This Monday July 24th is International Self-Care Day.  This annual day was established in 2011 by the International Self-Care Foundation to encourage people to be aware of the daily choices they make in promoting a healthy lifestyle.  When you choose to wear a bike helmet, go for a walk instead of sitting on the couch, apply sunscreen before going outside or to take your medication as recommended, these are all actions that exhibit self-care.

The seven pillars of self-care are:

• heath literacy
• self-awareness
• physical activity
• healthy eating
• risk avoidance
• good hygiene
• optimal use of products and services

At Charlton Health we strongly promote self-care and encourage you to ask questions about your medical condition and treatment.  We are happy to offer strategies to assist you in reaching your own health goals.  For more information on the International Self-Care Day, visit their website here.

As a pharmacist specializing in both arthritis and menopause, I am often asked about changes in libido with aging and if arthritis can affect this.  There is a natural lowering of libido with age as blood flow to the genital area decreases and hormone levels decline. This is true for both men and women.  As estrogen levels fall after menopause, there can be significant dryness and decreased blood flow which can affect drive and comfort associated with intimacy.  To make this worse, people with arthritis who may have pain and stiffness can have difficulty finding a comfortable position.

The Arthritis Society has published a series of booklets on lifestyle and one is entitled, “Intimacy and Arthritis”.  This can also be found on their website: www.arthritis.ca. Don’t hesitate to discuss options, including hormone therapy with your health care provider as there are many helpful strategies.

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 is a list of DON’TS….. key questions developed by Dr Geoffrey Nguyen, a Gastroenteritis at Mount Sinai in Toronto and Choosing Wisely Canada, a national healthcare campaign. A specialized group of physicians and patients worked on these questions.

1. Don’t use steroids such as prednisone (whose brand names include Deltasone and other labels) for maintenance therapy in IBD.
2. Don’t use opioid-based therapies for long term management of IBD abdominal pain.
3. Don’t continue giving intravenous corticosteroids to patients with severe ulcerative colitis who fail to respond to the treatment.
4. Don’t start or ramp up longterm medical therapies for IBD on the basis of symptoms only.
5. Don’t use abdominal computed tomography (CT) scans to evaluate acute IBD unless there is a suspected complication, such as a bowel obstruction, perforation, or abscess.

One definition of adherence is: attachment or commitment to a person, cause, or belief. When talking about medication, adherence refers to how closely a patient follows the treatment plan that was agreed upon between physician and patient. At the pharmacy level, this is often measured by looking at the interval between medication refills, with the pharmacist checking to see that these are reasonable.

There are many barriers to medication adherence, some of which may include complex treatment schedules, cost, social and cultural challenges, as well as the way our healthcare system is set up. For patients on long term therapies, non-adherence may be due to a loss of response to drug over time, a difficult to manage side effect, or frustration with the chronic nature of their disease.

For patients with chronic diseases, the rate of adherence to treatment tends to be anywhere from 50-75%.

When patients are not adherent to taking their medication, the effect is far-reaching. The non-adherent RA patient tends to end up with more prescriptions for prednisone or NSAIDs (like ibuprofen, naproxen, etc). They tend to make more visits to the emergency room, and have a higher hospitalization rate. They require more home care and rehabilitation services. In addition, the non-adherent patient creates more drug waste.

Please let us know if you are having trouble being adherent to your medication schedule. It is very likely that we can help manage a difficult side effect, manage insurance coverage concerns, simplify a challenging treatment schedule, or clarify your understanding of the benefits of treatment. We understand that a chronic condition can be a tremendous burden and want to help you gain success and confidence by improving adherence to treatment.

For most people, regular exercise will improve your overall health. Patients with IBD are no exception and may see additional benefits outside their GI system.

Ankylosing Spondylitis, an inflammatory arthritis, has been associated with IBD and can be improved with exercise. Symptoms typically appear in early adulthood and include reduced flexibility in the spine, which can eventually result in a hunched-forward posture. Pain in the back and joints is also common. Exercise therapy will improve spinal column flexibility and strength, and decrease joint pain.

Patients with Crohn’s Disease and Ulcerative Colitis should enjoy a regular exercise regimen to obtain and maintain bone density. Differences have been found in both the spine and hip on x-ray when patients consistently exercising. Patients should aim to exercise at least three times per week.

Small changes can make a big difference – think about taking regular walks. If you need to be close to a washroom, try heading to the mall and walk. Use small free weights, climb stairs or dance! Do what is most enjoyable to you!

Evelyn Gilkinson is the Nurse Lead for Charlton Health Inc. Before devoting herself solely to Infusing Biologics, Gilkinson worked at Toronto General Hospital, Flinders Medical Centre (Adelaide, Australia), and the London Health Science Centre in Thoracic Step Down, neonate, pediatric and adult Intensive Care, Recovery Room, and Emergency Medicine. Evelyn has done research for The Canadian Cervical Spine Study and with the AIM Health Group. She established the first out-of Hospital Infusion Centres in London and Waterloo. For the last twelve years, Evelyn was the Nurse Supervisor for South Western Ontario for many infusion sites until joining the Charlton team in the summer of 2016.

In recent years, there has been an increase in Clostridium Difficile (commonly known as C. Diff) which is a bacteria causing debilitating diarrhea.  C. Diff has various strains  which are often resistant to antibiotics,  which makes the infection difficult to treat. Surprisingly, C. Diff is often caused by over use of antibiotics.  Antibiotics disrupt the normal bacteria flora in the gut referred to as the gut biome. As a result of changing the healthy bacteria, the processing of carbohydrates ( fruits, vegetables, pastas and all grains) also changes which affects the body’s ability to absorb water from the bowel contents.  This causes a person’s stool to be more liquefied.

