Whelehans Health Blog

Long term medication options for rheumatoid arthritis

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

This is the final of three articles on rheumatoid arthritis (RA). Disease modifying anti-rheumatic drugs (DMARDs) are core to treatment as they slow down or stop the progression of the condition and prevent joint deformities. They allow people enjoy a normal life. 

Disease-modifying antirheumatic drugs (DMARDs)

DMARDs help ease symptoms and slow the progression of RA. The earlier a DMARD is started, the more effective it is. They must be started by a consultant rheumatologist; therefore, it is important to seek treatment with a rheumatologist early if showing signs of RA.

The most commonly used DMARDs include methotrexate, hydroxychloroquine and sulfasalazine. Methotrexate is often the first choice DMARD for RA. It can be taken on its own or in combination with another DMARD. Side effects of methotrexate can be sickness, diarrhoea, mouth ulcers, hair loss or hair thinning, and rashes on the skin. Regular blood tests to monitor blood count and liver are required as methotrexate can cause serious liver and blood count problems. Most people tolerate methotrexate well and more than 50% of patients take it for at least five years.

Methotrexate improves symptoms by 50-80%, slows the rate of joint destruction and improves function and quality of life. Doses of methotrexate up to 20mg weekly may be needed. Injection form may be considered in severe acute RA, if oral treatment is ineffective or in those unable to tolerate oral methotrexate. It takes 6 to 12 weeks for methotrexate to start working. Methotrexate may be combined with biological treatments. It is very important to emphasise that methotrexate is a weekly dose.

Sulfasalazine has a slow onset of effect (1 - 3 months). Patients may need to discontinue long-term treatment of sulfasalazine due to gastrointestinal complaints.

Hydroxychloroquine takes several weeks to exert its effect. It has been reported to be less effective than the other DMARDs but is well-tolerated; therefore, it may be useful in mild disease or in combination therapy. It can cause eye damage so regular eye checks are needed.

Immunosuppressants

Azathiaprine (Imuran^®) and Ciclosporin (Neoral^®) tend to be reserved for severe RA, when other DMARDs are ineffective or inappropriate. They tend to be last line as they have potential serious side effects, mainly due to their suppression of the immune system. 

Biological treatments

Biological treatments are a newer form of treatment for RA. They include TNF-alpha inhibitors (etanercept , infliximab, adalimumab and certolizumab), rituximab and tocilizumab. Etanercept (Enbrel^®) and adalimumab (Humira^®) are most commonly prescribed biological treatments for RA in Ireland. In general, biological agents are reserved for patients with moderate to severe active RA where conventional DMARDs have failed. They are usually taken in combination with methotrexate or sometimes with another DMARD. They work by stopping particular chemicals in the blood from activating the immune system to attack the lining of joints. They are given by subcutaneous injection. Side effects from biological treatments are usually mild and include skin reactions at the site of injection, infections, nausea, fever and headaches.

Educate yourself about your condition

Whelehans Pharmacy, in conjunction with Arthritis Ireland (Westmeath Branch) host a Rheumatoid Arthritis Information event next week (Wednesday Oct 12^th at 6:45pm) in Greville Arms Hotel Mullingar. Admission is free.

Guest speaker for the evening is Consultant Rheumatologist from Midland Hospital Tullamore, Killian O’Rourke MD MSc FRCP FRCPI. Dr O’Rourke will give first-hand information on RA along with self-help tips including information about surgery and aftercare. He will take questions from attendees.

Chartered physiotherapist Kevin Conneely MISCP of HealthStep Physiotherapy Mullingar will discuss role of physiotherapy in Rheumatoid Arthritis (RA).  The final speaker is pharmacist Eamonn Brady MPSI who will discuss medication.

Treatment options for rheumatoid arthritis

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

This is the second of three articles on rheumatoid arthritis (RA). There are self-help activities to help your arthritis; for more information on these ask in Whelehans.

