(12):1012-1026. doi:10.1016/S1474-4422(21)00241-6
  • Hahn, S. Lysosomal acid alpha-glucosidase deficiency (Pompe disease, glycogen storage disease II, acid maltase deficiency). In: Post T, ed. UpToDate. UpToDate; 2021. Accessed April 4, 2022. www.uptodate.com 
  • Six minute walk test (6MWT). American College of Rheumatology. Updated 2015. Accessed April 4, 2022. https://www.rheumatology.org/I-Am-A/Rheumatologist/Research/Clinician-Researchers/Six-Minute-Walk-Test-SMWT 
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Charlton Masking Policy

Although the Government of Ontario removed mandatory masking requirements for most indoor settings March 21, 2022, this does not apply to healthcare settings.

Mandatory masking requirements remain in effect for settings such as public transit, healthcare settings, long-term care homes, and congregate care settings. The Charlton Centre clinics are healthcare settings and provide treatment to patients whose immune systems are more vulnerable than the general population, and as such, anyone at a Charlton Centre clinic is required to continue masking. This masking policy will remain in place until further notice.

At Charlton Centres and at Charlton Health, all protocols that support patient safety remain in place. These policies are more stringent than seen in public due to the potential for compromised patients to shed the coronavirus longer, and to potentially be less protected from vaccination.

For example:
Patients are not permitted to attend an infusion clinic until 14 days after a positive COVID test and once symptoms have resolved.
Patients who have travelled outside of Canada must wait 7 days after their return before coming to the infusion clinic for an appointment.

These types of measures have kept our patients safe throughout the past 2+ years, and we will continue to work to provide safe care and treatment.

If you have any concerns about changes in your health, please contact your clinic in advance of your appointment to be sure you can safely receive your injection or infusion.

We value your health!

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Health Canada Approves Three New Adalimumab Biosimilars

A year ago (March 10, 2021) we posted about adalimumab having five biosimilars, we are happy to say that number has increased to eight! There are eight biosimilars approved by Health Canada now. The original adalimumab is Humira (Abbvie), and the biosimilars in alphabetical order include: Abrilada (Pfizer), Amgevita (Amgen), Hadlima (Merck), Hulio (Viatris), Hyrimoz (Sandoz), Idacio (Fresenius Kabi), Simlandi (Jamp), and Yuflyma (Celltrion). Bolded are the newest ones. 

As a quick reminder, biologics are protein-based substances that need to be injected/infused, as swallowing them would result in them getting digested in the stomach, which would destroy their effectiveness. Biologics are made by taking a living cell and programming it to make a certain protein, which is very different than how conventional synthetic medications are made. Conventional synthetic medications are based on a very reproducible chemical structure. Biologics, however, are not as easily reproducible because they are grown in a living cell, which results in differences even between batches of the same manufacturer. Companies that want to make a biosimilar need to make their own programmed cell that makes a protein similar to the original biologic.

In order for a company to get a biosimilar approved by Health Canada, the biologic needs to be studied in at least one condition that the original biologic is approved for. Research to prove equal efficacy and safety usually takes 7-8 years, so patients can feel confident using biosimilars for their approved conditions. Additionally, biosimilars have been used safely for multiple conditions around the world for years.  

Biosimilars prove they are equally safe and effective in studies; however, each manufacturer may use their own patented device. There can be differences in these devices which includes if the product is citrate-free, latex-free, and/or and the product’s needle gauge. 

Citrate is a non-medical ingredient that can be found in some injections. Many people do not get discomfort from injections that contain citrate, but some may. This discomfort may happen during the injection, at the injection site. If someone experienced this with Humira (which contains citrate) then choosing a citrate-free biosimilar may be beneficial, but if there was no discomfort while on Humira, this may not be a deciding factor.  

Some individuals have latex allergies, so a deciding factor for those people may be to choose a biosimilar that is latex-free. 

Needle gauge refers to the size of the needle hole. Understanding needle gauge is actually counterintuitive to what you may think. The larger the number, the smaller the needle. So, a size 29-gauge (29G) needle is actually smaller than a 27G needle. There are different reasons needles may be different gauges, but it can be due to the size of the protein or molecule that needs to go through it. As the gauge of the needle increases, there tends to be less discomfort during injection. However, the size difference between a 27G needle and a 29G needle may not be noticeable to most. 

