We often hear patients ask how they got an immune-mediated condition.  Autoimmune diseases occur when the immune system mistakenly attacks the body’s own cells, leading to long-term inflammation and damage. While genetics play a role in the development of these conditions, environmental factors can also contribute to them.

Trichloroethene (found in paint removers and adhesives), silica (used as a food additive), mercury (found in thermometers and fish), pristane (a lubricant), pesticides, and smoking, have been linked to a higher risk of autoimmune diseases. These substances can cause oxidative stress and disrupt the normal functioning of the immune system.

For instance, exposure to mercury (from a broken fever thermometer) can lead to inflammation and the production of autoantibodies, a reaction similar to what occurs in lupus. Pesticides and chemicals like trichloroethene can interfere with immune function, making autoimmune reactions more likely by altering how immune cells operate and communicate.

The gut microbiome also plays a crucial role in autoimmune diseases. This complex mix of microorganisms in our intestines helps regulate immune responses and maintain a healthy gut barrier. Environmental chemicals can disrupt this balance, leading to inflammation and increasing the risk of autoimmune diseases.

Although understanding and managing these environmental factors is important, it’s important to recognize that controlling them does not guarantee prevention of autoimmune conditions. The development of these diseases is more complex, with stress and genetics also playing a crucial role.

Joyce Ayad is a 4th-year pharmacy student from the University of Waterloo who completed one of her rotations at Charlton Health. She believes in providing patient-focused care, supported by her previous experience working with specialty drugs, the pharmaceutical industry, and more. Joyce is eager to become a licensed pharmacist this year. 

RSV is a seasonal virus that can cause serious lung infections, especially in young children under 2 years old and adults over 60. 

Recently, Health Canada expanded the use of the Arexvy vaccine to include adults aged 50–59 who have certain chronic health conditions that put them at higher risk for severe RSV. These conditions include stable chronic lung diseases like COPD and asthma, heart problems such as heart failure or coronary artery disease, diabetes (both type 1 and type 2), and chronic kidney or liver disease. This update makes the vaccine more widely available to people needing extra protection. We are also aware that people with immune-mediated conditions or those on medications that are considered immunosuppressive are at increased risk of RSV and specialists may also consider them for vaccination before age 60. 

There have also been updates about combining Arexvy with other vaccines. It can now be given at the same time as a flu shot, whether it’s a standard dose or a high-dose option. Studies are ongoing to see if it can be safely given alongside other vaccines, like the pneumococcal vaccine (PCV20) and mRNA COVID-19 boosters. Although Arexvy has been studied with the shingles vaccine (Shingrix), this specific combination isn’t officially approved yet. 

Remember, it is not necessary to hold or delay most biologic/advanced treatments while receiving non-live vaccines such as Arexvy. We would suggest not administering a new vaccine within a few days of a biologic injection or infusion, so if you feel unwell you can determine which was causing your symptoms.

Joyce Ayad is a pharmacy intern working at Charlton Health. She believes in providing patient-focused care, supported by her previous experience working with specialty drugs, the pharmaceutical industry, and more. Joyce is eager to become a licensed pharmacist this year.

In the summer, we wrote about the newest pneumococcal vaccine approved in the United States.  It is now available in Canada and is called Capvaxive and is manufactured by Merck.

There are about 100 types of pneumococcal bacteria.  Capvaxive protects against 21 of those types.  The great news is that the 21 strains chosen for the vaccine protect against 80% of the worst pneumonia strains which can cause disease throughout the body and lead to hospitalization.  This is the greatest level of protection available in a pneumococcal vaccine to date.  It is a single dose that is expected to provide long-term protection.  So far, this vaccine is not available through free public health programs but is available through prescription at community pharmacies. With that said, public health does provide the pneumonia vaccine known as Prevnar 20 for people at increased risk of pneumonia.  It protects against a different mix of 20 strains of bacterial pneumonia and still offers good protection for people who do not have a private plan or cannot pay out of pocket for the newer vaccine.

Most people are aware that pneumonia is an infection of the lungs that can cause cough, thick, discoloured mucus, shortness of breath, and fever.  It can be caused by a bacteria, virus or fungi.  What is not commonly known is that bacterial pneumonia (called streptococcus pneumonia,) can go beyond the lungs. This is called invasive pneumococcal disease.  When the infection enters the bloodstream, it is known as bacteremia.  When the infection reaches the tissue covering the brain and spinal cord, it is called pneumococcal meningitis. These are very serious infections requiring hospitalization.   Even pneumococcal pneumonia, affecting just the lungs, causes 150,000 hospitalizations in the United States each year.  Inflammation generated by pneumonia can also increase the risk of heart attack and stroke.   Vaccination is our best way to protect against bacterial pneumonia.

