Plaquenil... The Wonder Drug...

I love Plaquenil.

Also known as hydrochloroquine. It's a medicine that works wonders for a lot of my patients with lupus and rheumatoid arthritis. It can also help with Sjogren's syndrome, and even sarcoidosis. When it comes to treating autoimmune disease, there is no equal. It's a generic, it's time-tested, and effective.

It's an old anti-malarial medicine. The US Army gave it's precursor, Atabrine, to a few million GI's in the South Pacific to prevent malaria during World War II. A few of the Army doctors noticed that some of the men with autoimmune disorders got better... There wasn't much else to offer these patients, so they brought the medicine back to the states, and we've been using it ever since.

There are no drug interactions with plaquenil. It's very well tolerated, but does sometimes cause nausea, but that almost always gets better after you take it for a while. Most of my patients notice improvement in their fatigue within a couple of weeks. Then, over the next few months, many of my patients begin to feel their joints loosen up, their mouth sores clear, and their dryness improves... It's pretty unusual that it's the whole answer, but it's part of the treatment plan for a lot of my patients.

It's good stuff!!!

Which is why I can't, for the life of me, figure out why some clinicians don't at least try it!!!

I saw a new patient today, a nice girl who's been diagnosed with scleroderma at a young age. She developed some arthritis later, as well as Hashimoto's thyroiditis and interstitial cystitis. Throw in some mouth sores, rash, fatigue... She's a walking textbook of autoimmune illness. When she has a positive ANA last year her internist offered plaquenil. The patient called her rheumatologist, and he said 'no way, won't work...'

Huh?

How did he know? Why not try it? I've been shaking my head all evening over it.

I had another patient last month, with lupus, whose previous rheumatologist refused to write her for plaquenil even though she asked for it by name. He said he 'didn't have good luck with it'. Whatever. I started her on plaquenil and she's much better.

Sure, these are just a few patients. But my point is, if there's something out there that's low risk, effective, and can possibly help your patients, why not give it a try? Sure, there is the extremely small chance of eye problems with the medicine, but that's rare and with proper monitoring doesn't pose a long term risk.

 So, give it a try... You'll be glad you did...
 

A Birthday Blog, or What Gilgamesh Can Teach Us About the Meaning of Life

Today is my birthday. Please hold your applause.

Today is a great day to reflect on my life. As a husband, father, and member of the healthcare community, I am so fortunate to have a job where I am able to provide care, help people, and alleviate suffering.

I am reminded of the Epic of Gilgamesh. This was a story from ancient Mesopotamia, and the earliest tablets date back to the 18th century BC. There are 12 tablets and a lot of things going on, but the part I want to share is about the hero, Gilgamesh. He was quite the hero; part-god and part-man, and apparently was quite the specimen. He had it all, but went on a quest to find the meaning of life.

He went on an epic journey, crossing the ancient world seeking true meaning. He tried a solitary life, communing with nature, but that left him lonely. He thought that maybe killing the ogre Humbaba would give him renown, and elevating his status among his people would bring him meaning. Didn't really satisfy him. Gilgamesh tried wine, women, and song... I'm sure that was fun at first, but it soon left him empty... Longing.

He spends the night in the desert pondering his dilemma, with the enormous weight of the meaning of life on his mind. He finally collapses in exhaustion under a tree on a hill overlooking a city. He awakens as the sun rises.

Gilgamesh gazes upon the town as the morning sun begins to shine on the houses, and sees the townspeople begin their day. Men, women, children milling about, starting their morning chores, interacting, eating breakfast... Living their idyllic ancient Mesopotamian lives...

Then it hits him.

It's people. People are the answer. People are the answer to the question of meaning in life. Interaction with people, working with people, making people's lives better. Laughing, healing, growing...

Almost 4000 years ago the Mesopotamians figured it out. It's still true.

We were not meant to live in a vacuum. Our being, our DNA, our souls are all  programmed to be interacting with others. And by making other lives better our souls are fed, and meaning will fill our lives until it overflows.

I'm so lucky. I get paid to help people. Lots of them. Some of them desperate, with problems that very few clinicians want to deal with. And a lot of them get better. It's an amazing thing to see...

Some people dread birthdays. I say, bring 'em on!

The Pharmaceutical Companies Come Up With More Creative Ways to Suck Money from the American Health System...

So goes the latest scheme to come from the pharmaceutical industry...

The re-run. Marked way up.

It's the new trick from some enterprising pharmaceutical companies. Take an existing medication, tweak it ever so slightly, and charge 6 times the generic version! Sweeet deal!

But hey, no insurance company would go for that. They'll make it a 'tier 3 drug' and the patient would have to pay a bunch out of pocket. If the patients have to pay $100 for a new prescription, they'll say no thanks and leave the pills on the pharmacy counter.

Problem solved.

