This newsletter has three important articles – all affect you directly. The first is our plan to return to a more normal practice of seeing patients in the office. This transition will occur over the next few weeks and we want you to feel secure in our safety measures and precautions.
The second is about Vitamin D, an important vitamin both for bone and immune health.
Lastly, we have a set of recommendations on what to do with your rheumatic medications during the CoVid-19 pandemic.
We hope you had a great Memorial Day weekend.
Memorial Day is a time to honor those who have died while serving in the US Military. We thank or veterans for their bravery, sacrifices and efforts to protect our way of life.
Purchase materials to make the sanitizer from the links below:
TO OUR VALUED PATIENTS
We hope this finds you well, safe and looking forward to resuming a more normal lifestyle as we begin to reopen to full services. We will continue to provide our office as an safe place to receive care medical care. We will be expanding our direct in person services in our office and want to explain what we are doing and ask for your cooperation to protect yourselves and your fellow patients.
We have remained open throughout the entire CoVid-19 sheltering in place. We have kept the traffic in the office to a minimum providing essential care to patients needing infusions and injections for their arthritis or osteoporosis, evaluation of new patients and some urgent joint and tissue aspirations.
We are happy to announce that our office will be gradually opening up for face to face follow-up visits over the next two weeks. We encourage you to be seen directly by us for your continued care visits. E-Visits have their place but there is nothing that fully replaces the direct eye on and touch for the best medical care.
We will continue to offer E –Visits through a functioning video platform such as FACETIME, GOOGLE DUO, ZOOM, or SKYPE.
Scheduling your appointment:
- You can choose to have a face to face visit or an E- Visit.
- For face to face visits, appointments will be available and will allow for social distancing and appropriate time for room cleaning and disinfection.
- Screening questions will be asked when you schedule and when you arrive. If you have a fever and/or signs and symptoms of COVID-19, your appointment will be rescheduled. Any temperature greater than 100 will result in your appointment being rescheduled.
Arriving for your appointment:
- Arrive at least 10 minutes early for your appointment to permit needed screening
- If you need or want to be accompanied by someone during the visit, please have only one person attend with you during your appointment. We will permit only one additional person to accompany you during your visit.
- Please bring your own mask and wear it in the office at all times. You will not be seen without a mask.
- If your room is ready when you arrive, we will escort you to your room. Because we are limiting the number of people in the waiting room, you may be asked to return to your car and wait for our phone call to return to the office. We do not expect any waits of long duration.
During your appointment:
- Our team will keep our masks or face shields on at all times. While we will be very happy to see you, you won’t be able to see our smiles!
- New patient consultations
- Existing patients follow up visits in person or via E-Visits
- Medical Infusion therapy
- Nutritional IV treatments and immune enhancing infusions
- DEXA scans
- Retail supplement purchases
- Naturopathic services
Platelet rich plasma (PRP) injections for non inflammatory arthritis and musculoskeletal conditions
BUILDING YOUR RESILIENCE – VITAMIN D & IMMUNITY
Last week we discussed the important role Vitamin A plays in regulating your immune system and defending you from CoVID-19. This week we will delve into the role of Vitamin D.
Vitamin D and CoVid-19
Vitamin D has been mentioned in the headlines in light of the recent CoVID-19 pandemic. What does the data say?
Protection against CoVID-19 infection?
A study in Switzerland looked at the Vitamin D status of 107 individuals with flu like symptoms who were tested for CoVID-19.
The Vitamin D levels of the individuals who tested negative were then compared to a series of controls (healthy individuals) tested in 2019.
The findings were as follows:
Of those tested, 27 were positive and 80 were negative.
The positive group had a median Vitamin D level of 11.1 ng/mL.
The negative group had median level of 24.6ng/mL.
The negative group had median levels similar to healthy controls.
The findings suggest that those with lower Vitamin D levels may have higher risk of contracting CoVID-19 infection.
Protection against severe complications of CoVID-19?
There are two studies pertaining to this question. One done in Belgium and the other in South Asia.
The Belgian study reports 186 patients hospitalized with CoVID-19 pneumonia in March and April.
Patients were categorized into three stages based on CT scans of their lungs. Stage 1 the least severe, stage 3 being the most severe.
Deficiency rates and median Vitamin D levels of each category was as follows:
- Stage 1: 55.2%, 19.4ng/dL
- Stage 2: 66.7%, 16.5ng/dL
- Stage 3: 74%, 16.0ng/dL
The Southeast Asia study included 176 patients over the age of 60 diagnosed with CoVID-19. Subjects were divided into two categories – “mild” and “severe” and were tested for Vitamin D status. Sufficient Vitamin D levels were defined as greater than or equal to 30ng/dL and deficient less than that.
The findings were as follows:
46% of mild cases were Vitamin D deficient (average Vitamin D level of 30ng/mL)
86% of severe cases were Vitamin D deficient (average level of 20ng/mL)
Together these findings suggest that there may be a protective effect of Vitamin D against contracting and reducing the severe CoVID-19 outcomes.