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.

As newer biologic medicines can be incredibly useful in managing many conditions (e.g. immune-mediated, bone disorders, diabetes), their use can be limited by cost. 

The introduction of biosimilars, however, has offered biologic medicines that are just as safe and effective as the originator, at a fraction of the cost. This results in significant cost savings for the healthcare system, insurance companies, and patients. This was the key driving factor for the non-medical biosimilar switch in Ontario, which we blogged about on February 17, 2023. At the time, some of the existing treatments that had biosimilar options included: infliximab (Remicade©), rituximab (Rituxan©), adalimumab (Humira©), and etanercept (Enbrel©). Since then, however, biosimilars have been introduced for other treatments such as ustekinumab (Stelara©), and more recently denosumab (Prolia©). 

The biosimilar for denosumab,  Jubbonti© is also injected subcutaneously every 6 months to manage osteoporosis just as Prolia©. For cash-paying patients, the cost savings through using this biosimilar can be significant, especially over the years. 

At Charlton Health, we actively educate our patients on the use of biologic medicines and their biosimilars in managing immune-mediated and bone-related disorders like osteoporosis. Therefore, we are excited to offer this biosimilar to our patients which can improve access through cost reduction. 

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. 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. 

Living with an immune-mediated condition can be a difficult journey with many different treatments. For instance, patients with rheumatoid arthritis may begin their treatment with medications such as methotrexate, leflunomide, sulfasalazine, or hydroxychloroquine, but eventually have their doctor suggest trying a more advanced treatment. These options include medications made from protein called biologics which are expensive to produce. Pharmaceutical companies making these expensive medications have developed patient support programs to help the public access these treatments. 

When a physician orders a specialty medication, such as a biologic, the prescription is often sent to these support programs as a first step. A case manager will reach out to the patient to introduce themselves and find out what insurance coverage they may have. This could be through a government plan like Trillium or a private insurance plan through a person’s work. Insurance companies often require that an application be made to request coverage for expensive medications and these support programs can assist with these forms. Once the private insurance or government-based plan approves a treatment, there can sometimes still be a portion of the cost that is not covered. Support programs offer funding to cover this difference, so the patient is not spending out of pocket.  

At Charlton Health, our team of reimbursement specialists work closely with all support programs to secure any extra funding that might be required. In some cases, these programs can even offer complimentary doses of your medication while you’re waiting for approval or switching from one insurance plan to another.

Patient support programs can also provide additional resources and support. This might include funding for certain blood tests, vaccines, educational materials, and resources on healthy living including counseling services.

Joyce Ayad is a 4th-year pharmacy student from the University of Waterloo who completed one of her rotations at Charlton Health. She believes in providing patient-focused care, supported by her previous experience working with specialty drugs, the pharmaceutical industry, and more. Joyce is eager to become a licensed pharmacist this year. 

Cancer treatments have greatly evolved to offer better results with fewer adverse effects. A newer family, called Immune Checkpoint Inhibitors (ICPis), falls under this category. ICPis are a type of immunotherapy for various cancers such as multiple myeloma, non-small cell lung cancer, and Hodgkin’s lymphoma. In this blog, we will share some information on how these treatments work and why they may cause a patient to develop Rheumatoid Arthritis.

Our bodies have immune cells called T cells that constantly look for dangers like viruses and bacteria. Healthy cells have checkpoints on their surfaces to prevent T cells from attacking them. However, cancer cells can disguise themselves by copying these checkpoints, allowing them to spread unchecked. Checkpoint inhibitors work by exposing the cancer cells’ disguise, enabling T cells to recognize and attack them. This ramps up our immune system and may lead to autoimmune conditions like rheumatoid arthritis. In fact, studies have found that 1-7% of patients treated with ICPis develop this condition.

Treatment for rheumatoid arthritis caused by ICPis often starts with a steroid medication called prednisone to quickly manage symptoms. A recent study published in the Journal of Rheumatology found that traditional disease-modifying treatments (methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine) successfully led to low disease activity for patients who developed rheumatoid arthritis caused by ICPis regardless of whether the ICPi treatment was discontinued.

Early reporting of joint symptoms and a quick start to treatment can greatly improve outcomes for those affected by this unexpected side effect of immune checkpoint inhibitors.

