Take the Guess Work Out of Biologic Rheumatoid Arthritis Choice

April 9, 2024

Rheumatoid arthritis (RA) is a chronic inflammatory disorder that not only affects the joints but can exert systemic influence, potentially impacting various body systems. The journey through RA treatment is unique for each individual, necessitating a personalized approach. Enter precision medicine for rheumatoid arthritis—the practice of tailoring treatment to the individual characteristics of each patient.

Today we delve deep into how molecular signature testing is revolutionizing treatment decision-making in RA.

Understanding Molecular Signature Testing

Within precision medicine for rheumatoid arthritis, molecular signature testing is emerging as a novel way we can identify whether individuals might benefit from certain biologic medications. The molecular signature is essentially a unique ‘barcode’ of gene expression within an individual’s immune cells. This can predict the body’s response to different treatments.

The Study At Hand: A Pivotal Discovery

Recently, a critical study titled “Patient outcomes improve when a molecular signature test guides treatment decision-making in rheumatoid arthritis,” published in the Expert Review of Molecular Diagnostics, has provided substantial evidence supporting the integration of molecular signature testing in managing RA.

In the study, researchers elucidated the role of a specific test—the Molecular Signature Response Classifier (MSRC). The MSRC is designed to predict whether patients with RA will respond to tumor necrosis factor inhibitor (TNFi) therapies, a common class of biologic drugs used in treatment. These medications include Enbrel, Humira, Cimzia, Simponi, and Remicade as well as their biosimilar equivalents.

Unlocking Personalized Treatment Strategies

Biologic medications, which target specific components of the immune system, have transformed the landscape of RA treatment. However, the response to these drugs can vary significantly among patients—a challenge that precision medicine for rheumatoid arthritis seeks to address.

The Molecular Signature Response Classifier (MSRC) test functions as a sophisticated investigative tool employed to decipher the intricate workings of your immune system, particularly in relation to rheumatoid arthritis (RA). At its core, the MSRC examines the patterns of gene expression, which can be envisioned as the “on” or “off” switches of genes within your immune cells. These patterns can provide crucial insights into your body’s unique response to specific medications, specifically tumor necrosis factor inhibitors (TNFis)—a class of biologic drugs frequently utilized in RA treatment.

By measuring these gene expressions, the MSRC can predict with a remarkable degree of accuracy whether your body is likely to respond favorably to TNFis, thus avoiding the potential trial and error associated with medication effectiveness. This personalized approach not only guides your healthcare provider in selecting the most appropriate treatment for your condition but also reflects a conscientious and empathetic stride towards optimizing your healthcare experience, minimizing unnecessary interventions and focusing on treatments that align with your body’s individual genetic makeup.

The study showcases how MSRC testing can predict the efficacy of TNFi medications for individuals with RA. This innovative approach posits that using a patient’s molecular signature could improve rates of remission and help in selecting the most fitting biologic therapy.

Simply put, it seeks to take the guess work out of biologic therapy choice.

The Research Outcomes: A Patient-Centric View

Improving Patient Journeys

By analyzing a pooled cohort of patients who were subjected to MSRC testing to guide biologic therapy selections, the study demonstrated a significant improvement in patient outcomes, notably in remission rates and achieving low disease activity. Specifically, patients in the MSRC-tested arm achieved higher proportions of clinical disease activity index (CDAI) low disease activity or remission (CDAI-LDA/REM) and remission alone (CDAI-REM), compared to those in the external control group, over a six-month period. Furthermore, a notable improvement was observed in minimally important differences (MID) in CDAI scores, indicating a meaningful reduction in disease activity from baseline.

The Promise of Precision Medicine in Action

Each RA patient’s battle is distinct, often filled with trials and adjustments in treatment regimens. The clear message from this research is that precision medicine for rheumatoid arthritis, epitomized by molecular signature testing, can facilitate a more targeted treatment approach—a leap forward from the one-size-fits-all strategy.

What This Means for You: Precision Medicine’s Role

Contemplating Biologic Treatment Options

If you are considering initiating biologic therapy or are reevaluating your current regimen, precision medicine for rheumatoid arthritis offers a scientific beacon. By assessing your unique molecular signature, clinicians can better forecast which therapy aligns with your body’s intrinsic biology.

Precision Medicine for Rheumatoid in Clinical Practice

The clinical implications are considerable. The integration of molecular testing in treatment planning could not only enhance patient outcomes but potentially streamline the therapeutic trajectory, reducing the trial-and-error approach that many patients and their doctors face.

Collecting the Pieces: The Broader Implications

Beyond Individual Outcomes

Precision medicine’s implications extend beyond individual patient care not only for rheumatoid arthritis but also other autoimmune conditions such as multiple sclerosis, Crohn’s disease, ulcerative colitis, psoriatic arthritis, etc. This paradigm has the potential to enhance healthcare resource utilization by optimizing medication selection and reducing the economic burden of ineffective treatments.

Concluding Thoughts: The Precision Medicine Landscape

As we navigate the intricate landscape of RA, molecular signature testing stands as a promising lighthouse, guiding us towards safe harbors of effective treatment options. By embracing the tailored approach that precision medicine for rheumatoid arthritis offers, we can look forward to a future where patients are not only treated but understood on a molecular level.

