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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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Coadministration of COVID-19 Vaccines with Other Vaccines and Updates on Third Dose Eligibility in Ontario

With flu shot season just around the corner, the National Advisory Committee on Immunization’s (NACI), updated recommendations regarding the coadministration of COVID-19 vaccines with other vaccines have arrived in a timely manner. Previously, NACI had recommended that the COVID-19 vaccines be administered at least 14 days after or 28 days before other vaccines, as a precautionary measure. However, considering previous experience of giving other vaccines at or around the same time along with the emerging evidence on the COVID-19 vaccines, NACI has now recommended that the COVID-19 vaccines can be given at the same time as, or any time before or after, other vaccines.  This includes live and non-live vaccines.

Also, as the third COVID-19 vaccine dose eligibility for Ontario residents continues to expand, we’ve provided the list below regarding who may be eligible as per the most recent recommendations from Ontario’s Ministry of Health, released on October 7, 2021. 

When receiving your third dose, you will be asked to show the prescription receipt from one of the listed medications OR the labelled medication container.  Some people on medications beyond those listed below, may still be eligible to receive third doses, as the list may not be complete. These individuals will require a referral form/letter from their healthcare provider for a third dose of the COVID-19 vaccine. The recommended timing of the third dose remains the same as previously established, at least 8 weeks since the second dose. 

Table of Medications Considered Highly Immunosuppressive for Third Doses (Adapted from: Ministry of Health, COVID-19 Vaccine Third Dose, Recommendations, Version 2.0 October 7, 2021)

ClassGeneric NameBrand Name
Steroids (greater than 20 mg/day of prednisone or equivalent for more than 2 weeks)Prednisone

DexamethasoneDecadron


Methylprednisolone
SoluMedrol DepoMedrol Medrol





Antimetabolites
CyclophosphamideProcytox

LeflunomideArava



Methotrexate
Trexall Metoject Otrexup Rasuvo Rheumatrex

AzathioprineImuran

6-MercaptopurinePurinethol

Mycophenolic AcidMyfortic

Mycophenolate MofetilCellCept



Calcineurin Inhibitors/mTOR Kinase Inhibitor

Tacrolimus
Prograf Advagraf Envarsus PA


Cyclosporine
Neoral Gengraf Sandimmune

SirolimusRapamune

JAK (Janus Kinase) Inhibitors
BaricitinibOlumiant

TofacitinibXeljanz

UpadacitinibRinvoq








Anti-TNFα (Tumour Necrosis Factor)



Adalimumab
Humira Amgevita Hadlima Hulio Hyrimoz Idacio

GolimumabSimponi

Certolizumab PegolCimzia


Etanercept
Enbrel Brenzys Erelzi



Infliximab
Remicade Avsola Inflectra Remsima Renflexis

Anti-Inflammatory
SulfasalazineSalazopyrin Azulfidine

5-Aminosalicylic Acid/MesalaminePentasa



Anti-CD20


Rituximab
Rituxan Ruxience Riximiyo Truxima Riabni

OcrelizumabOcrevus
IL-1 RA (Interleukin 1 receptor antagonist)AnakinraKineret

CanakinumabIlaris
Anti-IL 6TocilizumabActemra

SarilumabKevzara
Anti-IL 12/23UstekinumabStelara
Anti-IL 17SecukinumabCosentyx

IxekizumabTaltz
Anti-IL17 RBrodalumabSiliq
Anti-BLySBelimumabBenlysta
Anti-IL 23GuselkumabTremfya

RizankizumabSkyrizi
Selective T cell Costimulation BlockerAbataceptOrencia

FingolimodGilenya
S1PR (Sphingosine 1-phosphate receptor agonist)SiponimodMayzent

OzanimodZeposia
Phosphodiesterase InhibitorsApremilastOtezla

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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Ontario’s Expanded Eligibility for Third Dose of COVID-19 Vaccine

We have had many calls about the expanded list of vulnerable populations who are now eligible for a third dose of COVID-19 vaccine.  Below is an excerpt of the new guidance which includes a  list of patients who are now eligible as well as the earlier list of eligible patients.

We have bolded the type on the fifth bullet of this list,  as it applies to the majority of advanced treatments patients with autoimmune diseases are prescribed.  The term ‘antimetabolites’ refers to treatments like methotrexate.  The third dose of vaccine can be received as soon as two months after the second dose.  Proof of eligibility may differ based on the public health unit where you live.  Many are requesting a letter from the specialist prescribing the immunosuppressive treatment, others will take a letter from a family physician or the pharmacist dispensing the medication.  Some regions have developed a third dose form for completion by the physician.  It is advised you call ahead to be sure you have the documentation required.

Read the Ontario government’s press release here.

