Friday April 10 News & Updates

Arthritis Health - Friday 20 Mar 2020 News & Updates

We are one month into social distancing, E-Visits, toilet paper shortages and a pandemic that has altered all of our lives. We are grateful for the kind comments concerning how our recent newsletters have provided helpful and current information concerning the CoVID-19 pandemic.

This most current newsletter (April 10th) will review a new post on the immune effects of CoVID-19 and three topics that have been discussed in previous editions of the Arthritis Health newsletter. We hope it will answer some questions that have been raised over the past few weeks from prior editions.

There is a new terrific video on hand washing – not just how to do it but why it works from a chemical and physics perspective, a posting by Dr. Howard on the overactive immune response to CoVID-19 infections, an addendum from an article on being immunosuppressed (March 29th issue), and some clarifying points concerning the article on methotrexate (April 6th issue).

All prior newsletters are stored on the Arthritis Health Web site – for reference.

We remain open. Follow up appointments are electronic. We prefer you have some established form of visual communication such as FACETIME, GOOGLE DUO, SKYPE, or the last resort ZOOM. They are preferred in that order due to security. Please try to have one of these established prior to any follow up visit.

New patient and any patient needing a physical service such as an injection of a joint or bursa, infusions or shot for their arthritis or osteoporosis will be seen in the office. We are screening all people (including ourselves) entering the office with a questionnaire and screening temperature.

Of course, we are available for questions on the Portal (preferred) or by phone.


Please watch this video – it is terrific and shows and says it all. If you want to read more detailed information, read on after watching the video. We have provided additional detailed written instructions and information to supplement the video

Hand washing Video – a must to see!

Proper Hand washing

The action of soap takes time and friction, hence recommendations to wash your hands for a duration of twenty seconds (the duration of singing happy birthday twice). This allows the soap to do the work in emulsifying the virus’ outer fatty membrane and increasing the probability you cover the most surface area on your hands.

Follow these four steps every time:

  • Wet your hands with clean, ideally warm, running water
  • Lather your hands (for 20 seconds)
    • Starting with your palms
    • Then the backs of your hands
    • Then between your fingers
    • Finally, under your nails
  • Rinse your hands
  • Dry your hands using a clean towel

If you’re at home, hopefully you are sanitizing your faucets, sink knobs and anywhere else hands interface once to twice a day.

When you are out at a public restroom, dry your hands with a paper towel and use that paper towel to turn off the faucet. If there is a door that you have to pull open, use the same paper towel to use the door handle.

If you are more a visual or auditory learner, we have attached a great learning video below helping to better understand the importance of washing your hands.

How Hand washing defends you from viruses

Most viruses, including CoVID-19 are non-living entities that consist of an outer fatty membrane which holds together anchors used to attach to a host’s cells. That same fatty membrane houses genetic material the virus injects into the host cell, converting said cell into a factory that creates more virus.

Soap and water eradicate viruses much in the same way soap eradicates grease on your dirty dishes from the lasagna you made recently. Imagine trying to wash your dishes without soap. It doesn’t work very well, right? The soap emulsifies or tears apart large chains of fatty molecules, making smaller molecules that can be easily washed away.

So too is it with the virus. Soap and ideally warm water tear the fatty membrane of the virus apart into its individual constituents. This renders the virus unable to cause infection, to be washed off of your hands and down the drain.


Cytokine Storm – The Real Damage Caused by COVID-19

Three weeks ago, at the onset of the pandemic in the United States, I received an amazing letter from an ICU physician from New Orleans.  Through his astute observational skills, described the progression of CoVID-19 viral infection in detail.  In the small percentage of people who have more serious illness, he outlined a progression of illness that occurs on day 9-12.  He called it a “cytokine storm”. This appears to be the reason for severe damage from this virus.

