News & Views Newletter
edited by Jack Nicholas, cornishpro@aol.co

PSORIATIC ARTHRITIS NEWS AND VIEWS
VOL. 3 ISSUE 3 March 1, 2003
PSORIATIC ARTHRITIS MEDICAL NEWS

NEW PSORIASIS DRUG AVAILABLE
WebMD Medical News Reviewed By Brunilda Nazario, MD

Date of approval: Jan. 31, 2003

What is approved: The FDA has approved Amevive (generic: alefacept) for the treatment of moderate to severe plaque psoriasis in adults.

Psoriasis, which affects approximately 1%-3% of the world's population, is a skin disease that appears as patches of raised red skin covered by a flaky white buildup. It's thought to be related to faulty signals sent by the body's immune system, although the exact cause is unknown. Plaque psoriasis is the most common form of psoriasis.

Amevive is designed to reduce the immune system reaction involved in psoriasis.

Side effects: Possible side effects of Amevive include sore throat, dizziness, increased cough, nausea, itching, muscle pain, chills, injection site pain, injection site inflammation.

Precautions: Amevive suppresses the immune system, which could increase chances of developing an infection or malignancy. Patients should have regular white blood cell counts during treatment. Patients who become pregnant while taking the drug should contact the manufacturer -- (866) AME-VIVE -- to be enrolled in a registry that will follow any effects that the drug may have on the developing fetus. The effects of the drug on pregnancy are unknown.

When it will be available: Biogen says Amevive was shipped to doctors and pharmacies on Feb. 3, 2003.

Basis of approval: Two randomized, double-blind, placebo-controlled studies of 1,060 adults with chronic plaque psoriasis showed that a significantly higher percentage of patients receiving Amevive responded to treatment compared with those receiving placebo based on pre- and post-treatment measurements of the percentage of affected skin surface area and severity of scaling and inflammation. Manufacturer: Biogen Inc. Sources: FDA o News release, Biogen, Inc. o WebMD Medical News: "New Hope for Heartbreak of Psoriasis."

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MORE INFORMATION ABOUT NEW FAMILY OF PSORIASIS DRUGS WebMD Scientific American® Medicine 2003. Posted 01/02/2003

Several drugs are poised for FDA approval for the treatment of psoriasis. Two medications, etanercept (Enbrel) and infliximab (Remicade), are already used to treat rheumatoid arthritis and Crohn disease; a third agent, alefacept (Amevive), has been recommended for approval; (Editors Note: This was approved on 1/31/03) (another medication, efalizumab (Raptiva)-approved 12/31/02, has undergone extensive testing; and several others are on the way. The purported efficacy of these agents is the result of their interference with specific targets that lead to psoriasis.

Infliximab is effective in most patients, works quickly, and results in long-lasting remissions (in most cases, over 6 months). It can be administered with methotrexate and is not associated with nephrotoxicity or hepatotoxicity. Infliximab's drawbacks are several: it has to be administered by I.V. infusion over a period of at least 2 hours, infusion reactions are common, and patients occasionally develop antibodies that result in an increased frequency of side effects. There have been reports of serum sickness, and there is concern over increased susceptibility to infection, specifically to tuberculosis. Once approved, the drug may cost approximately $12,000 to $20,000 annually.

Etanercept results in dramatic and rapid improvement of psoriatic arthritis and, like infliximab, can be given with methotrexate. Etanercept is administered by patients at home at a dosage of 25 mg twice a week S.C. Its drawbacks include the development of non-neutralizing antibodies, antinuclear antibodies, anti-double-stranded DNA, and anticardiolipin antibodies. There have been rare reports of lupus erythematosus, but in all instances, major organs and systems such as the kidney and the CNS have been spared.

The main adverse reaction has been the development of injection-site reactions, which occurred in over a third of rheumatoid arthritis patients treated with etanercept and in 9% of psoriasis patients. Exacerbations of demyelinating diseases such as optic neuritis and multiple sclerosis have occurred, and there is concern about susceptibility to infection in patients treated with TNF- blockers. There are currently no recommendations for monitoring patients on etanercept. However, the emergence of tuberculosis in patients treated with TNF- inhibitors warrants that baseline purified protein derivative values and, if necessary, chest x-ray be obtained. Etanercept costs approximately $12,000 to $20,000 a year.