Surgery

A number of RA sufferers will develop irreversible joint or tendon damage. For these, surgery can provide a return of functional ability, a decrease in symptoms and pain, and avoid deformity and disability. Typically, surgical interventions involve joint replacement (commonly hip, knee, shoulder, elbow and hand joints).

Medication

Current guidelines recommend early diagnosis and early referral (within 3 months of symptom onset) to a rheumatologist for the introduction of disease modifying anti-rheumatic drugs (DMARDs).

Pain Control

Although DMARDs may be introduced at time of diagnosis, they have slow onset of action and can take weeks for an improvement. Most patients will require at least initial courses of analgesics or non-steroidal anti-inflammatory drugs (NSAIDs). The need for painkillers may be reduced once the DMARDs start to exert their effect after a few weeks.

Paracetamol

Paracetamol on its own is seldom sufficient to control acute pain in RA; however, there is evidence that regular dosing of paracetamol enhances the painkilling effects of NSAIDs in RA.

Opioid analgesics

Opioid analgesics such as tramadol may be used during acute attacks of RA, especially in elderly patients who may not be able to tolerate NSAIDs. Continuous / long-term use is not recommended due to risk of addiction and cognitive impairment (eg) Memory loss, confusion, constipation, respiratory depression.

Corticosteroids

Corticosteroids such a prednisolone (Deltacortil^®) are useful for managing of acute pain and have disease-modifying properties. Their efficacy diminishes over time. The preferred method of administration of corticosteroids is intra-articular injection (directly into the joint) (eg) Depo-Medrone^® injection. This produces rapid symptom relief and has fewer side effects than oral corticosteroids such as stomach irritation. However, effects of intra-articular steroid injections can wear off within a month so they are not a long term solution. Where there is multiple joints involved, local injection directly into the joints is not possible, so an intramuscular injection (e.g. 120mg methylprednisolone) may be given, while waiting for DMARDs to take effect. Long-term use of even low-dose corticosteroids may result in osteoporosis and other steroid-related side effects such as weight gain, thinning skin, easy bruising and high blood pressure.

NSAIDs

NSAIDs reduce swelling and stiffness in addition to providing pain relief. Side effects can include gastric irritation, kidney damage, fluid retention and skin reactions, as well as evidence linking selective COX-2 inhibitors (eg. Arcoxia^®, Celebrex^®) to increased risk of heart attack. Diclofenac should be avoided in those with health problems. Long-term use of NSAIDs is not recommended, especially in those with heart and stomach problems.

Educate yourself about your condition

Whelehans Pharmacy, in conjunction with Arthritis Ireland (Westmeath Branch) host a Rheumatoid Arthritis Information event on Wednesday Oct 12^th at 6:45pm in Greville Arms Hotel Mullingar. Admission is free.

Guest speaker for the evening is Consultant Rheumatologist from Midland Hospital Tullamore, Killian O’Rourke MD MSc FRCP FRCPI. Dr O’Rourke will give first-hand information on RA along with self-help tips including information about surgery and aftercare. He will take questions from attendees.

Chartered physiotherapist Kevin Conneely MISCP of HealthStep Physiotherapy Mullingar will discuss the role of physiotherapy in Rheumatoid Arthritis (RA), such as the benefits of manual therapy, the importance of a tailored and comprehensive exercise program.  The final speaker is pharmacist Eamonn Brady MPSI who will discuss medication.

To be continued….Next week

This article is shortened to fit within Newspaper space limits. More detailed information and leaflets is available in Whelehans

Eamonn Brady is a pharmacist and the owner of Whelehans Pharmacy, Pearse St, Mullingar. If you have any health questions e-mail them to info@whelehans.ie

Arthritis is a general term used for the condition; however there are over 100 types of arthritis. The two most common types of arthritis are osteoarthritis and rheumatoid arthritis. Rheumatoid Arthritis (RA) is one of the most debilitating forms of the condition.