Biologic or BiosimilarCitrate-freeLatex-freeNeedle gauge
Biologic (Original product)
Humira (AbbVie)29
Biosimilar
Abrilada (Pfizer)29
Amgevita (Amgen)Needle cover is latex derived27
Hadlima (Merck)29
Hulio (Viatris)29
Hyrimoz (Sandoz)27
Idacio (Fresenius Kabi)29
Simlandi (Jamp)29
Yuflyma (Celltrion)29

Apart from what is in the chart, there are other considerations to be made when deciding which biosimilar to start. These include the biosimilar’s stability at room temperature and the type of autoinjector. Although all these medications need to be stored in the refrigerator, they do have some stability at room temperature, varying between 14-30 days depending on the manufacturer, which may be a consideration for those who travel. Most of the manufacturers have their own patented autoinjectors that differ slightly, but these differences may be important for some people. Many clinics and rheumatologists have demonstrator/training devices of each biosimilar and some individuals may discover they prefer certain devices over others, often due to to personal preference. 

With the approval of the newest biosimilars, it can take some time from them being approved to them being available on the market. Your healthcare providers will be able to guide you through the best selection for you at the time that you begin therapy. 

Marija Ilic is a Pharmacy Student from the University of Waterloo currently doing a rotation at Charlton Health as part of her final year of studies. Through Marija’s education she has gained experience in both hospital and community pharmacy settings and hopes to find a specialized pharmacy role when she graduates. 

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Management of Psoriasis

As a follow-up to our previous blog about the newly approved treatment for patients with psoriasis, we would like to share useful tips regarding lifestyle and healthy skincare. It is important to note that although these tips may help you manage your psoriasis, they are by no means a replacement for the medical treatments that are prescribed to keep your condition under good control. We have also provided some valuable resources at the end of the post that patients can review to learn more about psoriasis and its treatments. 

Skin Care:

  • Keep nails short and refrain from scratching
  • Use recommended creams on areas of plaque – do not remove plaque as this can create a worsening of the condition
  • Choose loose-fitting cotton clothing that reduces rubbing the skin while avoiding nylon, wool, and rough synthetic fabrics
  • A cool air humidifier in the home can be helpful
  • Take a daily bath or shower with warm water – never hot!
  • A minimum of SPF 60 sunblock is suggested when going out in the sun.  Products endorsed by the Canadian Dermatology Association are indicated on the label.
  • Applying a moisturizer once to twice daily is well worth the time! After a bath or shower, apply the moisturizer to the skin while it is still damp in the direction hair grows (hair will lie flat).
  • Prescription steroids creams/ointments are to be used only when needed. Apply an amount of cream/ointment equal to the size of the tip of the finger for an area equal to the size of the palm of your hand. (For example – an elbow or knee would require a “fingertip” of cream/ointment.  Larger areas on the stomach may need a few “finger tips” full)
  • When prescription creams/ointments are needed, apply them prior to using a moisturizer
  • Although there are no studied diets or supplements that have evidence in reducing psoriasis, it is important to avoid triggers that have been found to worsen your personal condition

Lifestyle measures include reducing stress, quitting smoking, and maintaining daily exercise (150 minutes per week) along with getting a good night’s sleep.

Stress increases the production of inflammation in the body and can contribute to flares of psoriasis. Quitting smoking is one of the most valuable interventions people can make to improve overall health and inflammatory conditions like psoriasis are improved by quitting smoking. People with active psoriasis also have a greater risk of cardiovascular disease.  Smoking can further increase that risk.  The most effective way to quit smoking is the use of medication along with counseling.

Sleeping less than 5 hours a night places stress on the body and increases cardiovascular risk.  Cognitive Behaviour for Insomnia (CBTi) is one of the most effective strategies to improve sleep.

Resources:

Canadian Association of Psoriasis Patients

Psoriasis Society of Canada

National Psoriasis Foundation

Psoriasis Support Canada

Canadian Dermatology Association

Canadian Skin Patient Alliance

The Arthritis Society

Kunal Bhatt, RPh, PharmD, HBSc is a staff pharmacist for Charlton Health. As a 2020 PharmD graduate from the University of Toronto, Kunal possesses a diverse range of experiences from working in hospital and community pharmacy settings. Since January 2021, Kunal was heavily invested in contributing to the efforts against COVID-19 by administering upwards of 5000 COVID-19 vaccines at William Osler Health System’s vaccination clinics.  

