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Treating Rheumatoid Arthritis With a Biologic: Risks and Benefits

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There was a time, not very long ago, when a diagnosis of rheumatoid arthritis guaranteed a life of pain and disability. While there still isn’t a cure, the outlook is much brighter.

“[Things] have definitely changed for the better,” says Beth Jonas, MD, a rheumatologist with the University of North Carolina’s Thurston Arthritis Research Center.

Medications called biologic response modifiers — or biologics — have turned the tables. The use and ongoing development of these drugs have given people with RA — and their doctors — hope.

“It is very unusual now, in the year 2017, for me to have [someone] that I just can’t treat,” Jonas says. “I can’t tell you how great that feels. It’s a world of difference from just 20 years ago, before biologics.”

Treatment for RA has come a long way since the days of bloodletting and leeching — the gold standards of care many decades ago.

In the 1930s, doctors used actual gold to treat patients with RA. These injections were part of a group of drugs called disease-modifying anti-rheumatic drugs. You probably know them as DMARDs.

Gold compounds aren’t used much these days. Since the 1990s, the cornerstone of RA treatment plans has been a DMARD called methotrexate. Instead of directly treating pain and symptoms, they go after the underlying disease. By doing that, Jonas says, folks have less inflammation, pain, and damage.

“Methotrexate was a real game changer. It got people up and moving,” she says.

Some, she adds, not all. Jonas says about half of folks with RA got going.

Over time, researchers got a better grasp of how the disease works in your body. That led to the discovery of new parts of the body to focus on, and the development of biologics.

These biologic DMARDs are genetically engineered proteins made from human genes. They’re designed to target parts of your immune system that drive inflammation.

They do so with a sniper’s aim.

Guy Eakin, senior vice president for scientific strategy at the Arthritis Foundation in Atlanta, says that’s a big change from non-biologic drugs like methotrexate, which fight RA with more of a sledgehammer-like approach.

“The greatest advantage of using biologics to treat rheumatoid arthritis is that they can be exquisitely targeted to a specific player in our body’s immune system,” he says.

One of the key issues with traditional, oral DMARDs like methotrexate is they take weeks to months to work. Not so with biologics.

“Meanwhile, biologics gave us a tool that was potent and fast, and their ability to prevent joint damage is better,” Jonas says. “What we have learned over time is that a combination of biologics and methotrexate works better than either one alone.”

 

Etanercept (Enbrel) was the first biologic to be approved by the FDA. Since that approval in 1998, there are now at least eight more biologics for RA.

The first ones were known as anti-TNF agents. In other words, they block a substance called tumor necrosis factor. TNF causes joint inflammation and destruction.

When your doctor decides to go the biologics route, you’ll usually get TNF inhibitors first.

But what if your RA has nothing to do with TNF?

“Predicting the right drug can be tricky,” Jonas says. “Most of our first choices are TNF inhibitors, but we might have to switch to biologics with different mechanisms.”

Other biologics used to treat RA include:

Abatacept: Blocks communication between inflammatory T cells (those are a type of white blood cell)

Anakinra: Hampers the protein interleukin-1, a major culprit in inflammation

Baricitinib: A JAK inhibitor that tamps down inflammation

Rituximab: First used to fight non-Hodgkin’s lymphoma, this destroys white blood cells that help cause inflammation.

Sarilumab: An antibody that blocks the interleukin-6 receptor, known to cause inflammation

Tocilizumab: Targets interleukin-6, an immune system protein that fuels inflammation

Tofacitinib is almost in a class by itself. You can take it by mouth. It inhibits enzymes that help cause inflammation.

When thinking about the biologic big picture, Eakin thinks of an adage from the “Spider-Man” movies: “With great power comes great responsibility,” he says.

“When we talk about RA, what we’re actually doing with biologics is turning off part of the immune system. Or, more broadly, we are manipulating the immune system.”

