As we have written previously, it is not clear whether Covid 19 creates additional risk for the biologic medications our patients take for inflammatory diseases. Most rheumatologists are not telling their patients to stop their medicines unless they have an infection. This advice has been given for many years. One unexpected medicine we especially want patients to continue if they are already on it is Plaquenil, (hydroxychloroquine). This drug, used for lupus, Sjogrens and rheumatoid arthritis, is a cousin of chloroquine. Chloroquine in studies done in China ( for whatever that may be worth) may be beneficial in treating Covid 19. There is not enough data to tell people to take Plaquenil for Covid 19, but if you are on it, talk to us before considering stopping it.
To accommodate our patients, Main Line Rheumatology has increased its hours to better serve you!
LANKENAU MEDICAL CENTER
Monday 9am – 5:30pm
Tuesday and Wednesday 8am- 4pm
Thursday 9am – 4pm
Friday 8am- 4pm
MAIN LINE HEALTH CENTER, Broomall
Tuesday, Wednesday and Friday 9am – 4pm
Systemic Lupus Erythematosus (SLE) or Lupus can be associated with gestational hypertension (maternal high blood pressure), preterm birth, intrauterine growth restriction and fetal death. Lupus patients may have abnormal placentation (attachment), which is a major contributor of many pregnancy complications due to reduction in maternal blood flow to the fetus. Despite potential risks, women with SLE can have healthy pregnancies. Women with SLE should have low disease activity for the 6 months prior to conception for the best chance of a successful, healthy pregnancy. The PROMISSE Study was a large multicenter prospective study of pregnant and postpartum SLE patients. The study showed that 26 % of patients had a flare (worsening) during pregnancy, and 24.4% had a flare in the postpartum period. Most of the flares were mild and infrequently required therapy. Only 6.3% of the patients had severe flares during pregnancy and 1.7% had severe postpartum flares.
Data suggests that the drug, Plaquenil, used during pregnancy was associated with fewer preterm births and less intrauterine growth restriction. Findings also suggest that discontinuation of Plaquenil is associated with higher lupus disease activity during pregnancy.
For SLE patients not looking to conceive, IUDs are considered safe and effective. Other acceptable contraceptive options, when used appropriately, include condoms, progestin (only oral contraceptives) or depo-provera injections. Estrogen-containing contraceptives are contraindicated in the setting of active lupus, as they may flare the disease.
Main Line Rheumatology’s Amy L. Lundholm, DO, is board certified in both rheumatology and internal medicine. Dr. Lundholm holds current membership in the Pennsylvania Osteopathic Medical Association and the American College of Rheumatology. She was chosen as a rheumatology Top Doctor 2018 Main Line Today magazine. To read more about Dr. Lundholm, go to Our Staff.
The doctors and staff at Main Line Rheumatology (MLR) are coming to the aid of government and furloughed workers who are practice patients currently experiencing a financial strain during the government shutdown. MLR will offer relief from current office co-payments, which can be received from patients at a later date after the government reopens. MLR has office locations at Lankenau Medical Center in Wynnewood, and Main Line Health Center in Broomall. CALL NOW 610-896-8400 for an appointment, and visit mainlinerheumatology.com
This could be a wake-up call to action!
Glucocorticoids or steroid medications taken for many medical conditions to help you feel better, can end up creating a serious bone fracture and disease problem for many adults. The question to ask yourself, and your family doctor or rheumatologist is, “Am I exchanging one problem for another?”
What are glucocorticoids, and why does my doctor prescribe them, if they lead to bone fractures and osteoporosis? Your body has naturally-occurring glucocorticoids, or steroid hormones, that have many important functions. They help to interrupt or suppress inflammation, help your body respond to stress, and regulate how your body uses fat and sugar.
Many health problems involve inflammation, and if your body’s natural glucocorticoids are not performing well, drug assistance may be indicated. Glucocorticoid drugs are man-made, or synthetic versions of natural glucocorticoids, and can help suppress inflammation from autoimmune reactions, reducing pain, swelling, cramping, and itching. They are prescribed to treat autoimmune diseases like arthritis, rheumatoid arthritis or lupus; skin conditions like psoriasis or eczema; allergic reactions; breathing disorders like COPD and asthma; inflammatory bowel disease like Crohn’s or ulcerative colitis; various cancers, multiple sclerosis; surgery recovery, or sepsis. These drugs are effective in stopping damaging inflammation, but are more potent than the naturally occurring steroids and can cause serious damage.
According to the January 2, 2019 New England Journal of Medicine (NEJM), approximately 1% of all adults and 3% of adults older than 50 years of age receive glucocorticoids for allergies, inflammatory conditions, or cancer. Long-term use of glucocorticoids is associated with clinically significant toxic effects. Fracture, followed by diabetes, is the most common serious and preventable adverse event associated with these agents. The risk of fracture increases with age and with the dose and duration of glucocorticoid use. Here are the facts.
Vertebral fractures are the most common fractures associated with glucocorticoids; the risk of vertebral fracture increases within 3 months after initiation of treatment and peaks at 12 months. The relative risk of clinically diagnosed vertebral fracture doubles and the risk of hip fracture increases by approximately 50% among patients who receive 2.5 to 7.5 mg of prednisolone daily. In a study with a follow-up of 6 months to 10 years, glucocorticoids taken at very high doses significantly increased the risk of vertebral fractures.
Glucocorticoids have direct and indirect effects on bone remodeling. Bone loss can lead to an early increased risk of fracture and osteoporosis. Bone formation also decreases early in glucocorticoid treatment. Indirect glucocorticoid effects predispose patients to reduced muscle mass leading to an increased risk of falls, decreases in renal calcium resorption and levels of sex hormones, and alterations in parathyroid hormone functioning.
