Dr. JoAnn Manson is a professor of medicine at Harvard Medical School and chief of the Division of Preventive Medicine at Brigham and Women’s Hospital, in Boston, Massachusetts. I have had the pleasure of hearing her speak at many meetings of the North American Menopause Society.  Amongst her various areas of research, Dr. Manson has looked at the impact of Vitamin D supplementation.

In a recent Medscape post, Dr. Manson identified Vitamin D’s role in boosting immune function against viral diseases. It also has an immune-modulating effect that can lower inflammation and this can have a positive impact on the excessive inflammation some COVID-19 patients have experienced – especially in the lungs. People with respiratory infections have been known to have lower Vitamin D levels. Dr. Manson also reports that three South Asian hospitals have analyzed Vitamin D levels in COVID-19 patients finding that those with a deficiency had much higher levels of severe disease compared to those without deficiency who had milder COVID-19 symptoms.

Although the dietary recommendation is 600-800 units of Vitamin D daily, during this time concern with COVID-19,  supplementing with 1,000-2,000 units is reasonable. We have found Vitamin D in the drop form, which is absorbed directly from the mouth cavity can provide greater absorption than tablets. Of course sunlight is also a good source of Vitamin D and can only be absorbed when a person is not wearing sunscreen, so moderation is the key as unprotected exposure should be limited.

I look forward to sharing Dr. Manson’s future research which will be a randomized clinical trial looking at moderate to high doses of Vitamin D in how it may impact on lowering the risk of developing COVID-19 as well as impacting on illness severity.

Ref: https://www.medscape.com/viewarticle/930152

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 had inquiries from our clients as to what can be done to obtain a prescription renewal when their physician is not available.  Ideally, prescriptions for maintenance medications are issued at your physician visit with enough renewals to last until your next scheduled appointment.  When the appointment requires re-scheduling (as has happened for many patients in the last couple of months), this can mean repeats have run out before the prescribing physician can be seen.

According to the Ontario College of Pharmacists, to ensure continuity of care, pharmacists have the authorization under their scope of practice to renew a quantity of the drug that does not exceed the lesser of:

• The quantity that was originally prescribed, including any refills that were authorized by the original prescriber; or
• A six month’s supply

Pharmacists do not have the authority to renew or adapt a controlled substance (narcotic, controlled drug and targeted substance), or a drug designated as a monitored drug under the Narcotic Safety and Awareness Act.

In order to extend a renewal the pharmacist determines that the therapy is safe and effective by considering the risks and benefits and other relevant individual circumstances of the patient, including, but not limited to the following:

1. The patient’s medical history, including co-morbid disease states and chronic conditions;
2. Laboratory or other tests, as available;
3. Symptoms reported by the patient;
4. The patient’s allergies and other contraindications and precautions;
5. Other medications the patient may be taking;
6. The patient’s gender, age, weight and height (where applicable);
7. Pregnancy and lactation status, if applicable;
8. Any other inquiries reasonably necessary in the circumstances.

The pharmacist must also document in the patient record his or her rationale for renewing the prescription (i.e. patient assessment, monitoring plan, etc.) and indicate the patient’s consent has been given for the pharmacist to renew.  The original prescriber must also be notified within a reasonable time frame after issuing the renewal.

Pharmacists have been exercising their scope of practice to support patients in many ways as they are the public’s most accessible health professional.  I am proud of the dedication and hard work of my pharmacist colleagues during these challenging times.

Ref: https://www.ocpinfo.com/regulations-standards/practice-policies-guidelines/adapting-renewing-prescriptions/

There have been many questions regarding starting a new therapy that can increase infection risk during pandemic times.  The consistent messaging from specialists treating autoimmune conditions has been that a person should maintain treatments as this has less risk of infection than a person off treatment who has a disease flare.

Of course this is with the understanding that isolation and/or social distancing PLUS regular hand hygiene must prevail.