Call to Action: Partner with Precision

If you are at a crossroads in your RA treatment journey, consider discussing molecular signature testing with your healthcare provider. It is a step towards a personalized treatment plan crafted with your unique genetic makeup in mind, offering the potential for improved outcomes and quality of life.

References

Molecular Signature Testing: PrismRA

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advise you to speak with your medical professional if you have questions concerning your symptoms, diagnosis, and treatment.

Diseases and Conditions Journal Club

Exploring New Ways to Keep ANCA Vasculitis in Check

February 12, 2024

ANCA Vasculitis is a rare but serious condition where the body’s immune system mistakenly attacks its own blood vessels, causing inflammation. This falls into a group of illnesses known as autoimmune diseases. Each year, about 3 out of every 100,000 people get diagnosed with it, mainly those who are between 50 and 70 years old. One of the biggest hurdles in treating ANCA Vasculitis is preventing it from coming back, which calls for some creative solutions to keep the disease in remission.

A groundbreaking study titled “Maintenance of Remission of ANCA Vasculitis by Rituximab Based on B Cell Repopulation Versus Serological Flare: A Randomised Trial” sheds light on a novel tactic for tackling this challenge. It zeroes in on the drug Rituximab, which helps calm the immune system’s overreaction that’s at the heart of this condition.

Why Focus on Rituximab for ANCA vasculitis?

Rituximab targets B cells, which play a big part in the body’s overactive immune response seen in ANCA Vasculitis. Doctors usually give this medication when they notice B cells coming back after treatment or when there’s a spike in ANCA levels, which can mean the disease is flaring up.

The Two Approaches Explained

The study looks at two ways of deciding when to give extra doses of Rituximab:

The first way is based on whether B cells are starting to show up again after being knocked down by treatment.
The second way relies on monitoring ANCA levels in the blood, even if the patient isn’t showing any symptoms, to catch any potential flare-ups.

What the Study Found

This research offers new insights by comparing these two strategies. It found that using Rituximab based on the return of B cells leads to fewer relapses than waiting for ANCA levels to rise, over an average follow-up of 4.1 years. This result supports the idea that tailoring treatment to each patient’s specific situation can really make a difference in managing complex autoimmune diseases like ANCA Vasculitis.

However, both methods have their challenges, such as predicting disease flares accurately and the feasibility of frequent testing. The study also closely monitored safety, noting similar side effects in both groups but a slightly higher risk of serious issues related to COVID-19 in those treated based on B cell repopulation.

Personalized Care for ANCA Vasculitis is Key

The findings highlight that there’s no one-size-fits-all answer to treating ANCA Vasculitis. Some patients might do better with one approach over the other, emphasizing the importance of customizing treatment plans.

Looking Ahead

This study is a significant step forward in improving how we maintain remission in ANCA Vasculitis. It encourages us to keep asking questions and searching for better ways to care for those affected by this disease.

Even though the medical terms might sound complex, they’re part of understanding how to best manage ANCA Vasculitis. As we work to unravel these complexities, it’s crucial to keep learning, adapting, and showing compassion for those living with this condition.

This research marks an important progress in our journey, and we’re committed to sharing the latest and most accurate information to help make informed health decisions. Our dedication to understanding and empathizing with your health challenges stands firm.

References

Zonozi R, Cortazar FB, Jeyabalan A, Sauvage G, Nithagon P, Huizenga NR, Rosenthal JM, Sipilief A, Cosgrove K, Laliberte KA, Rhee EP, Pendergraft WF 3rd, Niles JL. Maintenance of remission of ANCA vasculitis by rituximab based on B cell repopulation versus serological flare: a randomised trial. Ann Rheum Dis. 2023 Dec 11:ard-2023-224489. doi: 10.1136/ard-2023-224489. Epub ahead of print. PMID: 38123922.

Medical Disclaimer

The information in this video is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained in this article is for general information purposes only and does not replace a consultation with your own doctor/health professional

Diseases and Conditions When to see a rheumatologist

Signs you may be at risk for psoriatic arthritis

January 16, 2024

Psoriatic arthritis is a type of inflammatory arthritis that occurs in people with psoriasis, an autoimmune condition affecting the skin. It causes swelling, stiffness and pain in the joints as well as nail changes and overall fatigue.

Psoriatic arthritis can be difficult to diagnose in its early stages but it’s important to identify and treat it quickly. Early treatment helps relieve symptoms, improve quality of life, and potentially slow down the progression of joint damage that can occur if the disease advances untreated.

Joint Pain

One of the most common early symptoms of psoriatic arthritis is persistent joint pain, swelling, and stiffness (Mayo Clinic). This pain often affects the large joints like the knees, ankles, elbows, and wrists, but can also impact smaller joints like those in the hands and feet.

The joint pain of psoriatic arthritis tends to be asymmetric, meaning it occurs on just one side of the body rather than symmetrically on both sides. The pain and stiffness tend to be worse when joints are at rest, and improves with movement. Psoriatic arthritis joint pain may also alternate between periods of flare ups and remission.

It’s important to note that psoriatic arthritis joint pain can occur even in people who do not have skin psoriasis. The joint symptoms may precede the skin lesions in some cases. Persistent joint pain, swelling, and stiffness, especially when asymmetric and alternating between flares and remission, can be an early sign of psoriatic arthritis.