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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New Psoriasis Treatment Option

Psoriasis is an autoimmune condition resulting in chronic inflammation of the skin affecting roughly 1 million Canadians. Mild to moderate cases of psoriasis may be managed through topical treatments (e.g. creams, ointments, gels, foams) like corticosteroids, Vitamin D3 analogues, retinoids, or a combination of these agents. However moderate to severe cases of psoriasis often need to be managed with biologic therapies. 

Biologic therapies can vary in targeting and removing different chemical signalling molecules from the inflammation-causing process, resulting in better psoriasis control. One such signalling molecule that seems to be an important target in achieving remission of psoriasis is Interleukin-23 (IL-23). Until May 2021, there were only three biologic agents on the Canadian market that reduced IL-23 function as listed below:

  • Ustekinumab (Stelara© – blocks Interleukin-23 and Interleukin-12 activity)
  • Guselkumab (Tremfya© – blocks Interleukin-23 activity)
  • Risankizumab (Skyrizi© – blocks Interleukin-23 activity) 

However, since May 2021, an additional IL-23 inhibitor has been approved in Canada for treating patients suffering from moderate to severe psoriasis. Tildrakizumab (Ilumya©) now serves as an additional treatment option for these patients. Currently, Ilumya© has only been approved for use in adults as Health Canada has not received any safety or effectiveness data for use in children or adolescents (<18 years of age). 

As pharmacists specializing in autoimmune conditions, we are excited to have Ilumya© as a part of our treatment tool chest to best help our patients accomplish their goals. 

Kunal Bhatt, RPh, PharmD, HBSc is a staff pharmacist for Charlton Health. As a 2020 PharmD graduate from the University of Toronto, Kunal possesses a diverse range of experiences from working in hospital and community pharmacy settings. Since January 2021, Kunal was heavily invested in contributing to the efforts against COVID-19 by administering upwards of 5000 COVID-19 vaccines at William Osler Health System’s vaccination clinics.  

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Mental Health: Fighting the Stigma

We have spoken many times on our blog about the importance of mental health and how those living with chronic illness often experience mental health concerns at a higher rate. We know throughout the pandemic, these challenges have been amplified as so many immunocompromised people have had to take additional precautions to keep safe over the past two years. The toll that this has taken has been evident to our team in the many conversations we have with patients.

Today is a day that we work to fight the stigma surrounding mental health issues, through Bell’s Let’s Talk initiative. We encourage you to continue this dialogue beyond this annual day and to speak to your healthcare professionals to get the support you need. Always remember that everyone experiences changes in their mental health and there is no shame in asking for help.

If you would like further reading, here are some blog posts we’ve written that may be of assistance:

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Working Towards New Therapies for Sjogren’s Syndrome

With the ongoing development of new advanced therapies (e.g. biologics and small molecule medications), most patients are able to achieve a low level of disease activity for many of the commonly occurring autoimmune diseases (e.g. rheumatoid arthritis, ankylosing spondylitis, psoriasis). However, there is still a great need for treatments to manage people suffering from some autoimmune conditions. One example is Sjogren’s syndrome, which is an autoimmune condition that can affect multiple organs of the body.

Some of the symptoms of Sjogren’s include:
· Dry eyes
· Dry nose
· Dry mouth
· Fatigue
· Joint pain

For a more comprehensive list of symptoms from Sjogren’s please click here.

It is important to remember that symptoms can vary from person to person.

Currently, the options to manage Sjogren’s are limited, and often studies investigating treatments for this condition are unsuccessful. Nonetheless, as recently shared by American rheumatologist Dr. Jack Cush, early results from a preliminary study showed that a biologic treatment, Ianalumab, helped lower disease activity after 24 weeks of treatment.

As pharmacists specializing in autoimmune conditions, we are always excited about findings like this because it gives us a glimpse of the kinds of treatments that may be made available in the near future to best help our patients.

To learn more about Sjogren’s Syndrome, please visit our earlier blog posts from July 11, 2018 and April 26, 2017, or visit Sjogren’s Canada.

Kunal Bhatt, RPh, PharmD, HBSc is a staff pharmacist for Charlton Health. As a 2020 PharmD graduate from the University of Toronto, Kunal possesses a diverse range of experiences from working in hospital and community pharmacy settings. Since January 2021, Kunal was heavily invested in contributing to the efforts against COVID-19 by administering upwards of 5000 COVID-19 vaccines at William Osler Health System’s vaccination clinics.  

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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