One potential solution to combatting the increase in C. Diff is the use of probiotics. The claim is they decrease or prevent diarrhea by maintaining the flora in the gut and allow for ongoing carbohydrate fermentation and/or  competitively slowing down the growth of C Diff bacteria. Though animals studies found the use of probiotics for C. Diff inconclusive, probiotics are still marketed to humans to treat C. Diff and autoimmune diseases. With this in mind, it is important to stay tuned to ongoing studies that may give us a clearer picture regarding the effectiveness of probiotics for C. Diff.

Another option for battling C. Diff is fecal transplant, where a healthy patient donates their stool which is then processed into an enema to be administered to the person suffering with C Diff. Fecal transplantation has been around for decades, as it was first performed on humans in 1958.  Patients become candidates for fecal transplant after three reoccurrences of the infection. On average, 91-93% of cases are cured with fecal transplant. After fecal transplants, the antibiotic Vancomycin is again able to keep C. Diff in check without affecting the microflora of the gut. Of course, there are risks associated with fecal transplants, but many health practitioners believe that the benefit of the procedure outweigh the risks.

For more information, speak to your healthcare provider.

In some of our recent blogs we discussed ways to manage adverse effects of methotrexate.  One strategy to reduce potential nausea and increase the absorption of methotrexate is to give it by injection rather than swallowed tablets.

The most common form of methotrexate injection is supplied in vials, requiring the dose to be drawn into a syringe before injection.  This can be challenging for patients with arthritic hands.  A pre-filled syringe became available which made giving the injection easier, however the volume of liquid needed to achieve the same dose of methotrexate  was 2.5 times greater than the volume needed if using the vial, meaning that patients were injecting quite a bit of liquid into their bodies when it was not entirely necessary. Now, we have a new pre-filled syringe which is very concentrated and only half the volume of the standard vials is needed to achieve the same dose. For example, in the new syringe, 25mg of medication is contained in 0.5ml whereas in the vial, 25 mg of medication is contained in 1.0ml.

Private insurance plans are paying for this new syringe and our hope is that the government based plans will add this to their list of benefits soon.  If you are currently injecting methotrexate or interested in switching from tablets, ask your healthcare practitioner about the new pre-filled syringe option.

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.

I have touched on additives in food that may be impacting your health in the past and this week I will be elaborating on the topic.

There are many different products that companies may add to food in order to modify the quality of the food, such as the texture, shelf life, or colour. Carboxymethylcellulose and polysorbate-80 are two of these such products – they keep fats and oils from separating and improve texture and shelf life of salad dressings, non-dairy milk, veggie burgers, and hamburger patties. Similar emulsifiers include lecithin, carrageenan, polyglycerols and xanthum gum.

While these additives may seem to improve the quality of our food, these emulsifiers can have some negative effects as well. In testing, these emulsifiers caused chronic colitis in mice with already abnormal immune systems. In mice with healthy immune systems, they showed mild intestinal inflammation and metabolic dysfunction that led to obesity, high blood pressure and insulin resistance.

With all of this in mind, it is important to remember to read your labels and avoid these emulsifiers where possible.

In our last two blogs we discussed the importance of folic acid supplementation while on methotrexate,  and the use of dextromethorphan (DM) to reduce the potential “sick day” phenomenon which some people experience the day after taking methotrexate.  In this blog,  I am addressing strategies to avoid nausea that is associated with methotrexate use in some patients.  Of great importance is the use of folic acid as was mentioned earlier.

In addition, methotrexate can be given as a weekly injectable dose instead of swallowed tablets.  This avoids contact with the stomach and reduces nausea.  The injectable is available in three ways.  1. A vial where patients draw up their dose in a syringe,  2. a pre-filled syringe,  3. an auto-injector device (newly available in Canada).  Currently only the first option is a benefit under government based insurance where the other options may be a benefit under private insurance.  The injectable also provides excellent absorption and may be a more effective treatment than the tablets which aren’t as efficiently absorbed.

For patients using tablets, splitting the dose over the day the methotrexate is taken will reduce stomach upset and allow for better absorption.  The maximum number of tablets that can be absorbed at any time is 6.  Doses higher than this need to be split over the day, even if there is no nausea (ie. if you take 8 tablets weekly; swallow 4 after breakfast and 4 tablets after your evening meal on the same day).

It is important to note that many patients using methotrexate experience no adverse effects.

In our last blog, we looked at the role of folic acid and its importance when taking methotrexate. Even though folic acid reduces the adverse effects of methotrexate and is needed, it may fall short in managing the fatigue (or what some call their ‘sick day’) the day following their dose. Methotrexate is known to inadvertently stimulate a part of the brain referred to as the NMDA receptor. Dextromethorphan blocks this receptor and therefore can reduce the tiredness and foggy thinking that some people complain of after taking methotrexate.

An easy way to get the benefits of dextromethorphan, and combat this foggy thinking and fatigue is through taking DM Cough Syrup, which is readily available and can be purchased over the counter at any pharmacy. The suggested dose is two teaspoons twice daily the day before, day of, and day after taking methotrexate. While this tip is not commonly known, it was shared at past Ontario Rheumatology Association Conference by Dr. Jack Cush, a well respected American rheumatologist who uses this approach regularly.

Stay tuned to next week’s blog on options for methotrexate dosing…

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.