This disease is different.   The severe illness caused by most flu like viral illnesses is caused by a secondary infection, often bacterial that comes on after the initial viral infection weakens the infected persons immune system. CoVID-19 infects a person and in the second week of illness, an immunologic hurricane, I call it a cytokine storm, occurs.  This is an overactive response to the virus, releasing an uncontrolled outpouring inflammatory proteins (called cytokines) produced by a number of immune cells such as the white blood cell. This is not an under-active immune response but rather an overactive, uncontrolled response the leads to damage to blood vessels and tissue throughout the body, especially the lungs and an extreme and excessive leakage of fluid into many key organs.  Lungs cannot deliver oxygen to the body, liver does not detoxify the blood, and kidneys do not produce urine or clean the blood.

The scary part of the story is that the cytokine storm is unpredictable.  It can occur in the old and young, the compromised and the healthy.  Your genetic fingerprint determines your immune system’s response to the CoVID-19 immunologic challenge.  We are not able to predict the few who will have it.  Very much like we cannot predict who will develop rheumatoid arthritis, reactive arthritis or lupus.  We know that a persons’ genetic propensity to respond to immunologic challenges is a risk for developing autoimmune diseases but we are not there yet scientifically able to accurately predict who will get these disease.

The promising news:  Some of the very biologic medications used to treat autoimmune diseases are now being investigated to thwart and limit the cytokine storm caused by CoVID-19.  These life saving drugs used in rheumatoid arthritis, psoriatic arthritis, and vasculitis may be indeed the very key to halt the CoVID-19’s severe damage.

As I was writing this post yesterday, the Wall Street Journal came out with an article on line and printed in the paper today on this topic.  You may wish to read more.  Through all this, we are learning so much – about the immune system, public health measures to control the pandemic and how we adapt to living in an upside-down world.

Wall Street Journal Article  – Haywire Immune System   April 10, 2020


Definition of Immunosuppression: 

It is an immunologic state of your body that does not have the ability to respond normally to an infection due to an impaired or weakened immune system. This inability to fight infection can be caused by a number of conditions including illness and disease (such as diabetes, HIV, autoimmune disorders, chronic lung, heart, liver or kidney conditions), malnutrition, cancer, ageing and drugs.

Is all immunosuppression the same?

No – there are different forms and degrees of immunosuppression.   Lack of an immune system often caused by high dose chemotherapy or active blood cancers profoundly inhibit the body’s ability to fight off an infection. Autoimmune diseases are less immunosuppressive, as are biologic and conventional immunosuppressive drugs used to treat autoimmune diseases. Having active uncontrolled autoimmune disease is lessening the ability to fight off an infection.

We try to balance the good effects of controlling autoimmune diseases with minimizing the risks of treatment. The bottom line is this:

  • Keep you autoimmune disease under control – medications, diet, supplements, healthy lifestyle – it all counts.
  • Do not stop your current medication unless you contract an infection. If infected, hold your autoimmune medications until the infection resolved.

How immunosuppressed am I on my arthritis medications?

Mild to moderate and not all infectious agents are the same.   Bacterial infections are clearly more risky, viral infections are probably more at low to moderate risk. How I (PFH) read the literature, secondary infections following a viral infection are not the issue with CoVID-19 – it is the actual destructive nature of the virus itself.  Therefore, immunosuppressive medications for arthritis may not increase the risk of serious consequences from Covid-19.

Should I act any differently if I have an autoimmune disease or if I am on immunosuppressive medications?

Absolutely not. Everyone should be highly vigilant – adhering to social distancing, good hygiene practices and living a clean health lifestyle. It makes not difference.  We all need to assume we are immunosuppressed or at risk.

Methotrexate: is it safe?

We presented an article on the side effects of methotrexate from the largest safety placebo controlled study recently published in the Annals of Internal Medicine.

We would like to summarize some key take home messages.

1. Why present an article on methotrexate now?

Because low dose methotrexate is the most common immunosuppressive medication used for autoimmune diseases.

2. What are the take home messages from this article (data presented in the previous newsletter)?

Side effects, both innocuous and serious are uncommon but we need to be vigilant to void and detect them to minimize the low risk of a damaging problem. Lab monitoring and scheduled follow up visits are critical to ensure safely.

Stay tuned for next Friday’s update. Be safe and be kind.

Your Staff at Arthritis Health

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