What is Vitamin D?
Vitamin D is actually a steroid hormone commonly thought of only regulating calcium and maintaining bone health. However, Vitamin D is also intimately involved with your endocrine, cardiovascular and immune systems.
The functions of Vitamin D pertinent to pathogen defense
- Barrier defense
- Balance Innate and Adaptive Immunity
- Regulate your blood pressure and insulin secretion
Barrier Defense – Your own hand sanitizer
Did you know your body makes it’s own hand sanitizer? How cool is that!?
Vitamin D is a building block for antimicrobial peptides (AMPs) called “Cathelicidins.” And no, that has nothing to do with Catholicism.
These AMPs are secreted by macrophages and antigen presenting cells that reside in our skin, very densely concentrated in our palms and soles.
Do you recall the video we sent you on how soap work?
Similarly to soap, these AMPs destroy viruses and bacteria by punching holes in their lipid membranes.
In addition to your practices of hand washing and using hand sanitizer, Vitamin D adds this extra intrinsic layer of defense.
Balance of Innate and Adaptive Immunity
Traditionally, our immune system is broken down into innate and adaptive arms. Think of your innate immune system as the Marines, Army, Navy and Air Force and your adaptive branch as the special forces such as RECON, SEALS and GREEN BERETS. The latter are more highly targeted and specific.
You need both arms functioning and communicating well for optimal defense against bugs. The different means of evading the immune system that these bugs employ have less efficacy when your troops are appropriately numbered and communication is intact.
A side note, which we will discuss in the future is the important role Vitamin D plays in autoimmune diseases – lupus, rheumatoid arthritis, psoriasis, etc. Translational research suggests that too much activity in the special forces arm or too much in the regular forces contributes to these diseases. We describe some of these clinical entities as “autoimmune” versus “autoinflammatory,” respectively.
Regulation of blood pressure and insulin production
Vitamin D regulates the communication cascade between your blood vessels and kidneys by limiting the production of a hormone called renin. The downstream effect of renin is to tell your kidneys to retain salt and constrict its blood vessels.
Insulin is a hormone secreted by your pancreas that regulates blood sugar and fluid balance. When we eat, our pancreas releases insulin to partition some of the sugar, fats and amino acids consumed into storage. Faulty insulin signaling and elevation in blood sugar and blood fats is an expression of type II diabetes and metabolic syndromes. Vitamin D regulates insulin sensitivity and helps prevent this.
As it relates to fluid balance, like the renin-angiotensin system of the kidneys, insulin also tells your kidneys to retain salt and water.
You may ask how your blood pressure and insulin signaling relate to pathogen defense.
Preliminary data suggests that CoVID-19 infected individuals who have elevated blood pressure and diabetes have an increased risk of more severe outcomes. We are not exactly sure why, but these individuals tend to have a higher background level of inflammation, part and parcel of the conditions –diabetes and hypertension.
How to get enough Vitamin D
We strive to educate our patients to achieve optimal nutrient status the way nature intended. That said, the world is complex, and we must consider the status of the individual and their comorbidities.
The optimal way to get Vitamin D is via sunlight. UV-B rays convert cholesterol residing in the skin to Vitamin D. Of additional importance, sunlight converts cholesterol into numerous other steroid molecules that produce nitric oxide and anti-inflammatory agents.
Hold your horses! We do acknowledge the fact that UV light is a double-edged sword. Too much damages your skin and can cause cancer. However, sensible sun exposure on a regular basis is unlikely to do that.
What is sensible sun exposure you ask?
It depends on what we call your Fitzpatrick skin phototype – a classification system created by American Dermatologist, Thomas Fitzpatrick in 1975.
The image below highlights the six different types. As you can see those lower on the scale tolerate less sun exposure, whilst those higher may tolerate more.
To simplify, individuals lower on the scale can sensibly expose themselves to sun 10 minutes two to three times per week during the time the sun is closest to its zenith (between 11AM and 1PM). No full-on tanning required, light clothing defined as shorts and a singlet in your backyard or a park will suffice.
This is not a general recommendation appropriate for those who are elderly, frail, more sensitive to heat, prone to dehydration or have photosensitivity from their lupus or other autoimmune disease. For more specifics as it relates to your case, discuss with your physician.
This is a reliable way to ensure you are acquiring the health benefit of sunlight, but not necessarily to maintain ideal Vitamin D levels for everyone. Various factors including your skin type, tanning capabilities, seasonality and other factors make that difficult.
What are ideal Vitamin D levels?
There are more complicated means of optimizing Vitamin D levels looking at a few blood markers including PTH and a marker called 1-25-hydroxyvitamin D.
But for most people, reasonable Vitamin D levels will fall somewhere between 25 and 40ng/mL.
How do I achieve a target Vitamin D of 30-40ng/mL?
The first thing to do is find out where you are with testing.
If you fall lower than the above range, you may require high dose supplementation temporarily to get you there, with further testing for confirmation.