The best strategy is to talk with your doctor about the different side effects associated with each drug.

“The biggest risk with this whole class of biologic drugs is infection,” Jonas says. That’s because of the changes the drugs make to your immune system.

There have been other concerns. The FDA issued a warning in 2009 that there is an increased chance of cancer in kids and teens who use biologics to treat juvenile arthritis. But, Eakin notes, there’s also a risk from other drugs used to treat the same thing.

“When you look back at billing records from the last 15 years, you can see that the cancer risk is similar for kids taking biologics versus those who aren’t,” he says.

 

The biggest hurdle with biologics is the price.

“The expense is crazy, the cost is high,” Jonas says.

Some relief may come with a new line of drugs called biosimilars, which will be entering the marketplace soon.

According to the Arthritis Foundation, biosimilars “have the potential to provide safe and effective treatment to people with arthritis at a significantly lower cost than name-brand biologic medications.”

But make no mistake. Biosimilars are definitely not generic versions of biologics.

Generic drugs are copies of brand-name drugs, with the same active ingredient, the same everything: dosage, safety, strength, etc.

Biosimilars are just what the name implies. They’re similar to the biologic they’re based on, but, because they’re made from living organisms, there are acceptable differences. In terms of safety, potency, and purity, they have no meaningful clinical differences from the biologic.

“Biosimilars are different from biologics in very nuanced ways,” Eakin says. “But, by and large, they are considered identical to one another.”

The estimated cost reduction for a biosimilar is 15% to 20%.

Whatever the cost, the basic rule when treating RA with biologics is, the earlier, the better.

“We know that the longer you have RA, the more likely you’ll have joint damage, so the key is to get started before that happens,” Jonas says. “And when the timing works out, the results are sort of amazing.”



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5 Family and Community Engagement Strategies to Improve Student Outcomes

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Strong school-family-community partnerships bring exceptional value to children’s education. A recent book by Karen L. Mapp, a senior lecturer at the Harvard Graduate School of Education, and four other co-collaborators synthesizes the available research to explain who benefits from these partnerships and the many advantages of family and community engagement.

Everyone Wins! The Evidence for Family-School Partnerships & Implications for Practice (Scholastic, 2022) cites various research to demonstrate how family-community-school partnerships benefit all stakeholder groups when they’re approached effectively:

  • Students have higher grades, better attendance, deeper engagement in school, greater self-esteem, and higher rates of graduation and college attainment.
  • Educators enjoy better job satisfaction, better success motivating students from different backgrounds, more family support, and an improved mindset about students and their families.
  • Families have stronger relationships with their children and better rapport with educators. They can navigate school policies and advocate for their children more effectively.
  • Schools enjoy a better climate, more support from their community, and improved staff morale—leading to better teacher retention.
  • School districts and communities become better places to live and raise children. They experience fewer disciplinary problems, greater participation in afterschool programs, and more family and student involvement in decision-making.
community members talking and hugging in matching green volunteer t-shirts in front of an outdoor mural

What elements make school-family-community partnerships particularly effective? Here are five tips for how school systems can successfully promote family and community engagement in education and drive better student outcomes.

1. Successful Family Engagement Requires Intentional Leadership

Engaging with families has to be a core activity and not just an afterthought. It requires a total commitment by school and district leaders, and this commitment must include investing in the tools and training needed to help educators effectively engage with families from all backgrounds. It must be a real and intentional focus, and as Mapp says: “It’s real when I see it on your budget sheets.”

2. Teachers and Administrators Must Communicate Clearly and Consistently

To encourage family involvement in their children’s education, educators must interact with families frequently—and in many ways. For instance, teachers and administrators might engage with families in person during school drop-off and pick-up periods, set up a Family Information Board in the school’s lobby, write and distribute regular newsletters or blog posts, and/or send emails or text messages to parents.

