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.

Methotrexate is a medication used in low weekly doses in the treatment of many autoimmune conditions, from rheumatoid arthritis to psoriasis to inflammatory bowel disease.  One way methotrexate works is by decreasing the production of folate.  For this reason, folic acid supplementation is used to offset possible adverse effects.  If too much folic acid is taken, it could decrease the effectiveness of methotrexate and if not enough is taken, there is a greater chance of nausea, mouth ulcers and changes in liver function tests. The amount suggested ranges from 5 mg a week up to 5mg everyday except the day methotrexate is taken. 

If you are experiencing adverse effects from methotrexate and are taking a low dose, you may wish to speak to your specialist about the way you take folic acid.  Another option is to use the prescription medication folinic acid instead of folic acid.  It is the “activated” form of folic acid and is more costly.  As up to 20% of patients cannot process folic acid into the active form, folinic acid can be a good alternative.  In people who make this conversion, folinic acid doesn’t offer better protection against adverse effects but in others it could make a difference.  It is generally taken as 5mg once weekly.

Stay tuned for next week’s blog when more strategies for reducing potential fatigue from methotrexate will be discussed…

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.

Most  patients with inflammatory bowel disease (IBD) are familiar with certain blood and stool tests that can assess how active their bowel disease is. One such test is the fecal calprotectin test ( Fcal for short). Calprotectin is a protein found in the stool in high amounts when there is inflammation.   The Fcal levels are helpful to determine if there is active disease in the bowel; if they are low it means no active disease or high, means active disease. There is a ‘grey zone” in the middle between 100 and 250 mcg/g which is difficult to interpret.

A recent study looked at the benefit doing of doing a blood test called C Reactive Protein (CRP), which is a common blood test assessing body wide inflammation, in addition to the Fcal stool sample test.  When the Fcal test was in the “grey area,” this study showed that the CRP blood level does help predict active disease if it is greater than 5 mg/l and Fcal is between 100 and 250mcg/gm.

These simpler tests can avoid invasive procedures such as Colonoscopy in some IBD patients. Now you know why the combination of both stool and blood samples can be very helpful.

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.

People with autoimmune conditions such as Rheumatoid Arthritis and Lupus may also complain of dry eyes and mouth. This combination of symptoms is known as Sjogren’s (SHOW-grins) syndrome, which is also an immune system disorder. The glands in the mouth and eyes have a decreased production of tears and saliva which can cause significant distress.

Treatments focus on relieving symptoms as many of the disease modifying treatments used for other autoimmune diseases provide limited benefit. New guidelines for treating Sjogren’s have recently been announced by the American College of Rheumatology. Normal “tears” have three layers; each are produced by a different part of the eye. There is a water layer, oil layer and mucous layer. Eye drops that have a double or triple layer formula offer more comfort than less expensive drops which only mimic the watery layer. Eye ointments or gels can be used at bedtime. Prescription eye drops containing cyclosporine are the most effective.

Dry mouth products include specially formulated gums, lozenges, mouth washes, toothpaste, sprays and mouth patches. Our pharmacists are happy to offer suggestions. Additional information is available at The Sjogrens Society of Cananda.

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.

For people living psoriasis, consideration is often given to the fabrics that will cause the least skin irritation.  Cotton is most often recommended because it is considered the most breathable.  Silk is another possible choice as it tends to be soft and breathable. Generally it is best to avoid materials such as synthetic fabrics, wool, and linens. This is because many synthetic fabrics can cause heat retention and can stick to irritated areas and wool and linen fabrics tend to be itchy. For working out it is best to pick fabrics that wick away moisture. It is also best to avoid tight fitting clothing because rubbing the skin can cause increased irritation and the persistence of psoriasis over time. Lastly, when washing clothing, use dye-free, unscented laundry detergent.

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.

Project ECHO (Extension for Community Healthcare Outcomes) is a collaborative model of medical education that empowers all types of health care professionals to provide better care to more people in their own communities. Wait times to see specialists can be lengthy and those in remote communities may have challenges being able to travel long distances to these appointments. Project ECHO was first launched in New Mexico for better access to Hepatitis C treatments and recently came to Ontario, focusing on: Hepatitis C, pain, mental health. In January, ProjectECHO added rheumatology as a new speciality focus where family physicians, nurses, pharmacists, physiotherapists, occupational therapists, and chiropractors from over 20 sites across the province access a live video conference for a two-hour weekly session. A team of experts in rheumatology, called “the hub,” share their knowledge through a brief weekly lecture, followed by group discussion and problem solving of cases brought forward by the participating community members. It is a wonderful learning community.

Our pharmacist Carolyn Whiskin is the pharmacist expert on the Rheumatology “hub”. We encourage health professionals from across the province to join this wonderful government sponsored learning opportunity.

Fatigue can be caused by many factors from low levels of iron or vitamin B12 to low thyroid function.  However, feeling fatigued can be a complaint of people suffering with psoriasis and psoriatic arthritis in whom these levels are normal.   We can feel tired anytime our body is undergoing a stressor and chronic inflammation definitely places a burden on the body. At times of stress the adrenal glands produce cortisol.  After prolonged periods of stress, which may include poor sleep, pain, and inflammation, the ability to make cortisol can be reduced to a level below what is needed for healthy daytime function, leading to feelings of exhaustion.

In addition,  as psoriasis is a condition that can be visibly seen, and therefore carries a higher rate of depression than other chronic conditions. Depression also increases symptoms of fatigue. When well treated, all symptoms of psoriasis including possible fatigue are hoped to be improved. It is important to consult with your doctor or pharmacist as some of swallowed medication that is used to treat psoriasis may also be causing fatigue,  such as methotrexate.

There are plenty of ways that you can reduce tiredness. Exercise, a healthy diet,  7-8 hours of sleep and activities which reduce stress such as yoga and meditation, when done regularly, can help reduce fatigue.

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.

Moisturizing the skin is one of the hallmarks of psoriasis treatment. Choose a  moisturizer that is free from perfumes and is endorsed by the Canadian Dermatology Association. Multiple applications may be needed each day especially in cold dry weather.

The ideal time for applying a moisturizer is immediately after a bath or shower when the skin is just lightly patted with a towel but is still moist. This will allow the moisture to be trapped within the skin. It is important to note that although hot showers during the winter are relaxing, they can dry out your skin. When you shower you are not only washing away dirt, but also your bodies natural oils that keep your skin lubricated. Try to keep your showers to a maximum of 10 minutes long using lukewarm water to preserve your skin’s natural oils.

It may also be a good idea to have a humidifier in your house or where you work for when the weather gets cold and dry, especially during the winter months.

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.