Experts in women’s health now refer to a “window of opportunity” in regards to when to start menopausal hormone therapy (MHT). The consensus is that hormones are best started around the time of entering menopause. For some women this may mean they are in the late stages of perimenopause when cycles become more infrequent. Estrogen has a protective effect on blood vessels and the heart and when estrogen falls after menopause, this protection declines. Restoring estrogen needs to happen before changes to the blood vessels occur. Once ten years has passed since the last menstrual period, it is not recommended to initiate hormone therapy. If estrogen is added to blood vessels that have signs of damage, it can produce more harm than benefit and increase the risk of heart attacks or stroke.

Once hormone therapy is started, there is some evidence to suggest that stopping it prematurely before the age of 60 can increase heart disease risk, reiterating that there is no need to stop MHT after five years of therapy as was thought in the early 2000’s.

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 our last blog, we mentioned the many benefits of estrogen. This week we will address one of the main concerns women have when considering menopausal hormone therapy (MHT): breast cancer. Dr Robert Reid (Queen’s University in Kingston) spoke at the International Menopause Society Meeting in Vancouver in June. He helped put the risk of breast cancer into perspective.

This risk is thought to be insignificant in the first 5 years of hormone use. When compared to other lifestyle risks such as: being overweight, stress, smoking, alcohol use, late menopause, not having children, and not breast feeding, MHT has the lowest risk. If the use of MHT provides benefits such as reducing hot flashes or improving sleep and mood, then stress will be greatly reduced which can reduce the risk for breast cancer. The most significant risk a woman has once reaching menopause is heart disease. More women die of heart disease than all types of cancer combined; when started within the first 10 years of menopause, hormone therapy has a heart protective effect.

Each woman needs to be assessed for individual risks when deciding if MHT is appropriate. A 10-year Danish registry of patients showed that women using hormone therapy had fewer causes of death than those who did not use MHT. Something to seriously consider…

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.

The impact of estrogen levels falling as women enter the menopausal transition is well known. At the International Menopause Society Meeting, the full extent of the impact on the body was discussed. Here are some of the changes that occur throughout the body when estrogen falls:

• Memory: a decrease in neuronal protection (nerves die off faster in the brain without estrogen) leading to a decrease in cognitive speed and verbal memory of 4.9% over the first 10 years from menopause
• Mood: increase in depressive symptoms especially in the 2 years before the last period and 2 years after
• Sleep: Decreased sleep quality (not only due to night sweats) is seen in 80% of women
• Body Temperature: temperature dysregulation resulting in hot flashes and night sweats along with greater cold intolerance
• Bone Quality: decreased bone density beginning with the vertebrae in early menopause with greater loss in cortical bone (hip) later in menopause
• Pain: joint inflammation is increased leading to greater osteoarthritis and reduced subchondral bone repair.
• Vaginal Dryness: the vaginal lining atrophy leading to dryness in 43% of women by age 61 and 32% of women abstaining from intercourse
• Bladder Control: 67% of women having a change in bladder routine and 47% having stress incontinence (laughing or coughing and leaking). ¾ of women have some degree of urinary incontinence.
• Cardiovascular Disease: blood vessels become less reactive and and dilate less. In addition, LDL (bad cholesterol) begins to increase in perimenopause and HDL (good cholesterol) begins to decline. In fact the lower the estrogen level and the higher the FSH, the greater the risk for atherosclerosis (cardiovascular disease).

It is because of these health risks that estrogen supplementation is recommended for many women. Of particular interest is our many patients who suffer from autoimmune diseases where their inflammation is already high, leading to greater cardiovascular risk. Transitioning into menopause can be very difficult as inflammation can be further increased, leading to greater pain and stiffness. The concern many women have is regarding estrogen stimulating breast tissue and when the appropriate time is to start treatment. Our next blog will look at estrogen’s impact on the breast.

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.