But what about a person who has not yet started an advanced therapy such as a biologic; should they wait?

What we know is the longer we delay the start of any treatment that can help control disease, the greater the risk is that damage can occur to the tissues involved (such as the gut in inflammatory bowel diseases and joints in rheumatic conditions) and that these changes are often irreversible.  As we are also in a time of less contact with the public we are reducing our risk of all types of infection spread.

Hence for the flared person who has no infection symptoms currently, one could argue that this is the BEST time to start a treatment and get control of disease!  As always, each person must be assessed for the risk of treatments compared to the benefits by their prescriber.

Based on this information, it is not surprising that the number of people starting new therapy remains high.  We have been educating and welcoming many new patients to our clinic at this time.

We have featured blogs over the last two years on the importance of vaccination, especially for patients who have autoimmune conditions and have a greater risk of infection than the general public.  During COVID-19 many family physician offices have been doing virtual visits over the phone/computer and have not had the capacity to manage vaccines.  Public Health departments across the province have been focusing efforts on COVID-19 management and testing, and some have reduced their distribution of publicly funded vaccines to physician offices.

We cannot forget however the importance of protecting against many of the known viruses and bacteria that have can also have serious health consequences. Pneumonia, Shingles and Influenza are only part of a number of adult vaccines that must be updated.  Maintaining childhood vaccines is also of significant importance as we do not want the return of illnesses that have previously been eradicated.  In England they are very conscious of this and have begun curbside vaccinations, where patients are screened over the phone upon arrival outside the clinic, the nurse then vaccinates through the car window and then returns into the office to complete the documentation. The person waits in their car post shot to ensure no reaction and then calls back into the office for clearance to drive home.

At Charlton Health we have maintained our vaccination clinic to ensure patients receive needed vaccines prior to starting advanced therapies and maintain their vaccination schedule.  By booking patients 15 minutes apart and using personal protective equipment this clinic is running well.  Remember that community pharmacists also have the ability to administer vaccines but some may be limited in their capacity to do this currently.

As restrictions ease, vaccination catch-up will be a necessary priority and one not to be forgotten.  If a second or third dose in a vaccination series has been delayed, you do not need to repeat the vaccination series; just have the next dose as soon as the service becomes available.

We all may remember the dreaded Freshman 15, well unfortunately self-isolation can pose similar challenges of  weight gain that we have to try and combat.

In these uncertain times we may be choosing to do more at home baking to pass the time or consuming more comfort foods to lift spirits. Our normal routines and sleep patterns have been disrupted and we may be either sleeping too much or not enough. Many of us may no longer be able to join our friends in walking groups, have had to stop going to the gym or pools or visiting public parks and recreation facilities therefore reducing our activity levels. Some of us may be consuming more alcohol in order to cope with these new restrictions and uncertainties during this time.

Now is the time, more than ever, that we need to focus on our own general health and well-being. We need to stay in control of the things we can control …ourselves.

• Try to stick to a regular getting up and bedtime routine. Getting up and getting dressed as if you were going out/ or to work for the day maintains a sense of normalcy. Try to have 8 hours quality sleep- turning off  devices, computers and TVs.
• Eat healthy- well balanced meals that are high in lean protein, low in carbohydrates and have plenty of fruits and vegetables. Refer to Canada’s Food Guide for example.
• Stay hydrated. Drink 8-10 glasses of water a day.
• Limit Alcohol and refined sugars.
• Remember smoking (although a vice for some) does worsen disease activity.
• Try to stay active. Do frequent short bouts of activity throughout the day. Practice stretching and Range of Motion Exercises at home to ease joint stiffness and symptoms of bursitis. Motion is lotion. Activity is also good for our bone health.
• Try to keep a positive mindset. Focus and reflect on the things we are grateful for. Try a new at-home hobby, learn a new skill or simply just take the time to do the things we may not be able to do during our “normal” hectic pace of life.