Fatigue

Fatigue is a very common symptom of psoriatic arthritis, with studies showing that up to 80% of people with PsA experience some degree of fatigue (SOURCE). The chronic inflammation associated with PsA can contribute to feelings of tiredness and lack of energy (SOURCE). This type of fatigue is different than normal tiredness after a long day – it is often described as an overwhelming, debilitating exhaustion that affects your ability to perform daily activities.

Psoriatic arthritis fatigue can range from mild to severe. You may feel generally run down or constantly drained. Simple tasks like grocery shopping, cleaning or caring for your family may wipe you out. This fatigue can be mentally exhausting as well, making it hard to concentrate or be productive. Unlike normal tiredness which gets better with rest, psoriatic arthritis fatigue may persist even when you get adequate sleep.

If you are experiencing new, unexplained and persistent fatigue along with other psoriatic disease symptoms like joint pain, stiffness or skin changes, be sure to contact your doctor. Finding the right treatment can help manage inflammation and greatly improve psoriatic arthritis fatigue.

Joint Redness and Warmth

One early symptom that should prompt suspicion of psoriatic arthritis is redness and warmth over the joints, especially when it is confined to one side of the body. Unlike regular aches and pains, the joints affected by psoriatic arthritis often become noticeably red and feel warm to the touch. This occurs when the immune system mistakenly attacks the joints, causing inflammation. According to the Mayo Clinic [“results”][0][“url”]}>, this redness and warmth is a hallmark feature of inflammatory types arthritis like psoriatic arthritis.

Some people first notice the redness and warmth before feeling any arthritic pain or stiffness. The joints most likely to develop redness and warmth are those in the hands, wrists, elbows, knees, ankles and feet. If you notice persistent redness and warmth in these joints, particularly if it is asymmetric and predominately affecting one side, be sure to point this symptom out to your doctor during your appointment. Redness and warmth in your joints in combination with other psoriatic symptoms should prompt referral to a rheumatologist for further evaluation for psoriatic arthritis.

Swollen Fingers/Toes

One early sign of psoriatic arthritis is dactylitis, also known as “sausage digit.” This refers to swelling in the fingers or toes that causes them to appear sausage-like. Dactylitis is caused by inflammation of the tendons and soft tissues of the digits. According to the National Psoriasis Foundation, dactylitis affects roughly 40-50% of people with psoriatic arthritis^[1]. It often presents before any joint damage is apparent.

Dactylitis most commonly affects the middle joint of the fingers or toes, though it can occur in the wrist, ankles, and feet as well. The swelling and inflammation is often asymmetric, meaning it appears on just one finger or toe at a time, rather than symmetrically on both sides. Dactylitis causes stiffness, pain, and limited mobility in the affected digits. If you notice sausage-like swelling in your fingers or toes, it is important to see a doctor promptly, as it may be an early red flag for psoriatic arthritis^[2].

Nail Changes

Nail changes are a common early sign of psoriatic arthritis. The most frequent nail manifestations are pitting, grooves, and detachment of the nail from the nail bed (onycholysis).

Pitting appears as small depressions or holes in the nail surface and gives the nail a spotted look. These pits are caused by defects in nail growth. Pitting occurs in up to 50% of those with psoriatic arthritis^[1].

Nail grooves are furrows or channels that run vertically down the nail. They may be deep or superficial lines. Grooves are present in around 25% of psoriatic arthritis patients^[2].

Onycholysis refers to separation of the nail from the nail bed. The nail becomes detached from the skin underneath. This occurs when inflammation damages the nail matrix. Onycholysis is seen in approximately 10-15% of those with psoriatic arthritis^[3].

Getting early treatment for psoriatic arthritis can help prevent permanent nail deformities. See a doctor if nail changes accompany joint pains.

Lower Back Pain

Lower back pain is a common symptom of psoriatic arthritis. About 30-50% of people with psoriatic arthritis will experience pain and stiffness in their lower back caused by inflammation of the joints in the spine ¹. This is known as axial arthritis or spondylitis. The lower back is commonly affected before other areas of the spine.

Lower back pain from psoriatic arthritis often comes on slowly and worsens over time. It can range from mild to severe. The pain and stiffness tend to be worse in the morning and improve with movement and activity. However, prolonged sitting or standing can also aggravate the pain. Lower back pain from psoriatic arthritis may switch between sides or stay on one side consistently.

If you have lower back pain along with other symptoms of psoriatic arthritis like joint swelling and skin changes, be sure to see a rheumatologist. Getting an early and accurate diagnosis is key to preventing permanent spinal joint damage. Treatment for psoriatic spondylitis aims to relieve pain, improve function, and slow the progression of the disease.

Signs you may be at risk for psoriatic arthritis

If you experience any symptoms of psoriatic arthritis, it’s important to schedule an appointment with your doctor to get an evaluation. The earlier psoriatic arthritis is diagnosed, the better the outcome with treatment. You should see a doctor if you have:

Joint pain, swelling, or stiffness that persists for more than 2 weeks (https://www.mayoclinic.org/diseases-conditions/psoriatic-arthritis/symptoms-causes/syc-20354076)
Redness or warmth over joints
Swollen fingers or toes that look like sausages
Morning joint stiffness lasting over 30 minutes
New pitting, ridges, or separation of the nails (https://www.healthline.com/health/psoriatic-arthritis-early-signs)
Fatigue that is not relieved by rest
Lower back pain, especially with joints affected elsewhere

Don’t dismiss unexplained joint pain or wait and see if it goes away. The sooner psoriatic arthritis can be diagnosed, the better the outcome with early treatment to relieve symptoms and slow disease progression. See a doctor right away if you have psoriasis and develop any joint pain or swelling.