But, the pharm companies figured out a way around that! They will give us prescription writers a co-pay card! I can write a prescription for the 'newish' drug, give the patient the co-pay card, and the pharm company eats the $100 co-pay, and the patient pays nothing!

Wow, I'm going to feel so good about myself as a health-care provider. My patient won't pay a dime for their pills!

But what's the real cost? I was approached by a sales rep who promised me my patients would get their medication FOR FREE, but of course, they need to have some kind of health insurance. But not medicare. Or medicaid. He conceded the prescription would be tier 3, but don't worry about it with this handy-dandy co-pay card.

So after he left I called the pharmacy and found out the true price on those pills. While the generic was about a dollar a pill, these babies were about 6 dollars a pill... Wow!

So, for a standard prescription, the insurance company will have to pay $1100, and the company will cover the $100 co-pay. For the generic alternative, the insurance company pays about $160, and the patient will pay $20.

I confronted the rep when he came back a couple of weeks later. I asked him exactly what kind of R&D did his company do on this product to justify $6 a pill. He smiled.

"I don't really know," was his retort. "All I know is your patients are gonna get their medication for FREE!!!"

"Well," I replied, "I cannot write a prescription for your medication. I am morally opposed to your company's business model."

"But what about your patients? They're gonna have to pay a copay!"

I nodded. "I know, and I'm the last guy who would want to come to the defense of the insurance companies, but I'm not going to play your game."

He packed up his stuff and took off. Haven't seen him since.

He never even brought donuts.

Fibromyalgia... The Great Debate...

"Well, you know I have fibromyalgia..."

Before I worked in rheumatology those words used to send my internal eyes rolling upward. I would nod professionally and pretend I understood, but inside my reaction would be to label the patient with some sort of psychogenic ailment (meaning, it's all in their head). And most of my colleagues believed the same thing, that anyone who brings forth this fact as a part of their medical history was, well, probably crazy.

And I was guilty of the same thing.

I worked for seven years in neurosurgery as a physician assistant, helping my doctors with mostly spine cases. I got to know a lot of my patients quite well, and I would always hesitate to inform my doctors that the patient claimed to have fibromyalgia. It would taint their view of the patient in a negative way, so I would usually just let the patient inform the surgeon themselves. The reaction was always the same. A polite nod, and then the rolling of the eyes as the physician left the room.

I then worked for 5 years in orthopedic surgery, and the thought process was about the same.

Now I've been a rheumatology physician assistant for a year. I still have much to learn. But I am seeing and taking care of patients with a different frame of mind. These are my patients, and I figure I'm better off believing ALL of their complaints are real, and then treating ALL of their complaints aggressively. Then, if we're still left with some unresolved issues, we can delve into those from a psychogenic standpoint. I think that's what a lot of rheumatologists do. I hope.

Trying to piece together fibromyalgia has been difficult. Wrapping my mind around what I previously thought was a bunch of hooey, and treating it as a real ailment, has been quite a journey. It was after listening to a fascinating lecture by Frederick Wolfe, M.D., a world-renowned expert on fibromyalgia, that I was able to finally wrap my mind around this whole thing.

Hello, my name is Eric. I'm a fibromyalgia believer.

There. I said it.

I think it's real.

I have a slightly different approach, however, and it seems to work for most of my patients.

My approach:
1. Fibromyalgia is real.
2. Fibromyalgia is generalized muscle pain, and it is usually the result of an undiagnosed, or poorly understood autoimmune disease, such as rheumatoid arthritis, lupus, and ankylosing spondylitits.
3. Usually proper treatment of the underlying autoimmune disease helps the muscle pain.
4. Some patients with autoimmune diseases have a lot of muscle pain, some have just a little. It's a spectrum.
5. Many of my patients have been diagnosed with fibromyalgia by their primary care providers. And they accept that and leave their primary care physician's office. But a lot of my patients also have insomnia. If they went to their PCP and said, "I can't sleep", and their PCP said, with a very serious voice, "Well, Mrs. Smith, you have insomnia," she would probably say, "Thank you, doctor, but WHY?" I wish when my patients were diagnosed with fibromyalgia, they would say, "Thank you, doctor, but WHY?"
6. So I basically place fibromyalgia in the same category as insomnia. a lot of my patients have muscle pain, just like a lot of my patients have trouble sleeping. I take their complaints seriously and address them as best I can. I do know that the SNRI's can help quite a bit, and use them frequently to help with the muscle pain my patients have.
7. I do have a couple of patients with true fibromyalgia, and little else to go on as far as a true autoimmune disease. It's a struggle. But those patients seem content continuing to see me because they know I believe them, and I'm not going to give up on them.

Does fibromyalgia deserve to be it's own disease? Well, now that the pharmaceutical industry is involved, we're stuck with it. The FDA blessed it as a disease when it gave some medications indications for fibromyalgia. Millions are being spent every year on medicines and research. Which is good, I suppose.

But does giving "disease" status to something that is more like a "symptom" really help anyone?

Time will tell...