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.

Recently I have had people come into the clinic who started on a new medication months prior and persevered with very difficult adverse effects of nausea, fatigue, and headache that were affecting their quality of life. Although most of our medications have a very low incidence of these adverse effects, when you do find that a medication doesn’t agree with you, it is essential that you consult your healthcare professional about ways to manage the adverse effects and to verify if what you’re experiencing is likely due to the medication. In many cases, disease modifying treatments for autoimmune inflammatory conditions are prescribed and then assessed for their full effectiveness three months later. It is important to not suffer for three months if you are experiencing unpleasant side effects but rather call for guidance as a new medication could be ordered to replace the one you are taking or dosage adjustments made.

• Eat fresh non-processed foods with low sugar content
• Drink plenty of water daily (often start with full 8 oz glasses right after you get up to start your day and continue to carry a water bottle with you, drinking often)
• Keep moving; regardless of limited mobility (we’re happy to help with ideas), 150 minutes/week of exercise is so important for overall well being (hot pools, mall walking in the cold weather, chair fitness are all options)
• Spend time with people that make you feel good; human contact and socialization are vital
• Get plenty of rest; 7-8 hours of sleep is important in reducing body stress, repairing tissue, decreasing pain, improving mood, and energy to name a few

We wish you all the best in the new decade!

It is not a surprise that special occasions create both good and bad stress. For some these are happy times spent with friends and family, and for others it can be a very difficult time of year. Regardless of this, managing stress is important. Our body produces cortisol in response to stressors and excess cortisol production translates into increased inflammation in the body. For many conditions where high inflammation causes flares, this can very difficult as not only is the person stressed, but they are also flaring.

So, as we enter into this holiday season filled with busy schedules and many expectations, remember to look after yourself, take some deep breaths and try to enjoy the moments rather than getting overwhelmed.

We wish everyone all the best for the season however you choose to celebrate.