Communicating effectively is one of the National PTA’s “National Standards for Family-School Partnerships,” which guides how schools and families should work together to support student success. Teachers and administrators should learn about and meet families’ preferred methods of communication, and families should be able to share and receive information in culturally and linguistically relevant ways.

3. Develop Healthy, Positive Relationships Based on Mutual Trust and Respect

Interactions between educators and families should be positive and reciprocal, with families feeling valued and supported. Educators can establish trust and encourage healthy, two-way communications with families by sharing information about their children’s positive behaviors and accomplishments and which skills may need work. Listen to all parents and provide opportunities for shared decision-making.

4. Be Mindful of Diversity, Equity, and Inclusion

Welcoming all families and fostering a sense of belonging is another National PTA standard. When families engage with your school, do they feel respected, understood, and connected to the school community?

To ensure equity and inclusion, learn about the families you serve and their unique needs and challenges. Use culturally responsive engagement practices. Create opportunities for connection, especially with historically marginalized families and students. Learn about and seek to remove barriers for families to participate fully in their children’s education.

5. Help Families Support and Extend the Learning at Home

Students learn more effectively when they have opportunities at home to practice, reinforce, or extend the skills and lessons they’ve learned in school. Educators can facilitate this process by giving families specific ideas for expanding their children’s learning at home, such as by incorporating core math and literacy concepts into everyday routines.

Schools can also make instructional resources such as take-home packs, activity sets, and other materials available to families to support their children’s education.

How School Specialty® Can Help

School Specialty has more than six decades of experience in providing tools, resources, and strategies that promote successful education both in school and at home. We offer arts and crafts, early childhood, ELA, math, science, STEM/STEAM, physical education, special needs, and social emotional learning resources for families, as well as games, puzzles, and general supplies.

How do you promote family engagement in your classroom and community? Let us know in the comments!





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Preteens and skincare: What parents should know – CHOC

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Published on: April 16, 2024
Last updated: April 9, 2024

Should teens and preteens be using so many skincare products with fancy ingredients? A pediatric dermatologist answers parents’ questions.

Link: https://health.choc.org/preteens-and-skincare-what-parents-should-know/



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Living With Crohn’s: My Daily Routine

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By Michelle Pickens, as told to Danny Bonvissuto

As early as I can remember, I’ve had issues with my health. When I was little, I had severe constipation, nausea, vomiting, and food sensitivities.

As I got older, those symptoms transitioned into diarrhea, irregular bowel movements, and pain. I was always very fatigued and my immune system was weak: The second someone in my class had the cold or flu, I’d get it, too. Looking back, it was a sign.

From a mental perspective, my anxiety was high. What if I need to find a bathroom? What if I’m nauseous? Doctors would say, “Oh, you’ll grow out of it. It’s just your anxiety.”

Finally, a Diagnosis

After years of misdiagnosis, I was finally diagnosed with Crohn’s disease in 2015. I was 23 and had just finished up college while working full time. My symptoms were getting worse. I had a lot of vomiting and pain. The fatigue was at the point where it was difficult for me to work or even get out of bed some days.

It was so bad it pushed me to seek additional care. I took a couple months off, looked for another job, and went through all the doctor appointments it took to get the diagnosis.

There’s no blood test for Crohn’s. No way to prove what you’re feeling. Eventually I saw the right doctor, who did a test with a pill camera called a small bowel capsule. (This is a pill-sized camera that you swallow, allowing doctors to see inside your digestive system.) It tracked my intestines and was able to get into a blind spot where neither a colonoscopy nor endoscopy can see inflammation. 

It was such a relief to get the diagnosis because it made me feel like I wasn’t crazy. For so many years I knew something was wrong and couldn’t name it. I also felt hopeful. Once I knew what I was dealing with, I knew I could work to get to a better place.

Sharing My Story

In 2016, I started a blog called Crohnically Blonde as an outlet to connect with people as I go through the stages of dealing with Crohn’s. When I first started to share, there weren’t as many people talking about it.