Medical Disclaimer

The information in this video is not intended nor implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained in this video is for general information purposes only and does not replace a consultation with your own doctor/health professional

Diseases and Conditions

Pneumonia vaccines in people with autoimmune diseases

December 19, 2017

Do you need to get the pneumonia vaccine? Patients that have concurrent autoimmune diseases are at a higher risk of infection than others. In fact, infection is one of the most common causes of hospitalization in patients suffering from rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE); therefore, it is important to do everything possible to protect yourself from getting sick. The “pneumonia vaccine” or pneumococcal vaccine protects patients from pneumococcal diseases caused by the bacterium, Streptococcus pneumonia. Pneumococcal diseases can be serious and even fatal. Each year, in the United States alone, approximately 18,000 older adults die from pneumococcal diseases.

What is Streptococcus pneumoniae?

Pneumoniae is a gram-positive, spherical bacterium that has more than 90 known variations of the species, also known as serotypes. These bacteria typically group together in pairs or chains. They are the bacteria responsible for pneumococcal diseases including pneumonia, meningitis, bacteremia (infection of the blood), and many other severe illnesses. Pneumococcal pneumonia is the most common clinical presentation of a pneumococcal disease. It is a major cause for community-acquired pneumonia and results in about 400,000 hospitalizations every year. Pneumococcal meningitis can result in deafness and brain damage. It kills about 1 child in 10 who get it.

What are some signs and symptoms of pneumonia?

Pneumonia can look a lot like the common cold or the flu. Common symptoms include:

Abrupt onset of fever
Chills or rigors (uncontrollable shaking)
Chest pain
Productive cough
Trouble breathing
Malaise
Feeling of weakness

Which vaccine should I get?

Currently, there are two forms of pneumonia vaccine that is available in the US. Both forms of the vaccine are inactivated or “killed” vaccines.

Vaccine	Brand Name	Abbreviation
Pneumococcal conjugate vaccine	Prevnar 13	PCV13
Pneumococcal polysaccharide vaccine	Pneumovax	PPSV23

The pneumococcal conjugate vaccine (PCV) 13, also known as Prevnar 13, covers 13 serotypes. The pneumococcal polysaccharide vaccine (PPSV) 23, also known as Pneumovax, covers 23 serotypes. Typically, both PCV13 are PPSV23 are required with PCV13 being given prior to PPSV23. The minimum interval between PCV13 and PPSV23 is 8 weeks. The table below shows the recommended vaccine schedule for immunocompromised people. Talk to your healthcare provider or pharmacist for more information about which vaccine would be most appropriate for you.

Pneumococcal vaccine status:	Age	FIRST give:	THEN give:	THEN give:
None/Unknown	19-64 years	PCV13	PPSV23 (at least 8 weeks later)	PPSV23 (at least 5 years after first PPSV23 dose)
None/Unknown	65+ years	PCV13	PPSV23 (12 months after PCV 13)
PPSV23	65+ years	PCV13 (at least 1 year after PPSV23)	PPSV23 (6-12 months after PCV 13 AND 5 years after PPSV23)
PPSV23	Under 65 years	PCV13 (at least 1 year after PPSV23)	Second dose of PPSV23 (at least 8 weeks after PCV13 AND at least 5 years after first dose of PPSV23)	Third dose of PPSV23 at age 65 (if at least 5 years have passed since last dose of PPSV23)
PCV13		No additional PCV13 doses are needed. At least 8 weeks must elapse before getting a dose of PPSV23.

What are some potential side effects?

These vaccines are normally well tolerated; however, side effects may still occur. Possible side effects may include

Injection site reactions including redness, pain, and swelling where the shot was given
Flu-like symptoms (mild fever, fatigue, headache, chills, or muscle pain)
Loss of appetite
Irritability
Life-threatening allergic reactions from this vaccine may also occur but are very, very rare

Where can I get the pneumonia vaccine?

Most doctor’s offices carry the pneumococcal vaccination. Call your primary care provider or specialist to see whether they can give you your pneumococcal vaccination. If not, most pharmacies also give this service as well.

Who should NOT get the vaccine?

Patients with a known hypersensitivity or allergy to any part of the vaccine should not receive the vaccine. Patients who have had allergic reactions to vaccines containing diphtheria (ex: Tdap, DTaP, tetanus vaccine) should tell their healthcare provider or pharmacist before receiving PCV13.

If you are feeling sick, wait until you feel better before getting the pneumonia vaccine.

Patients who are pregnant should not get the vaccine. Although there is no evidence of the vaccine being dangerous to the mother or the baby, as a precaution, it is recommended to receive the vaccine prior to conception.

