Posts Tagged ‘Biologic’
In the last 24 hours some guidelines have been published by the Irish Society for Rheumatology (ISR) which offer advice additional advice (to the Stay at Home advice offered by the HSE) to patients on immunosuppressive therapies.
Because patients who are on treatments which suppress their immune systems are at higher risk than others, additional restrictions have been recommended to keep them safe.
Firstly, the guidelines help identify the medications which put patients at risk (see the blue box at the bottom of the graphic).
This list includes standard immunosuppressive therapies, biologic medications, and steroid medications.
High Risk Group
The guidelines also help identify those who are, because of their age, underlying medical problem(s), or steroid intake at especially high risk.
It recommends that those at especially high risk Cocoon.
Examples of those in the very high risk category would be those over 70 yrs, those taking regular steroids (prednisolone / deltacortril), those with underlying heart or lung problems, high blood pressure, recurrent infections, or those with diabetes.
Increased Risk Group
Those on immunosuppressive treatments who do not fall into the high risk group still need to be careful. They still need follow the HSE stay at home guidelines, can exercise outside, but two additional recommendations are made; that they limit social contact, and that they do avoid shopping.
It is Cocooning advice but with an allowance for exercise.
The Government have identified certain categories of workers who are deemed essential, many of whom are keen to stay at work despite the fact that they are immunosuppressed. This is very challenging. Many of those who are in this category who are under my care, have been calling because they are either keen to remain at work, or anxious to remain at home.
My feeling on this is that those who are immunosuppressed should not be in any work environment where they could be exposed to someone with Corona Virus infection.
As there are so many who could be infected, even without symptoms of Corona Virus, any contact is a potential source of infection.
Anything other than staying at home is going to increase their risk. Home working seems to be the obvious solution where practical for most.
This is going to be an increasing problem for those working in healthcare over the among months. I’m not sure I have a simple solution for this – but expect that if you are on any of immunosuppressive treatments on this list – and you inform your employer (and you should), it is likely you will be sent home.
Updated safety information
Over the coming weeks, we will begin to get a sense of the impact of Corona Virus infection for rheumatology patients from an international research project which aims to define the risk more clearly. Until we know more, I would err on the side of caution.
1. Ankylosing Spondylitis (AS) was first described by an Irish man
Kerry physician, Bernard Connor first described the condition in 1693 in a skeleton from a church graveyard. If you look carefully at the above illustration from that skeleton you can see how the spine is fused.
2. It takes an average of 8 years to diagnose it.
3. Blood tests can be normal
The blood tests which are traditionally used in the diagnosis of other forms of inflammatory arthritis, the ESR and CRP tests, are normal in up to 50% of patients.
The HLA B-27 genetic test can be positive in up to 90% of patients. Sound good? Unfortunately 8% of healthy adults (without AS) have a positive test as well. This means if you test 100 people with low back pain unrelated to AS, at least 8 of them would have a positive test. The test needs to be used carefully and interpreted in the light of other features of the disease.
4. MRI scans can miss it too.
Although MRI is probably the most reliable test for making a diagnosis, its important to scan the correct body part. An MRI of the sacroiliac joints (the joints where the spine jomeets the pelvis) is abnormal in 70% of patients with established AS. MRI of the rest of the spine scan can show signs of AS in the 25-30% of patients with AS who have normal MRI’s of their sacroiliac joints. The sensitivity of the test is improved where the scans are looked at by a radiologist who has an interest in arthritis related conditions.
5. Can cause chest pain
In addition to causing inflammation of the spine itself, AS can cause inflammation of lots of other structures e.g. the ribs and their attachments (aka ‘costochondritis’)
6. Can cause sore heels
In addition to causing spinal inflammation, AS causes ‘enthesitis’. Enthesitis is a form of inflammation of where ligaments and tendons attach to bone. It can cause inflammation at the attachment of the plantar fascia (a ligament in the sole of the foot) – plantar fasciitis. It can also cause inflammation of the achilles tendon – Achilles tendonitis.
7. Can cause sore eyes
AS can be associated with an acute inflammation of the eye (uveitis) in up to 25% of patients. This will typically cause an eye that is red AND painful and needs to be treated urgently. If you have AS and an acutely painful red eye, you should be assessed by an ophthalmologist.
8. It is very treatable
For some patients with years of chronic low back pain it can be a relief to get a diagnosis of a condition like AS which is very treatable. Until about 10 years ago, the treatment of AS revolved around anti-inflammatory medications and physiotherapy (this still sufficient for some patients). In the last few years the development of biologic therapies (Enbrel, Humira, Remicade, Simponi) has resulted in dramatic relief from the symptoms of Ankylosing spondylitis for many patients. There are subtle differences between the drugs (not every drug works for every patient) but as whole they tend to be very effective.