The risk of fracture rapidly decreases when glucocorticoids are discontinued. A prospective study showed clinically significant improvement in bone mineral density at the lumbar spine within 6 months after discontinuation of glucocorticoids. A large retrospective study showed an increased risk of a major osteoporotic fracture among patients with recent prolonged glucocorticoid use but not among those with intermittent or past use of these drugs.
What you need to know from this NEJM Report
- Risk factors for glucocorticoid-induced fractures include age (>55 years), female sex, white race, and long-term use of prednisone at a dose of more than 7.5 mg per day.
- Screening for fracture risk should be performed soon after the initiation of glucocorticoid treatment. The risk of fracture among patients who are 40 years of age or older can be estimated with the use of bone mineral density testing and the fracture risk assessment tool (FRAX).
- Patients who receive glucocorticoids should be counseled about adequate intake of calcium and vitamin D, weight-bearing exercise, and avoidance of smoking and excessive alcohol intake.
- Pharmacologic treatment is strongly recommended for anyone who has had a fracture and for patients who are at least 40 years of age if, according to the FRAX tool, the risk of major osteoporotic fracture is 20% or higher or the risk of hip fracture is at least 3%. Among patients who are receiving glucocorticoids and have a bone mineral density T score of −2.5 or less (indicating osteoporosis) at either the spine or the femoral neck, pharmacologic treatment is also recommended for men who are 50 years of age or older and for postmenopausal women.
- Bisphosphonates (i.e. Fosamax, Actonel) are recommended as first-line treatment of osteoporosis because of their low cost and safety.
- The risk of fracture decreases rapidly when glucocorticoids are discontinued. Exposure to glucocorticoids should be minimized as much as possible.
Non-drug options that can help (with or without taking glucocorticoids) bone loss, osteoporosis and fractures
- Weight-bearing exercise, maintenance of normal weight, smoking cessation, limitation of alcohol consumption, and the assessment and management of fall risks.
- Calcium and Vitamin D: Adequate dietary intake of 1,000 mg calcium per day and 600-800 IU of vitamin D (600 to 800 IU) is routinely encouraged in patients who receive glucocorticoids.
- Bisphosphonates increase bone mineral density, help strengthen bone preventing further weakness, and slow down further bone loss.
Be an informed consumer! Talk to your doctor about glucocorticoid drugs that include beclomethasone, betamethasone, budesonide, cortisone, dexamethasone, hydrocortisone, methylprednisolone, prednisolone, prednisone and triamcinolone.
Make every effort to reduce your chance of disabling osteoporosis, fractures and bone loss. Discuss all medication and potential side effects with your primary care doctor, rheumatologist, and/or endocrinologist and together, make the best choices for your overall health and well-being.
“Doc, I’m having trouble at home. You know…?” Not a great conversation starter in an office visit with a rheumatologist, but common to hear from patients suffering arthritis.
According to health.clevelandclinic.org, patients with various forms of arthritis talk about how it affects their feelings of sexuality and their sex lives. Close intimate, sexual relationships are part of a healthy, quality of life. Working on achieving that might take a little extra work, but the benefits are worth it!
Arthritis sufferers say the following issues affect the quality of their sexual identity and sex lives: pain, exhaustion, fatigue or decreased endurance, loss of self-esteem and feelings of sexual attractiveness, decreased sexual desire and satisfaction, difficulty with sexual arousal, decreased sensation, erectile dysfunction or impotence, vaginal dryness, extreme sensitivity to touch, limitation of movement/flexibility, effects of surgery, depression, and side effects from medication.
Inflammatory arthritis is a group of diseases characterized by inflammation of the joints and tissues, and include rheumatoid arthritis, psoriatic arthritis, lupus and ankylosing spondylitis.
How do these conditions affect sex and relationships? Inflammatory arthritis can cause joints to be tender or painful, and when it hurts to move, sex feels like the last thing on your mind or agenda. Swollen or misshapen joints or weight gain can make you feel older, and less attractive and confident. Offshoot immune disorders like Sjögren’s syndrome, can decrease women’s lubrication. Often men’s’ penile blood vessels are affected, causing arousal and erectile dysfunction. So, who wouldn’t be depressed from all of this, which can then further exacerbate the problems?
There’s hope. We’re bringing sexy back.
Having sex can help your pain and your brain! Pleasurable touching and sex releases those blessed endorphins that bathe your brain in happy feelings, and holistically lubricate parts of your body. We’re not kidding!
There is no sex czar to make arthritis complications disappear, nor one magic bullet. But here are some RECOMMENDATIONS AND OPTIONS that can help.
- Boost open and honest communication; allow yourself to be more vulnerable about fears, sexual needs, desires and difficulties
- Accept change; we’re all in process at every age!
- Plan ahead: Take medication or muscle relaxants beforehand, nap with a heating pad, take a warm shower or relaxing hot bath, use an electric blanket to relieve joint stiffness and add more pillows
- Connect: Hug, kiss, cuddle, massage
- Be spontaneous; there are more times than bedtime when you are naturally more tired
- For improved intimacy – more kissing, and experiment with new positions, oral or manual stimulation, visuals, lubricants and sex aid devices
- Make sure to stay active with exercise to increase stamina, strengthen muscles and improve range of motion
- Recognize and address any depression and sadness; seek professional help
- Following joint replacement surgery, discuss recovery and safe positions for sexual activity, with your doctor
Sex and all forms of arthritis can coexist. It’s the journey and destination to achieve satisfaction, happiness and peace in your life, so GO FOR IT!