Key points

The pneumonia vaccine can help protect you against serious or even fatal diseases.
Medications used in autoimmune conditions including RA, psoriatic arthritis, lupus, etc. can further weaken your immune system and predispose you to getting infections. Staying vaccinated can help keep you healthy and lower your risk of getting sick.
Pneumococcal diseases can spread from person to person through close contact.
Patients should receive up to 1 dose of PCV13 and up to 3 doses of PPSV23 in their lifetime. PCV13 and PPSV23 should not be administered on the same day.
The pneumonia vaccine can be given year-round. You can even get the flu shot on the same day. Just try to get one in each arm to reduce any pain associated with getting the vaccines.
When thinking about starting chemotherapy or other immunosuppressive therapy (ex. steroids, biologics, etc.), the interval between vaccination and initiation of immunosuppressive therapy should be at least 2 weeks.
You will not get sick after getting the vaccine; however, it is not uncommon to have flu-like symptoms that are caused by your body’s response to the vaccine.
It will take a couple weeks before the vaccine will take its full effect.

Final thoughts

For immunocompromised people, it is recommended to receive vaccination against the bacterium S. pneumoniae as outlined by the Center for Disease Control (CDC) vaccine schedule. Many studies and government organizations also support the use of the vaccination as the benefits outweigh the risks of this preventable infection. Other people who are also immunocompromised or over the age of 65 should also receive the vaccine. These patients may include those with congenital or acquired immunodeficiency, HIV infection, chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, multiple myeloma, solid organ transplant, or iatrogenic immunosuppression. Iatrogenic immunosuppression is based on the use of immunosuppressive drugs, including long-term systemic corticosteroids (e.g., prednisone) and radiation therapy. Talk to your healthcare provider or pharmacist if you have any questions or concerns on the pneumonia vaccine.

Guest Authors: Yahya Rasoully, PharmD Candidate 2018; Stephanie Tchen, PharmD, PGY-1 Pharmacy Resident; and Jessica Farrell, PharmD

References

Pneumoccoal Disease. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015.
Rákóczi É, Szekanecz Z. Pneumococcal vaccination in autoimmune rheumatic diseases. RMD Open. 2017;3:e000484.
Nagel J, Saxne T, Geborek P, et al. Treatment with belimumab in systemic lupus erythematosus does not impair antibody response to 13-valent pneumococcal conjugate vaccine. Lupus 2017;26:1072–81.
Alten R, Bingham CO, Cohen SB, et al. Antibody response to pneumococcal and influenza vaccination in patients with rheumatoid arthritis receiving abatacept. BMC Musculoskelet Disord 2016;17:231.
Centers for Disease Control and Prevention. Pneumococcal Vaccines (PCV13 and PPSV23): Addressing Common Questions about Pneumococcal Vaccination for Adults. Available from https://www.cdc.gov/vaccines/hcp/adults/downloads/fs-pneumo-hcp.pdf

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

1 Comments

Overcoming Inflammation

Flu vaccines and autoimmune diseases

September 19, 2017

Should people with autoimmune diseases get a flu vaccine? If so which ones?

Have you received your annual flu vaccine? Flu season is just getting started. People who suffer from autoimmune diseases, like rheumatoid arthritis, lupus, and Sjogren’s syndrome, often have a weakened immune system, either from the disease itself or from the medications used to treat their disease. Today I’d like talk about the flu also known as influenza, and discuss what steps you can take to protect yourself this season.

What is the flu or influenza?

The medical word for the flu is influenza. Influenza is a type of virus that mainly attacks the respiratory system. There are two general types of influenza: influenza A viruses and influenza B viruses. Different components make up the flu virus: one hemagglutinin (H1, H2, H3) and one neuraminidase (N1, N2). There are many different strains of influenza and to make matters worse, it tends to mutate.

The stomach flu is NOT caused by influenza. The stomach flu is a general word used to describe a gastrointestinal infection caused by other types of viruses like Norovirus, the most common cause of gastroenteritis in the United States.

What are some of the signs and symptoms of the flu?

The signs and symptoms of the flu vary widely and are rather nonspecific. They can include:

High fever
Muscle pain
Rigors, uncontrollable shaking
Headache
Malaise
Sore throat
Nonproductive cough
Runny nose

Complicated cases

Sometimes the flu can morph into a much more serious illness. It can cause viral pneumonia and then can lead into a secondary bacterial pneumonia, sinusitis, and/or an ear infection. This tends to happen in people who have a weakened immune system like children and older adults. People with autoimmune conditions and especially people taking medications that weaken the immune system also are at high risk.

How is the flu transmitted?

The flu spreads from person-to-person by large particle droplets.

Airborne droplets: Coughing and sneezing
Skin-to-skin: handshakes and hugs
Saliva: Shared drinks and kissing
Touching contaminated surfaces: Keyboard, doorknob

What are the best ways to prevent the flu?

The best ways to prevent the flu are first, by washing your hands and second, by getting vaccinated for the flu at the beginning of each flu season. Choosing healthy lifestyle practices, like eating clean, exercising, and getting a good night’s sleep, are also important.

What are the most convincing reasons for getting vaccinated against the flu?

During the 2016 – 2017 flu season, it caused 5.1% of outpatient visits.
Pneumonia and the flu caused 2% of reported deaths.
There were at least 18,000 confirmed flu related hospitalizations, 60% of cases occurred in people aged 65 years and above.
There were 98 confirmed flu related pediatric deaths.[1]
Risks of complications, hospitalizations, and deaths from the flu are the highest among people age 65 and above, young children and people who have medical conditions that weaken the immune system.
If you end up getting the flu, the flu vaccination may make your flu illness milder
By getting the flu vaccine, you decrease the risk of passing it on to the people you love

Who should get a flu vaccine?