After attending the International Menopause Society Meeting in Vancouver, our pharmacists Kerry and Carolyn were very pleased to see that an app has been developed for patients to have a better understanding about what they can expect during the menopause transition and the treatments available. This app is called ‘Menopause Health Tracker.” The International Menopause Society uses the highest level of evidence in providing quality information for the public and health professionals. It is an excellent resource.

Women are often hesitant to discuss menopausal symptoms with their health care provider, especially regarding intimacy. Many women feel their changes are part of aging and there is no help for them. It is our hope that this app encourages women to seek help as quality of life is vital.

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.

Carolyn Whiskin and Kerry Roberts, two of our pharmacists at Charlton, have just returned from the International Menopause Society Meeting in Vancouver. They are both Certified Menopause Practitioners and were very proud to be attending, as this is the first time this meeting has been hosted in Canada. Presenters from around the world shared their research and many new treatments not yet available in Canada were discussed.

One of the first areas discussed was the amount of menopausal hormone replacement prescribed to patients. Although up to 46% of women go to their health professional with menopausal complaints, only 10% or women receive hormone replacement therapy. This is in part due to the lack of awareness surrounding the most recent evidence: that the benefits of hormone replacement outweigh the low level of risk. IMPART is an online series of educational modules for health professionals designed as a refresher course in the treatment of peri-menopausal and menopausal women. It was launched at the conference and is available through the International Menopause Society’s website at no charge. Experts from around the world wrote the content which will updated on a regular basis. We invite you to share this information with your healthcare practitioners.

We will be sharing some of the information learned at this meeting over the next few weeks.

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.

Saturday July 28th is World Hepatitis Day. The main goal of World Hepatitis Day is to help gain awareness around diagnosing the nearly 300 million people living with viral hepatitis that aren’t aware.

Mark Your Calendars: On Friday July 27th, the Charlton Health Hepatitis C Team will be at Gore Park alongside colleagues and other healthcare providers to provide information, testing, and enjoy some entertainment.  We will be there from 11am to 2:30pm – this is a date you won’t want to miss!

July 23rd is World Sjögren’s Day, a day meant to put a face on the millions of people who live with this disease or suffer from symptoms and have yet to be diagnosed. What is Sjögren’s syndrome? It is an autoimmune condition where glands in the mouth and eyes have a decreased production of tears and saliva which can cause significant distress. Learn more in our past blog.

For our many patients suffering with Sjögren’s we acknowledge this special day to draw awareness to this condition.  As research continues to evolve in this area we are happy that there is a new prescription eye drop for dry eyes that was recently released.  It is called Xiidra (lifitegrast) and it is used twice daily.  If you suffer with dry eyes and are not being managed well with your current eye drop, speak to your ophthalmologist about this new medication.

If you wish to donate to research surrounding Sjögren’s syndrome, please visit this donation page.

For our last blog, we continued a series of how specific biologic medications work.

Rituxan was the first medication presented in February 2018 and last week we shared how anti-TNF biologics work.  This was prompted by a patient asking me to express in writing what I verbally explain when someone is starting this medication.

There are many inflammatory substances produced in the human body.  In rheumatoid arthritis, two inflammatory substances have been identified that are made in excess.  One is TNF (tumour necrosis factor) and the second is interleuken-6, known as IL-6.  Whereas TNF can be made in excess in many autoimmune conditions, IL-6 is only made in excess in the joints of people with rheumatoid arthritis.  There are five treatments approved by Health Canada that remove TNF and these were featured in last week’s blog.  There are two approved biologics that remove IL-6:

• Sarilumab (Kevzara)- taken every other week by pre-filled syringe
• Tocilizumab (Actemra)- taken every other week or weekly depending on the person’s weight.  An intravenous form is also available and given monthly.

Treatments which remove IL-6 or TNF have an equal chance of putting a person with rheumatoid arthritis in low disease activity or remission.