If you are much higher than this, work with your physician to modify your dose.
When you are in this range, somewhere around 2000 international units per day will likely keep you there. You can modify this number downward if you enjoy eating oily fish. Every three ounces tends to yield somewhere between 100-500 international units. There are other foods fortified with Vitamin D, but they tend to be enriched with a cheaper form that may not reliably increase Vitamin D levels.
There you have it. You are now a Vitamin D expert. Go forth, stay healthy and spread the word!
- Glicio, El James. “Vitamin D Level of Mild and Severe Elderly Cases of COVID-19: A Preliminary Report.” Available at SSRN 3593258 (2020)
- De Smet, Dieter, et al. “Vitamin D deficiency as risk factor for severe COVID-19: a convergence of two pandemics.” medRxiv (2020).
- D’Avolio, Antonio, et al. “25-Hydroxyvitamin D Concentrations Are Lower in Patients with Positive PCR for SARS-CoV-2.” Nutrients 12.5 (2020): 1359
COVID-19 RHEUMATOLOGY UPDATES
We have been asked repeated by many of you about what to do with your medications and how to stay safe in our current world of the Corona Virus outbreak We have written several article over the past three months in our newsletters concerning some of these concerns. If you missed them, previous newsletters are available on our website www.arthritisheatlh.net under the section “Latest news”
This will review, with my edit and personal distillation, the most recent set of recommendations authored by The American College of Rheumatology (ACR) concerning rheumatic therapies in the setting of the current CoVid Pandemic. Use these recommendations as guidelines but clearly individualize the recommendations based on your specific needs and situation. This is my advice based on our current knowledge of the pandemic.
What are your greatest risks for CoVid-19?
It is not your medication or your rheumatic disease. It still is:
- Your age over 65
- Co-existing medical conditions – especially lung, heart, kidney, liver and poor nutrition.
How to stay safe?
Stopping your current therapy is not the answer. If you are well, continue to take your prescribe medications and supplements, adhere to an anti-inflammatory diet and continue to exercise daily.
Greatest safety benefit:
- Diligent and careful hand washing
- Social distancing
- Facial mouth/nose barriers
As previously reviewed, the risk of contracting CoVid-19 is most highly associated with close personal contact such as in your home setting. Casual social contacts have a much lower risk especially if the three measures above are adhered to.
What to do with your treatments and medications?
In any situation:
If on steroids, use the lowest effective dose. Do not stop them abruptly.
If on non-steroidal anti-inflammatories (NSAID’s) continue but if possible use acetaminophen (Tylenol) in their place as a safer alternative.
If you are well and your rheumatic condition is well controlled:
Continue hydroxychloroquine, sulfasalazine, immunosuppressant medication including methotrexate, azathioprine, mycophenylate, all biologics, and JAK inhibitors (Xeljanx, Oluminant, Rinvoq).
Denosumab (Prolia) for osteoporosis should be continued every 6 months. We do not recommend extending the interval between doses beyond the recommended every 6-month dosing. Here I differ from the ACR, who allow an increase in dosing intervals up to 8 months. This makes little sense to me and offers no advantage only adding to confusion and possible non-compliance.
If you need to start a new medication and are free of CoVid -19 infection:
You may start hydroxychloroquine, sulfasalazine and immunosuppressant medication including methotrexate, azathioprine, mycophenylate, all biologics, JAK inhibitors (Xeljanx, Oluminant, Rinvoq). If steroids need to be started, again use the lowest effective dose.
We do not exceed the equivalent of 20 mg a day of prednisone unless there is an active life threatening or organ threatening rheumatologic condition. I differ again from the ACR who use a maximum 10 mg dose. Doctors often disagree. We do agree that the lowest effective dose of steroids is preferred.
Patients with SLE (Lupus)
- Should start full dose hydroxychloroquine
- If pregnant, continue hydroxychloroquine
- If needed, the biologic belimumab (Benlysta) can be started or continued.
If you are on rheumatic therapy and have been exposed to a person with confirmed CoVid-19 infection:
Hydroxychloroquine, sulfasalazine and NSAID may be continued
Hold all immunosuppressants except for the IL-6 biologics (tocilizumab – name brand Actemra and sarilumab-name brand Kevzara may be protective) pending a negative test result for CoVid-19 or after 2 weeks of symptom-free observation.
Rheumatic disease treatment in the context of documented or presumptive CoVid-19 infection:
Regardless of COVID-19 severity, hydroxychloroquine and sulfasalazine may be continued but all immunosuppressant medication including methotrexate, azathioprine, mycophenylate, all non IL-6 biologics, JAK inhibitors (Xeljanx, Oluminant, Rinvoq should be stopped or held.
For patients with severe respiratory symptoms, NSAID’s should be stopped but again we prefer they are not used at all and are replaced with acetaminophen.
In select circumstances, as part of a shared decision-making process, IL-6 inhibiting biologics (Actemra and Kevzara) may be continued.