Everyone six months and older. This is especially important for people who have a high risk of getting flu-related complications. These include:

Children younger than five
Adults 65 years of age and older
Pregnant women, up to two weeks postpartum
People that live in a nursing home or another type of long-term care facility
People that have a medical condition that weakens the immune system, this includes almost everyone with an autoimmune disease

Medical conditions

People with weakened immune systems (autoimmune diseases, cancer, HIV or AIDS, people on chronic steroids and biologic medications)
Asthma
Neurological and neurodevelopmental conditions
COPD and cystic fibrosis
Coronary artery disease and heart failure
Diabetes mellitus
Blood diseases like sickle-cell anemia
Kidney disease
Liver disease
People with an extremely high body mass index (BMI) > 40

When is flu season and when should I get my flu vaccine?

In the United States, flu season occurs during the months of October into May. Historically, the greatest number of cases occur during the month of February. The CDC recommends that people get a flu vaccine by the end of October. If you’ve missed the deadline, no worries, better late than never!

What viruses will the 2017 – 2018 flu vaccines protect against?

Every year, manufacturers must change the structure of the flu vaccine, because the virus is constantly changing. Scientists use data from the previous year to try to guess which strains will be more problematic in the upcoming season. Flu vaccines typically have 3 to 4 specific strains of influenza. This year, the vaccinations that have three types of virus should contain the following:

A/Michigan/45/2015 (H1N1)pdm09-like virus (updated)
A/Hong Kong/4801/2014 (H3N2)-like virus
B/Brisbane/60/2008-like (B/Victoria lineage) virus

Vaccines that contain four strains should contain the above as well as the following:

B/Phuket/3073/2013-like (B/Yamagata lineage) virus

Where can I get a flu vaccine?

Most doctor’s offices carry the flu shot. Call your primary care provider or specialist to see whether they can give you your flu shot this year. If not, most pharmacies also give this service as well.

Still unsure, please follow this link to find a flu shot near you.

Which flu vaccine should I get?

According to the CDC’s of published guidelines for the 2017 – 2018 season, they recommend the use of the inactivated influenza vaccine or IIV, or the recombinant influenza vaccine (RIV). These come as injections. They recommend against vaccination with the nasal spray flu vaccine. The latter is a live attenuated vaccine. People who take biologic medications should not receive live attenuated vaccines.

Can I get a flu vaccine if I’m allergic to eggs?

The following are the CDC recommendations regarding egg allergies and the flu vaccine.

People who have experienced only hives after exposure to egg can get any licensed flu vaccine that is otherwise appropriate for their age and health.
People who have symptoms other than hives after exposure to eggs, such as angioedema, respiratory distress, lightheadedness, or recurrent vomiting; or who have needed epinephrine or another emergency medical intervention, also can get any licensed flu vaccine that is otherwise appropriate for their age and health, but the vaccine should be given in a medical setting and be supervised by a healthcare provider is able to recognize and manage severe allergic conditions. (Settings include hospitals, clinics, health departments, and physician offices). People with egg allergies no longer have to wait 30 minutes after receiving their vaccine.[2]

Disclaimer: I have some safety concerns about the latter. I’m simply stating what the CDC has issued. When in doubt, talk to your doctor.

Why does the flu vaccine sometimes cause flu-like symptoms?

Here are a few reasons.

You have the flu

The incubation period is between one and four days. It also takes about two weeks for your body to build immunity after receiving the vaccine. Therefore, you can get the flu after a flu shot if your body hasn’t had time to build immunity yet.

You have a cold

Rhinoviruses are a common culprit. These are the viruses responsible for the common cold. In severe cases, the common cold can feel like the flu and you can catch it the same way.

The vaccine failed

Last year, the vaccine was only 34% effective at protecting against influenza A (H3N2) and 56% against influenza B viruses. Unfortunately, over the past six seasons, vaccines have been less and less effective.[3] However, any immunity is better than no immunity.

The flu vaccine gave you the infection

This can occur if you’ve received a particular type of flu vaccine that uses a live attenuated virus. This is the vaccine that comes as a nasal spray. Live attenuated vaccines are vaccines that contain a less potent form of the real virus. The immune system reacts to the virus and develops antibodies without causing the infection. Sometimes the virus is stronger than the immune system. The real infection can occur when this happens.

The CDC advised against the use of this particular type of vaccine.

Most common cause, your immune system is reacting to the vaccine

Scientists make injectable flu vaccines with inactivated virus or without any virus at all. Therefore, by definition, these are not infectious. You cannot get the real infection from them.

Some people may experience some soreness, redness or tenderness from the shot itself. Some people actually develop a low-grade fever, headache, and muscle aches (i.e., flu-like symptoms). These typically last about 2 days and resolve without any intervention. This is your body’s way of telling you that it’s mounting an immune response to the vaccine. This means your body is responding to the vaccine and making antibodies to protect you from the real infection, which is MUCH more severe.

Final thoughts

I know vaccines have received a bad reputation over the past few years. However, when you look at the data, vaccination particularly for the flu, ultimately saves lives. Let’s take example.