Joyce Ayad is a 4th year pharmacy student from the University of Waterloo, currently completing her final rotation at Charlton Health. She believes in providing patient-focused care, supported by her previous experience working with specialty drugs, the pharmaceutical industry, and more. Joyce is eager to become a licensed pharmacist this year. 

Vaccines are important in protecting us from many types of bacterial pneumonia, which can lead to serious illness including hospitalization and death. To increase protection, Ontario’s publicly funded pneumonia vaccine program now provides Prevnar 20 to adults 65 years of age and older, as well as high risk adults regardless of age. This replaces the previously funded Pneumovax 23 and Prevnar 13.

What is Prevnar 20?

Prevnar 20 protects against 20 types of bacterial pneumonia (known as Streptococcal pneumonia). This vaccine has been approved by Health Canada since 2022 and is given as a single injection. Until now, many adults have received this vaccine through private coverage or paying out-of-pocket.

Comparison to Other Pneumonia Vaccines

Prior to this new coverage, Prevnar 13 was publicly funded for all adults 65 years of age and older as well as high-risk adults aged 50 years and older. Prevnar 13 protects against 13 types of bacterial pneumonia. The additional 7 types covered by Prevnar 20 cause about 40% of pneumococcal disease cases and deaths.

Pneumovax 23 (Pneumovax) was given 8 weeks after Prevnar 13 to protect against 23 strains of bacterial pneumonia. However, Pneumovax’s effects last approximately 5 years due to the vaccine formulation. Prevnar 20 offers longer protection and a greater immune response because of the newer technology in how the vaccine is prepared.

What if I have already received a pneumonia vaccine?

• If Prevnar 13 alone was given, wait 8 weeks and give Prevnar 20
• If Pneumovax given, wait one year and give Prevnar 20 (can wait 8 weeks then give Prevnar 20 if rapid completion is required).
• If 1 dose of Prevnar 13 and 1 dose of Pneumovax given, wait one year and then give Prevnar 20 (can wait 8 weeks then give Prevnar 20 if rapid completion is required).

The Future of Pneumonia Vaccines

Vaccines continue to evolve to cover even more types of bacterial pneumonia. It is important to receive the best protection that is currently available. Although no booster for Prevnar 20 is suggested, make sure you remain informed on the latest vaccine updates.

Joyce Ayad is a 4th year pharmacy student from the University of Waterloo, currently completing her final rotation at Charlton Health. She believes in providing patient-focused care, supported by her previous experience working with specialty drugs, the pharmaceutical industry, and more. Joyce is eager to become a licensed pharmacist this year. 

Last month we celebrated World Hepatitis Day. At Charlton Health, we are pleased to provide treatment for Hepatitis C and wanted to share more information about this virus.

Hepatitis refers to inflammation of the liver, often caused by a viral infection. The most common types of hepatitis are A, B, C, D, and E. The goal is to reduce new hepatitis cases by 90% and reduce deaths by 65% by 2030. Hepatitis B and C are the most serious, causing the most deaths and health complications.

Testing for hepatitis is very important because many people with the virus don’t have symptoms right away. Usually, hepatitis is found through blood tests. Sadly, over 80% of people with hepatitis can’t get tested or treated, especially in low-income countries. For hepatitis C, it is advised that every adult gets tested at least once, pregnant people get tested with each new pregnancy, and anyone with risk factors gets tested.

There are effective treatments for hepatitis C that can cure over 90% of those infected, but there is no vaccine for hepatitis C. That is why testing and preventing hepatitis C is so crucial. Hepatitis C spreads through infected blood, not through physical contact or sharing food. To lower the risk, don’t share needles or personal items like razors or toothbrushes. If untreated, 75-85% of newly infected people can develop long-term infections and possible liver damage.

Vaccines are available for hepatitis A and B, but there is no cure for long-term hepatitis B. The hepatitis B vaccine also protects against hepatitis D. The initial presentation of hepatitis B often has no symptoms before it becomes a long-term concern and causes liver scarring. Since treatment for hepatitis B is only supportive and only available for initial infection, vaccination is essential, especially for newborns. All infants should get the hepatitis B vaccine within 24 hours after birth.  In Ontario, hepatitis B vaccination is offered to all students in grade 7.  For those that travel outside of North America, a vaccine protecting against both hepatitis A (spreads through infected food) and hepatitis B is suggested, such as Twinrix. 

By raising awareness and improving access to testing, treatment, and vaccination, we can make significant progress in the fight against hepatitis!