As with all biologics used in autoimmune conditions, the risk of infection is a little greater than in the general public and therefore updating adult vaccines is suggested.  Anti-I-L-6 therapies are not given when someone is experiencing an active infection.

These treatments not used in patients who have diverticulitis.  Regular blood work is done to measure liver enzymes and a complete blood count.  Anti-IL-6 medications may increase both the “good” cholesterol HDL and the “bad” cholesterol LDL, but due to their ability to lower inflammation in blood vessels, they are considered protective against cardiovascular disease.

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.

Recently, we’ve discussed how specific biologic medications work.

Rituxan was the first medication presented and we also shared how Orencia (abatacept) works.   This was prompted by a patient asking me to express in writing what I verbally explain when someone is starting this medication.

This week we are featuring biologic therapies that reduce the inflammatory substance TNF (tumour necrosis factor).

Within our immune system are dendritic cells.  Their job is to survey the body and report any irregular cells or invaders, such as a virus or bacteria.  Unfortunately, in many autoimmune conditions (rheumatoid arthritis, ankylosing spondylitis,  psoriatic arthritis, psoriasis, Crohn’s and ulcerative colitis) , these cells generate an alert to the immune system which results in excess inflammation being made within specific tissues (joints, skin or the gut lining) where there is no infection.  In all these diseases, TNF (tumour necrosis factor) is made in large amounts leading to damage, which is irreversible.  The goal of anti-TNF biologics is to attach to TNF and remove it from the body, to prevent further damage and put the disease into a state of low disease activity if not remission.

As with all biologic medication, anti –TNF treatments are composed of protein and therefore cannot be swallowed or they would be digested in the stomach and destroyed. There are five anti-TNF therapies on the Canadian market.  Some of them are approved for multiple conditions and others for arthritic conditions only.

• Adalimumab (Humira) – given every other week by injection.
• Certolizimab (Cimzia)- given every other week or two injections monthly
• Etanercept (Enbrel –originator, Brenzys /Eralzi – Biosimilar forms of etanercept- given weekly by injection
• Golimumab (Simponi)- given monthly by injection or by infusion (rheumatoid arthritis only)
• Infliximab (Remicade –originator, Inflectra/Renflexis – Biosimilar forms) given by infusion.

As with all biologics used in autoimmune conditions, the risk of infection is a little greater than in the general public and therefore updating adult vaccines is suggested.  Anti-TNF therapies are not given when someone is experiencing an active infection.  These treatments are used in caution in patients who have a demylinating disease (ie. multiple sclerosis) or congestive heart failure.

By lowering inflammation in blood vessels, anti-TNF therapies are considered protective against cardiovascular disease.

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 a previous blog we spoke about what a biologic medication is, and how it is produced through the programming of live cells to produce a treatment that mimics a protein structure in a human. Biosimilars are produced after the originator biologic’s patent has expired. The living cells used to produce the biosimilar will be different than the originator biologic and therefore the final product can never be called identical, but can be considered highly similar.

Health Canada requires testing in humans to ensure the biosimilar will be as effective and safe as the original biologic. We now have two biosimilars for the medication Remicade (infliximab): Inflectra and Renflexis.. There are also two biosimilars for the medication Enbrel (etanercept):Brenzys and Erelzi. There are many more on the horizon.

The cost of biosimilars is significantly less than the originator biologic and therefore many government and private insurance plans are requesting a biosimilar be used when a person is first starting this type of treatment. Many Canadians are currently using biosimilars with great success.

As a cost saving measure, there are now insurance plans requesting patients who are on a biologic and doing well, switch to the biosimilar (if one exists for the biologic they are taking). There are many studies that have been done assessing switching from the originator biologic to a biosimilar. In most trials, patients experienced no changes. There are however situations where the switch resulted in greater improvement in a person’s disease and others where the person’s condition worsened. As we gain more experience with biosimilars, it will be important to track each manufacturer’s biosimilar to monitor any changes in effectiveness and adverse effects. There are no studies regarding switching between different biosimilars.

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.