During the 1918 – 1919 flu season (i.e., the Spanish Flu), 1/3 of the world population experienced a terrible flu pandemic. About 50 to 100 million died. Now this was a particularly bad season, “the mother of all flu seasons”, and the reason it was so deadly has to do with many factors that we have yet to confirm. The CDC has experimented with an influenza virus that has the genetic material from the 1918 virus. Their results suggest that our modern-day vaccines and FDA-approved antiinfluenza medications like Tamiflu, would have worked against the 1918 virus.[4]

Bottom line, flu vaccines save lives.

If you want to learn more about the flu, please follow this link.

References

Fingers smiling against flu shot message image by wavebreakmedia via Shutterstock

[1] http://www.mdedge.com/jfponline/article/145540/vaccines/latest-recommendations-2017-2018-flu-season

[2] https://www.cdc.gov/flu/about/season/flu-season-2017-2018.htm

[3] http://www.mdedge.com/jfponline/article/145540/vaccines/latest-recommendations-2017-2018-flu-season

[4] https://wwwnc.cdc.gov/eid/article/12/1/05-0979_article

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

4 Comments

Diseases and Conditions

Can small fiber neuropathy mimic fibromyalgia?

July 19, 2017

Can small fiber neuropathy (SFN) mimic fibromyalgia? The simple answer is yes, but it’s more complicated… So why does a rheumatologist care about small fiber neuropathy? The answer is very simple. Many people get referred to a rheumatologist for fibromyalgia, which is a disease that causes widespread pain, brain fog, non-restorative sleep, and various other unexplained symptoms such as headaches. While fibromyalgia IS NOT an autoimmune disease, small fiber neuropathy can present very similarly but CAN BE caused by autoimmune diseases.

There’s a lot of controversy in the medical community about fibromyalgia. One group believes that it’s a separate entity, some do not believe in its existence, and some people are somewhere in the middle. Personally, I believe that fibromyalgia likely represents many diseases that we haven’t identified yet. Until we can categorize them into distinct entities, we’re going to have a hard time understanding them, let alone come up with effective treatments.

First, let’s review the clinical criteria that doctors use to make a diagnosis of fibromyalgia.

2010 ACR criteria for fibromyalgia

Criteria A patient satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met:

Widespread pain index (WPI) ≥ 7 and symptom severity (SS) scale score ≥5 or WPI 3–6 and SS scale score ≥ 9.
Symptoms have been present at a similar level for at least 3 months.
The patient does not have a disorder that would otherwise explain the pain.

Number #1 are various validated pain scores. These are rarely used in clinic but are often used for clinical trials. It helps researchers objectively quantify pain levels at any given time. As you can see, we don’t use trigger points to check for fibromyalgia anymore.

Small fiber neuropathy in people with fibromyalgia

So is small fiber neuropathy a feature of fibromyalgia, just like it is for diseases like Sjogren’s syndrome or are patient’s with small fiber neuropathy mistakenly diagnosed with fibromyalgia?

In one study, 46 patients with fibromyalgia and 34 normal controls were tested for small fiber neuropathy with a specialized skin biopsy. I’ll talk more about this later on. The researchers measured pain intensity with a survey called the Neuropathic Pain Symptom Inventory. They found that 32.6% of patients with fibromyalgia had reduced nerve fiber density on their biopsy, i.e, they had small fiber neuropathy. Interestingly, they also didn’t find any correlation between pain scores and nerve density.

This implies three things. First of all, the level of pain and symptoms experienced by people with fibromyalgia was the same as those with small fiber neuropathy. So you can’t distinguish between fibromyalgia and small fiber neuropathy based on symptoms alone. Second, about 1/3 of people diagnosed with fibromyalgia have small fiber neuropathy. Finally, having worse nerve density doesn’t necessarily mean you’ll experience more pain. Other studies have also found similar results.

Now this still doesn’t answer all our questions but I think it’s safe to say that testing for small fiber neuropathy should happen when there is a clinical diagnosis of fibromyalgia. Now let’s talk about small fiber neuropathy.

What is Small Fiber Neuropathy?

Small fiber neuropathy results from damage to the small, unmyelinated nerve fibers that send pain and temperature and control autonomic functions like sweating. The following are some of the symptoms caused by SFN:

Burning pain
Numbness and tingling
Pain that is out of proportion
Cramping
Unexplained itching
Lack of sweating
Temperature dysregulation
Dryness

How to diagnose small fiber neuropathy?

The first step to diagnose small fiber neuropathy is taking a care history, reviewing risk factors, and performing a detailed physical examination. On physical exam, deep tendon reflexes (e.g., knee jerk reflex) are normal and there’s no loss of strength. If there is a suspicion for SFN your doctor may send you for electrodiagnostic tests (EMGs). These are colloquially called nerve conduction tests.

Small fiber neuropathy affects small myelinated A-delta and unmyelinated C fibers, NOT large fibers. This means that EMGs are typically negative because these are good for looking for problems affecting large fibers like carpal tunnel syndrome.