Symptoms and Diagnosis

Stiffness, especially in the morning is a classic symptom of RA, this stiffness often reduces during the day (for osteoarthritis, the symptoms tend to get worse as the day goes on). The hands, wrists, feet, ankles and knees are affected in over 80% of cases.

It can be difficult to diagnose RA because many other conditions may make the joints painful. Symptoms are a good indicator of the condition. However X rays of joints and blood tests such as testing for the presence of a “rheumatoid factor” or an “anti-CCP antibody” can be more conclusive in diagnosing the condition.

Doctors consider if you have four are more of the following symptoms, you are likely to have RA:

1. Morning stiffness in affected joints lasting at least one hour
2. Soft tissue swelling of at least 3 joint areas
3. Swelling of finger, hand, or wrist joints
4. Symmetrical swelling (ie) equal both sides
5. Rheumatoid nodules (fleshy lumps that usually appear on hands, feet and elbows)
6. Presence of rheumatoid factor (rheumatoid factor is an auto-antibody which shows up in blood tests and it an indicator of arthritis)
7. Erosion of bone which shows up in X-rays, particularly in hand, wrist or feet joints

Other symptoms

Up to 30% of patients may present with non-arthritis type symptoms without obvious joint swelling such as malaise (general feeling of being unwell), weight loss and myalgia (muscle pain). Depression can be a feature of RA. RA is associated with increased rate of heart disease and there is evidence of increased mortality rate from heart related problems in RA patients.

Causes

The exact cause is unknown but there is a genetic link as RA tends to run in families. RA is three times more common in women than in men. It's common for the symptoms of RA to improve during pregnancy - this suggests that hormones and the immune system may be involved in triggering the condition. Obesity and smoking can be factors. The risk of developing rheumatoid arthritis being almost twice as high in smokers compared to non-smokers. For reasons unknown, RA onset is twice as common in winter than in other seasons.

Educate yourself about your condition

Whelehans Pharmacy, in conjunction with Arthritis Ireland (Westmeath Branch) are hosting a Rheumatoid Arthritis Information event on Wednesday Oct 12^th at 6:45pm in the Greville Arms Hotel in Mullingar. Admission is free.

The guest speaker for the evening will be an expert in this field, Consultant Rheumatologist from Midland Hospital Tullamore, Killian O’Rourke MD MSc FRCP FRCPI. Dr O’Rourke will give first hand information on the condition along with self-help tips including information about surgery and aftercare for those thinking of going down this line. He will take questions from attendees.

Chartered physiotherapist Kevin Conneely MISCP of HealthStep Physiotherapy Mullingar will discuss the role of physiotherapy in Rheumatoid Arthritis (RA), such as the benefits of manual therapy, the importance of a tailored and comprehensive exercise program.  The final speaker is pharmacist Eamonn Brady MPSI who will discuss medication.

To be continued….next week I will discuss treatment of RA.

With kids back at school, here are a few healthy tips to help kids and teenagers perform to their best ability this term.

Get enough sleep

Going to bed and getting up at the same time each day reduces stress and ensures a child’s mind is sharp. Having a regular sleep pattern can increase exam performance by up to 30%.

Avoid marathon study sessions

In the run up to exams, breaking the study day into sections will mean more efficient learning as it is harder to concentrate for long periods without a break. A study plan will help achieve this. It is important to allow time for sleep, exercise and fun. 

Fish Oils

Omega 3 stimulates serotonin in the brain which boosts mood and relieves stress. The fatty acid DHA (contained in omega 3 fish oils) has been shown in research to aid memory and concentration. Omega 3 fatty acids are primarily found in oily fish such as salmon, fresh tuna, mackerel, herring, sardines and pilchards. Everyone should eat two portions of fish per week, one of them oily. Irish children eat less than fish than their European cousins so supplementing on Omega 3 can be beneficial. MorEPA^® from Whelehans is the richest and purest source of Omega 3 EPA fish oil available. Each once daily 1,000 mg capsule contains 535 mg EPA (approx) and 87 mg of DHA (approx), pure essential Omega 3 fatty acids. The capsules are free from odour and any fishy taste due to the addition of natural lemon. MorEPA Mini^® is a strawberry flavour omega 3 supplement for children from age five upwards. It can be mixed with food and drinks such as yogurt and fruit juices. Recent research has shown that students who took MorEPA^® fish oils were able to perform better at mental tasks.