I’ve been able to form relationships in an online community through shared experiences. I hope someone can see my story and feel that, if they’re at the beginning of their journey, there’s a way to get through.

Managing My Medication

At first, I was on a lot of medication that wasn’t working well and was a huge imposition on my schedule. Now I get infusions of an immunosuppressive drug every 7 weeks.

It means being away from my family and job for 4-5 hours, and managing child-care coverage during the treatment and the weekend after, because I feel almost flu-like. The extra help allows me to rest and fuel back up after the treatment.

I have the option to be on more medications to control my symptoms. But I try to shy away from those and manage it on my own because I don’t want to be on medicine for every single thing.

Before I had my son, I was more willing to try different medications. But while I was pregnant, I could barely be on any of the Crohn’s medicines. After I had him, it didn’t make sense to be reliant on them.

Crohn’s, Pregnancy, and Motherhood

Crohn’s affected me throughout my pregnancy. I got very sick in my third trimester because I went off my immunosuppressive drug to avoid passing any on to the baby. I ended up having to be induced early so I could get back on the medication as soon as possible.

My son, Maddox, is 1 now. Crohn’s changed my expectation of what I thought motherhood would be.

I’ve learned that I’d rather be present and able to enjoy him in the good moments than push it when I’m sick. It’s been difficult. But if I’m not well, I can’t be there for my child. I try to be with him as much as I can, but there are times when I need to step back and take an hourlong nap.

I have a great support system: My husband, mom, or mother-in-law can step in and help out for a little while, and when I feel better, I can be a better mom. There are also days when I don’t have accessible help. In those situations, I’ll do lower-key activities that I can enjoy with him but that aren’t physically demanding on me.

Schedule and Adjust

Right now I’m in a pretty good spot. I work from home now, as a recruiter for a tech company, and that makes a huge difference. A lot of my anxiety in the past was around being in an office and being sick. Now that I can work remotely, it’s such a game changer.

But Crohn’s still affects my day-to-day. I have days where I’m feeling sick, and need to rest and change my plans so I’m home and not out somewhere.

No matter how planned-out I have my day or week, if I’m not feeling well that takes precedence. I like to be a very scheduled person. But I have to roll with the punches and have a plan B.

The biggest challenge is managing my sleep and stress. They’re both very influential in symptom flare-ups. I have to get at least 8 hours of sleep, no matter what. And I try to incorporate time to de-stress, like reading a book or relaxing at the end of the day.

Going to therapy helps offset stress as well, and is now part of my ingrained self-care schedule.

Social Life Strategies

My co-workers, family, and friends are very understanding. But that wasn’t the case at first. The more open I’ve been about Crohn’s, the more people understand that I’m not flaking out if I have to change plans; there’s an underlying reason.

I only have a certain amount of energy, so now I pick and choose. I know I need to work and be with my family, which means I have less energy to put into social situations.

I plan out what I’m comfortable doing, but have also become comfortable with changing plans. Even if I’m excited to go out to dinner with a friend, I don’t push it if I feel terrible that day.

Food in Flux

I’ve followed a gluten-free diet for years. I started with an elimination diet and realized that gluten was bothering me.

Other foods aren’t as black and white. I can eat a salad one day and it’s fine, and eat the same salad the next day and it makes me sick. I repeat the safe foods that don’t make me sick and stick to a general schedule of three meals a day that are pretty much all gluten free.

Sometimes the timing matters: I’ll wake up and feel nauseated and need a starchy food like dry cereal. If I’m going on a road trip, or have a big event, like a wedding, I plan it out and try to be careful about what I eat leading up to it because I don’t want to be sick. But it’s hard because you never really know. It’s kind of a gamble.

Flexibility Is Key

I’ve learned to be as flexible as possible. I never know what each day is going to bring, I just have to trust that my body is telling what it needs for that specific day. That’s my priority, and everything else can wait.

 



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