One way to diagnose small fiber neuropathy is with a skin biopsy, more specifically epidermal nerve fiber density testing (ENFD). This technique allows direct visualization, quantification, and morphologic assessment of small sensory fibers innervating the skin. This technique has a sensitivity of 88% and a specificity of 95 – 97%. In layman’s terms, the test will miss 12% of cases of small fiber neuropathy, but if the test is positive, there’s a 3 – 5% chance that it’s a mistake (false positive). These are actually pretty good values. A report by the European Federation of Neurological Societies states that ENFD is a reliable and efficient tool to assess for SFN.

How is epidermal fiber density testing done?

Epidermal fiber density testing is done by taking 2-4 three mm punch biopsies. This test happens in clinic. It’s quick and safe. Your doctor can only do these in areas that have been validated: near the ankle, upper thigh, the foot, near the wrist, and the upper arm.

The biopsy is then sent to a specialized pathologist and stained with anti-protein gene product 9.5 antibody (PGP 9.5), which stains all the axons. The pathologist can then painstakingly count all the nerves and calculate the density. The density is then compared to age and sex matched control values to decide whether it’s abnormal.

Common causes of small fiber neuropathy

Once your doctor makes a diagnosis of small fiber neuropathy, then the question is whether there is an underlying cause. About 50% of small fiber neuropathy cases are idiopathic, meaning that doctors can’t find an underlying cause. As a result that leaves us with the other 50%. Of those cases, the most common cause is diabetes mellitus. In fact, autoimmune diseases make a relatively small proportion of cases, so it’s important to look for other causes first. There are MANY other causes but these are some of the more common conditions that can cause small fiber neuropathy.

Non-autoimmune causes

Diabetes mellitus
Lyme disease
Hepatitis C infection
HIV
Celiac disease
Chronic kidney disease
Hypo/hyperthyroidism
Alcohol abuse
Medications, especially chemotherapy
Vitamin B12, B6, B1 deficiency
Paraneoplastic syndromes
Amyloidosis
Exposure to heavy metals

Autoimmune causes

Sjögren’s syndrome
Systemic lupus erythematosus
Sarcoidosis
Rheumatoid arthritis
Scleroderma
Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)
Vasculitis
Psoriasis and psoriatic arthritis

Some genetic conditions can also cause small fiber neuropathy, like Fabry’s, but these are very rare.

Treatment

I won’t talk too much about treatment because it really depends on the underlying cause. If you’re dealing with an autoimmune disease… treat it. Sometimes symptomatic treatment is also necessarily. The following are some medications that are often used:

Tricyclic antidepressants
Serotonin norephinephrine re-uptake inhibitors (SNRIs)
Pregabalin
Gabapentin
Topical lidocaine
Topical capsaicin

Doctors sometimes use intravenous immunoglobulin (IVIG) in extreme situation, particularly in situations where an autoimmune disease is the culprit. The evidence supporting this type of treatment isn’t great. Sometimes it works, sometimes it doesn’t. Moreover, there are no large randomized controlled studies looking at IVIG treatment for small fiber neuropathy.

Ultimately, we’re going to need to understand why and how small fiber neuropathy happens to come up with effective treatments.

Conclusion

I hope this helps explain how small fiber neuropathy (SFN) mimics fibromyalgia and why it’s important to distinguish between both. For those who want to learn more about small fiber neuropathy and how to live with it, I’ve included a link to a great YouTube video.

Please leave your comments below!

References

Lauria G, Devigili G. Skin biopsy as a diagnostic tool in peripheral neuropathy. Nature Clinical Practice Neurology. 2007 Oct 3;3(10):546-57.

Devigili G, Tugnoli V, Penza P, Camozzi F Lombordi R, Milli G, Broglio , Granieri E, Lauria G. The diagnostic criteria for small fibre neuropathy : from symptoms to neuropathology. Brain 2008; 131; 1912-19.

Lauria G, Hsieh ST, Johansson O, Kennedy WR, Leger JM, Mellgren SI, Nolano M, Merkies IS, Polydefkis M, Smith AG, Sommer C, Valls-Sole J. European Federation of Neurological Societies/Peripheral Nerve Society Guideline on he use of skin biopsy in the diagnosis of small fiber neuropathy. Report of a joint task force of the European Federation of Neurological Societies and the peripheral nerve society. J Peripher Nerv Syst. 2010 Jun;15(2):79-92.

Giannoccaro MP, DonadioV, Incensi A, Avoni P, Liguori R. Small nerve fiber involvement in patients referred for fibromyalgia. Muscle Nerve. 2014 May;49(5):757-9.

Kosmidis ML, Koutsogeorgopoulou L, Alexopoulos H, Mamali I, Vlachoyiannopoulos PG, Voulgarelis M, Moutsopoulos HM, Tzioufas AG, Dalakas MC. Reduction of intraepidermal nerve fiber density (IENFD) in the skin biopsies of patients with fibromyalgia: a controlled study. J Neurol Sci. 2014 Dec 15;347(1-2):143-7.

Chan AC, Wilder-Smith EP. Small fiber neuropathy: getting bigger! Muscle Nerve. 2016 Feb 13. [Epub ahead of print]

UpToDate 2017

Uceyler N, Zeller D, Kahn AK, Kewenig S, Kittel-Schneider A, Casanova-Molla J, Reiners K, Sommer C. Small fibre pathology in patients with fibromyalgia syndrome. Brain. 2013 Jun;136(Pt 6):1857-67.

Medical Disclaimer

This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.

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