There is no conclusive evidence, but Omega-3 supplementation is thought to be beneficial in preventing Attention-deficit hyperactivity disorder (ADHD), a condition that affects 3-5% of children. Research is ongoing on this subject.

The Perfect lunchbox

Including more fruit and vegetables in children’s diet will improve growth, development and vitality and prevent a range of chronic diseases such as type 2 diabetes, heart disease, high blood pressure and cancer in later life. Research shows that the more fruit and veg are available and easily accessible for children, the more likely they are to eat them. Therefore if fruit is chopped up and ready to eat, children will eat more of them. There is evidence that children need to try new fruits and vegetables up to eight or nine times before they are liked or accepted.

Lunch

Many students experience fatigue or a dip in energy after lunch. High-protein lunches produce greater alertness and more focused attention, whereas lunches that are high in fat tend to lead to greater fatigue, sleepiness and distraction. Chicken, tuna, lean beef and eggs are examples of lunch options that are high in protein and low in fat.

Lunch box tips

Milk or water are best as drinks. Sugar free squash (one part squash to four parts water) is better than sugary minerals. Always opt for brown or wholegrain bread rather than white bread for sandwiches and rolls; they are higher in fibre and will keep your child fuller for longer. Cut sandwiches into fingers, squares or triangles for a bit of variety. For fillings, cucumber, tomatoes and apples are tasty. Relish can add flavour. Convenience snacks are high in fats, salts and sugar so should not be eaten on a regular basis. Include a piece of fruit every day. Vary the fruit everyday; examples include grapes, plums, peaches, bananas, orange segments, apple slices and kiwis (cut in half and eaten with a spoon). A good tip to prevent a sliced fruit going brown during the day is to sprinkle lemon over the sliced part. Try to include something from the dairy group every day which could include milk, yogurt or cheese. For variety, try cheese slices, cubes, triangles or grated cheese. Encourage your child to help you make their lunch or even to make their own lunch. Children are more inclined to eat it if they had a part in making it.

Just the Tonic!

Supplements should not be considered an alternative to a healthy diet. However, Whelehans Children’s Tonic is a good option for those kids who won’t eat enough fruit and veg. It contains iron and all the B vitamins which may be lacking in kids not fond of fruit and veg. Iron can relieve fatigue and improve concentration. B vitamins help with mental function and aid memory, growth and development, remove toxins and break down the proteins, carbohydrates and fats consumed to release energy.

Health Services for children

Whelehans Pharmacy has many health services for children as well as adults. Whelehans has an in store chiropodist every Tuesday and Thursday. Common conditions he treats for children include warts and verrucas, athlete’s foot and ingrown toenails. He has a reduced rate of €25 for adults over 60 on Tuesdays. Our food intolerance test is aimed at children and adults. We can check for food intolerance to 59 of the most common causes of food intolerance. Food intolerance can be a cause or exacerbating factor for many childhood conditions including asthma, ADHD, bed wetting, eczema and sleep disturbance. Many children, especially those who are fussy eaters can be low in iron. Low iron can cause lethargy and can lead to poor concentration and school performance in children. We can check your child’s iron levels with our 2 minute haemoglobin check. You don’t need to book an appointment and it costs €5.

Call us at 04493 34591 to book any of our clinics.

For comprehensive and free health advice and information call in to Whelehans, log on to www.whelehans.ie or dial 04493 34591. You can also e-mail queries to info@whelehans.ie