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.

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

Learn more and join the discussions here.

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

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

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

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

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

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

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

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

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

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

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

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

Since our last blog providing guidance for the COVID-19 vaccine, we have had many calls asking if patients on disease modifying treatments, such as biologic therapies, methotrexate, leflunomide etc. should hold their dose after getting the COVID-19 vaccine for a short period of time while the body produces antibodies to the vaccine.  We do not yet have the research to let us know if this would make a difference, however it is in the process of being studied. Experts from the American College of Rheumatology are developing a guidance statement in this regard based on expert opinion.  We are hoping to see this in the next 2 weeks and will share it with you.  In the meantime, when you next have an appointment with your specialist, it is a discussion worth having.  We do not want a person to flare by delaying a dose and we also want the most benefit possible from this vaccine.

In the meantime, the Canadian Rheumatology Association along with the Canadian Arthritis Patience Alliance has developed a patient decision tool for the COVID-19 vaccine.  Click here to find this document, which could be helpful for all patients with autoimmune conditions.

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.

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. 

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

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.