There are many great resources for staying active at any level of mobility. Some of those include:

• Top 10 Arthritis Exercises You Can Do Almost Anywhere
• Yoga for Rheumatoid Arthritis
• From Soup to Tomatoes (Armchair Exercise Classes) 
• Arthritis Consumer Experts: #ArthritisAtHome Ep.10: How to stay active and exercise at home during #COVID19 with Dr. Linda Li 

Of course, we always love Canada’s Food Guide as a great resource for eating healthy year round.

As we all work together to combat the COVID-19 virus and its spread- remember to take care of our hearts, minds and body at the same time.

Stay well, stay strong and stay healthy!

Melissa Deamude, RN BScN CCRC has worked as a rheumatology clinical nurse specialist for over 23 years with a commitment to rheumatology and her patients in improving quality of life and optimizing disease outcomes.

As we have written in past blogs, the importance of maintaining treatment and staying in low disease activity is crucial at this time. In addition to this, we also need to address the impact that isolation has on autoimmune diseases. For some, a time of isolation allows for personal reflection, an opportunity for a new hobby, reading a great book, and/or can be seen as a time of rejuvenation. For others, this can be a time of extreme loneliness, especially when living alone or without the technology to support some of the online opportunities to reach out to others. When this time is experienced as one of stress, this can result in an increase in cortisol production leading to higher levels of inflammation, which could promote disease flare.

For those with access to the internet, the good news is that now, more than ever, there are lots of opportunities to connect with each other remotely. The Canadian Ministry of Health has recently launched Wellness Together Canada to help people connect to peer support workers, social workers, psychologists, and other professionals for confidential chat sessions or phone calls. Learn more here.

Another way to connect can be done via seniors/community centres, many of whom have developed online programming to keep people connected.

Another resource that may be helpful is through the Arthritis Consumer Experts’ JointHealth publication, who are sending out a series of videos called #ArthritisAtHome. This week, they released Episode 7, titled “Isolation and Loneliness in the Age of COVID-19” by Dr. Susan Bartlett. You can watch the episode here.

Tomorrow night, the Arthritis Society is doing a webinar to answer questions about COVID-19 and arthritis. The webinar is free and you can register here.

We hope you will find some of these suggestions helpful during this unprecedented time. Overall, the message is to stay home, but stay connected.

We welcome Dr Neeraj Narula, McMaster University gastroenterologist and director of the IBD Clinic, to share his thoughts on COVID-19. 

Given the use of biologics and immunosuppressive agents, many patients and physicians are concerned about whether IBD patients using these therapies are more susceptible to COVID-19 infection. 

In general, although biologic therapies do act on the immune system, they are reasonably specific and do not compromise the entire immune system.  Rather, they act on one or two soldiers (molecules) in the entire army (immune system) which tend to be overactive in patients with IBD.  Most of the immune system is intact, however and usually able to fight off pathogens like viruses that attack the body.

There is not too much literature on COVID-19 risk in IBD yet.  From China, as of March 8, 2020 (two months into the outbreak), no IBD patients from the seven largest IBD referral centres in China (looking after 20,000 IBD patients) have been reported to have COVID-19 infection.  Further, no patients from the three largest IBD centres in Wuhan have been reported to have COVID-19 infection (Mao R et al. Lancet Gastroenterol Hepatol. Published March 11, 2020,https://www.thelancet.com/journals/langas/article/PIIS2468-1253(20)30076-5/fulltext).  There is an ongoing registry (covidibd.org) to monitor for worldwide cases of IBD patients.  As of April 1, about 239 patients worldwide have contracted COVID-19, and their overall outcomes (i.e. rates of ICU admission, ventilator use, etc) seem comparable to what is seen in the general population.

