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.

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.