  • Those undergoing active treatment for solid tumors;
  • Those who are in receipt of chimeric antigen receptor (CAR)-T-cell;
  • Those with moderate or severe primary immunodeficiency (e.g., DiGeorge syndrome, Wiskott-Aldrich syndrome);
  • Stage 3 or advanced untreated HIV infection and those with acquired immunodeficiency syndrome; and
  • Those undergoing active treatment with the following categories of immunosuppressive therapies: anti-B cell therapies (monoclonal antibodies targeting CD19, CD20 and CD22), high-dose systemic corticosteroids, alkylating agents, antimetabolites, or tumor-necrosis factor (TNF) inhibitors and other biologic agents that are significantly immunosuppressive.

Individuals in these groups can receive their third dose at a recommended interval of eight weeks following their second dose and will be contacted by their health care provider such as their primary care provider, specialist, or their hospital specialty program when they are eligible to receive the vaccine.

Locations and timing for third doses may vary by public health unit and high-risk population based on local planning and considerations, with third doses mainly to be administered at transplant clinics and cancer clinics.

This expanded eligibility supplements the government’s previous decision to offer third doses of the COVID-19 vaccine to select vulnerable populations:

  • Transplant recipients (including solid organ transplant and hematopoietic stem cell transplants);
  • Patients with hematological cancers (examples include lymphoma, myeloma, leukemia) on active treatment (chemotherapy, targeted therapies, immunotherapy);
  • Recipients of an anti-CD20 agent (e.g. rituximab, ocrelizumab, ofatumumab); and
  • Residents of high-risk congregate settings including long-term care homes, higher-risk licensed retirement homes and First Nations elder care lodges.

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 Antibody Testing

We have had several questions from our patients with autoimmune diseases regarding antibody testing.  The first thing to be aware of is that there are two different antibody tests.  The initial testing that labs offered is called the Total Nucleocapsid Qualitative Test.  This testing is to measure the antibody that the body generates when exposed to the actual COVID-19 virus (SARS-CoV-2).  It does not measure antibodies produced from having a vaccine.  The second antibody test is for the Total Spike Quantitative Antibody Test and this measures antibodies made in response to being vaccinated.  Some labs are offering a panel of both antibodies, where others only have the initial antibody test.

It is important to know that it is not known what level of antibody to the spike protein is needed to provide protection from developing symptomatic COVID-19 disease.  This testing is an out-of-pocket expense.  Before considering an antibody test,  speak to your specialist to see if this will provide any valuable information in managing your care.

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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Reflecting on Ontario’s Updated COVID-19 Vaccination Eligibility

On August 17th,  Ontario updated its vaccine eligibility criteria.  Anyone turning 12 years old in 2021 can now be vaccinated, rather than having to wait until their 12th birthday.  In addition, those who are living in long-term care settings are eligible for a booster dose of COVID-19 vaccine as long as their last dose was at least 5 months prior. Patients who are receiving immunosuppressive treatments that have been shown to impact vaccine efficacy may also receive a booster if at least 2 months have passed from their second COVID-19 vaccine. This includes transplant patients and those receiving treatments for hematological cancers.  In addition, patients with autoimmune diseases and who receive therapies that lower their B Cell levels are now eligible for a booster dose.

Many patients with autoimmune diseases are on treatments that are considered immunosuppressive, however, those with the greatest risk of not responding to the vaccine are people on medications that suppress their ability to make antibodies when getting the vaccine. Treatments such as rituximab (Rituxan, Ruxience, Riximyo) and ocrelizumab (Ocrevus) are in this category. If you are receiving one of these treatments, any vaccine is best given 5 months or more post the last rituximab/ocrelizumab dose.  Where possible individuals with upcoming appointments should consider getting this third dose, 2-4 weeks before their next rituximab/ocrelizumab infusion.  A note from your specialist confirming you are on one of these therapies will likely be needed when booking this appointment. Other evidence may also be accepted, so check ahead with your public health unit. To date, third doses are only available through public health and not at the pharmacy.  Some public health units began giving third doses to eligible patients last week.  It is suggested that whichever vaccine you had for your second dose, be the same vaccine for the third dose.

Learn more about the updated eligibility 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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Have you thought about quitting?

We have all felt a burden of stress during this pandemic.  For many, it has been a time to reflect on what we really value in life and the people and experiences that we have missed.  Reflecting on one’s health and trying to prevent disease has certainly been the focus in getting vaccinated. 

However, the most valuable intervention a person can make to prevent disease and prolong life is to quit smoking.  Those who smoke tend to have worse outcomes if they get COVID-19.  There are many health professionals who can support you on your QUIT journey, such as public health, family physicians, nurses, and pharmacists. Smoker’s Helpline is an excellent free resource https://smokershelpline.ca or call 1-866-366-3667. Reaching out is the first step towards quitting.

Regardless of your age, it is never too late to quit as benefits begin within hours. As an example, within one year of quitting, the risk of a heart attack decreases by half.  At one month post quitting, skin appearance improves with less greyish tone and wrinkles lessening. Within 10 years of quitting the risk of lung cancer decreases by half compared to a smoker. Smoking also increases inflammation in the body and increases the progression of many autoimmune diseases. Our most advanced therapies work better in non-smokers. So take a moment to reflect on life as a non-smoker, and all the ways that would impact your life and those around you.  This may be the time to act!

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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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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