Current guidance is stable patients on biologic or immunosuppressive therapy should continue these therapies, and should take the same kind of precautions that everyone has been recommended to do (social distancing, frequent hand washing, etc).  Some societies that have provided this guidance:

https://www.ioibd.org/ioibd-update-on-covid19-for-patients-with-crohns-disease-and-ulcerative-colitis/

https://www.crohnscolitisfoundation.org/what-ibd-patients-should-know-about-2019-novel-coronavirus-covid-19

Stay safe out there!

Neeraj Narula MD MPH FRCPC
Director of the IBD Clinic, McMaster University

Charlton Health is very proud of our team as they continue to offer excellent care during this difficult time.  As we are very aware of the importance of maintaining treatment for autoimmune diseases, we are making every effort to ensure your treatment continues with the highest measures of  safety.   All infusion clinics are screening every patient before they come for an infusion to be sure they have no symptoms, have not been in contact with a positive case of COVID-19, or a quarantined person and have not travelled outside of Canada in the last 14 days.  Each clinic fully cleans all surfaces before and after each patient and is positioning patients to maintain an appropriate distancing.  A person on treatment in a state of low disease activity, has less infection risk than a flared untreated person.

Our advice is:

• Maintain treatment
• Practice excellent hand washing
• Don’t touch your face
• Maintain physical distancing
• Continue with your medical treatment and appointments when appropriate, and other than that: STAY HOME!

As a follow-up to last week’s  message on Covid-19, we are sharing the Ontario Rheumatology Association (ORA) statement regarding medications provided at infusion clinics as essential medications.   All of our clinics continue to operate with the highest vigilance to protect patients and maintain their treatments.

Read the protocol here.

The Ontario Ministry of Health guidelines are being updated daily. Current guidance at our clinics is if you have travelled outside of Canada in the past 14 days and have symptoms of infection, such as fever or feeling feverish, cough, shortness of breath, or breathing difficulties; or if you have been in contact with a person with confirmed or suspected COVID-19 that you self-isolate. Cancel and reschedule your appointment with our clinics. Contact Telehealth Ontario at 1-866-797-0000 or your local Public Health department for further direction. If you’re in Hamilton, you can reach the City’s COVID-19 Public Health line at 905-546-2424 ext. 7970.

It is well known that people with autoimmune diseases or any chronic condition have an increased risk of infection, irrespective of their treatment. We have received many calls from people who are currently on disease modifying treatments, such as biologics, that are concerned about their treatment during this COVID-19 pandemic. It is important to note that a person who is in low disease activity on their medication has less infection risk than someone who is off treatment and in a flared state, and that prednisone carries a greater infection risk than our disease modifying treatments.

The decision to hold medication is one between you and your prescriber. General advice would include holding your medication during any active infection which would include fever, cough, and shortness of breath, which are also signs of COVID-19. If you have been exposed to a confirmed or presumed case of COVID-19 or a person with an acute respiratory illness, consideration should be made to hold your treatment and monitor symptoms of infection for up to 14 days as a precautionary measure.

It is important to note that these are general principles to help guide you through this time. This information does not replace individual advice from your prescriber.

For all those that receive home delivery of your medication, our drivers will have an altered protocol over the coming weeks. New procedures will include delivery of medication to the door wearing gloves, ringing the doorbell, setting down the delivery package and stepping back two metres. When the door opens, patients are to acknowledge receipt of package but will not be required to sign. The delivery person will be signing on their behalf confirming date and time and any details of the delivery. They will not leave until they know medication is safely in your possession. This is being done to reduce potential exposure and to respect your personal space during this time. As always, those that visit our clinics can be assured that we are highly vigilant in sanitizing our spaces as always.

It is highly recommended you follow Health Canada guidelines for hand washing (including using paper towels on door handles where possible), surface cleaning, and avoiding situations where large crowds are gathered in close proximity. As always, we encourage you to optimize your own health.  Stay hydrated, get enough sleep, fresh air, and exercise and eat a balanced diet following Canada’s Food Guide.  These actions will help you maintain a strong immune system.