Joyce Ayad is a 4th year pharmacy student from the University of Waterloo, currently completing her final rotation at Charlton Health. She believes in providing patient-focused care, supported by her previous experience working with specialty drugs, the pharmaceutical industry, and more. Joyce is eager to become a licensed pharmacist this year

Certain autoimmune diseases such as lupus, rheumatoid arthritis, type 1 diabetes, and multiple sclerosis affect minority groups more than others. In addition, up to 50% of all patients with autoimmune diseases experience mental health issues like depression and anxiety which can impact their quality of life.

Minority groups face difficulties when accessing mental health care.

• Statistics show that minority groups visit doctors less often. Many minorities have limited healthcare coverage, making it harder to access mental health services and treatments.
• Cultural stigma about mental health issues can prevent individuals from seeking help.
• Previous bad experiences in healthcare have caused many to lose trust in doctors and nurses.
• There is a lack of cultural variety among mental health professionals. This can make it difficult for patients to find providers who understand their experiences. 

While the exact relationship between autoimmune diseases and mental health problems is not clear, some possible explanations include:

1. Individuals with autoimmune diseases generally have higher levels of chemical signals that promote inflammation, which can affect other signals in the body responsible for regulating mood and energy (serotonin). This can look like depression-related symptoms, including fatigue and disrupted sleep and appetite.
2. The ongoing stress of managing an autoimmune condition can worsen mental health concerns.
3. Complications from autoimmune diseases can reduce the functional ability of patients, leading to difficulties performing daily activities and can affect mental health.

How to prioritize your mental health while managing your immune-mediated condition:

1. Learn About Your Condition: Gain a detailed understanding of your autoimmune disease to better manage its symptoms.
2. Build a Support Network: Surround yourself with supportive family members, friends, or people in similar situations by joining support groups to share your experiences and emotions.
3. Work with your family doctors and specialists to ensure you receive care tailored to your needs.
4. Incorporate Stress-Reduction Techniques: Engage in activities you enjoy, such as playing sports, doing crafts, or mindfulness exercises to alleviate stress and manage the emotional toll of your illness.
5. Seek Professional Help: Explore mental health counseling to address any psychological challenges you may face. Websites like psychologytoday.com provide a wide range of therapists, psychologists, and social workers in your area, including those who may share a similar background as you.

Joyce Ayad is a 4th year pharmacy student from the University of Waterloo, currently completing her final rotation at Charlton Health. She believes in providing patient-focused care, supported by her previous experience working with specialty drugs, the pharmaceutical industry, and more. Joyce is eager to become a licensed pharmacist this year. 

Traveling can be an exciting adventure, but if you’re on biologic medication for an autoimmune condition, it requires some extra planning. Whether you’re heading out for a weekend getaway or embarking on an extended vacation, here are some tips to help you travel smoothly while managing your biologic treatments.

Plan your Doses

Ensure you have enough medication for the entire trip, plus a few extra days’ worth in case of delays. If you’re traveling across time zones, adjust your medication schedule as needed to maintain consistent dosing, if necessary.

Packing your Biologic

To keep your biologic medication at the right temperature (2-8 degrees Celsius), pack it in a cooler bag. Place an ice pack at the bottom, followed by a layer of cardboard or bubble wrap. Next, place your medication on top, add another layer of cardboard or bubble wrap, and finish with another ice pack. This setup should keep your medication cold for 6-8 hours. It would be a good idea to test your cooler using a thermometer and ice packs to mimic the time you will be in transit.

If your trip duration is longer than 6-8 hours, you may request the flight attendant to keep your medication in the airplane’s fridge. However, in case that is not possible, make sure to carry ziplock bags with you to get ice from the attendant.

Always carry your biologic medication in your carry-on bag. Checked luggage can be subjected to extreme temperatures and rough handling, which can damage your medication.

Have Documentation Ready

We will gladly provide you with a travel letter along with a copy of your prescription to help avoid issues at airport security and border crossings.

Store Medication Properly

Once you arrive at your destination, ensure your biologic is stored properly. If it needs refrigeration, confirm that your hotel room has a fridge, or use the hotel’s mini-bar fridge if necessary. Some hotels can provide a medical fridge upon request.

By following these tips, you can ensure that your travels are as smooth and enjoyable as possible while managing your biologic treatment. Bon voyage!

Joyce Ayad is a 4^th year pharmacy student from the University of Waterloo, currently completing her final rotation at Charlton Health. She believes in providing patient-focused care, supported by her previous experience working with specialty drugs, the pharmaceutical industry, and more. Joyce is eager to become a licensed pharmacist this year.