Alefacept, which has been recommended for approval by an FDA panel, results in extremely long remissions. Although CD45RO+ T cells are reduced, naive cells are unaffected. In over 1,500 patients treated with several courses over a few years, there has not been a single instance of opportunistic infection. Unfortunately, not everyone treated with alefacept experiences clearing of psoriasis. Another perceived drawback is the need to return to the physician's office each week for an intramuscular or intravenous injection. Moreover, the response to this drug is slow, with peak response occurring weeks after a 12-week treatment course; some patients experience further improvement with additional therapy.

Efalizumab, like etanercept, has the advantage that patients administer it subcutaneously at home, once a week. There is no hepatotoxicity and no nephrotoxicity associated with the use of this drug, but like all of the other biologics, it is likely to be expensive, and unlike the others, patients may experience exacerbations in psoriasis upon discontinuation of the drug, necessitating long-term therapy.

The nomenclature of the biologics is clinically important. Drugs that end in the letters mab are monoclonal antibodies. If they end in ximab, they are chimeric monoclonal antibodies and therefore may form neutralizing antibodies. Drugs that end in the letters zumab are humanized monoclonal antibodies and are therefore less likely to result in formation of neutralizing antibodies. Drugs ending in the letters cept involve the fusion of a receptor to the Fc portion of human IgG1.

Abandonment of current psoriasis treatment is not likely to occur. Safe and effective options still remain, including 80-year-old ultraviolet B phototherapy, one of the safest treatments available. WebMD Scientific American® Medicine. Mark Lebwohl, MD, Mount Sinai School of Medicine.

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ARTHRITIS COMMITTEE WILL DISCUSS RISK OF LYMPHOMA WITH TNF INHIBITORS FDA's Arthritis Advisory Committee will likely discuss the need for formal epidemiological studies regarding the risk of lymphoma associated with tumor necrosis factor inhibitor use during its March 4 meeting.

Several CBER scientists recently published a case study of the occurrence of lymphoproliferative disorders in patients treated with TNF inhibitors, based on MedWatch data. Twenty-six cases were identified between May 1999 and December 2000; 18 with etanercept and 8 with infliximab. The majority of the cases (81%) were non-Hodgkin's lymphomas.

Sixty-eight lymphoma cases from November 2001 to September 2002 were subsequently reviewed: 54 had a "probable" association with TNF agents (29 infliximab, 25 etanercept) and 14 had a "possible" connection (10 infliximab, 4 etanercept).

"A case-series such as this cannot establish a cause-and-effect relationship between drugs, such as etanercept and infliximab, and an adverse outcome, such as lymphoma," the Dec. 12, 2002 Arthritis & Rheumatism article states.

"However, associations identified in this manner may prompt caution in the clinical use of a particular medication and may provide a rationale for the development of formal epidemiologic studies to assess the purported relationship in a more quantitative manner," CBER Epidemiology Division Director Miles Braun, MD, et al., maintained.

All three TNF inhibitors - Abbott's Humira (adalimumab), Amgen's Enbrel (etanercept) and Centocor's Remicade (infliximab) - will be reviewed by the committee. Centocor and Amgen could present data from their patient registries, which were established near the time of the committee's first TNF inhibitor safety review August 17, 2001.

Labeling for Humira, which was approved Dec. 31, 2002, contains a warning that "lymphomas have been observed in patients treated with TNF blocking agents including Humira. In clinical trials, patients treated with Humira had a higher incidence of lymphoma than the expected rate in the general population."

Forty-eight malignancies of various types, including 10 patients with lymphoma, were observed out of 2,468 RA patients treated with Humira for a median of 24 months in clinical trials. Malignancies occurred in 18 out of 1,372 patients in long-term Remicade trials (up to 102 weeks), and 17 of 1,197 patients on Enbrel in clinical trials up to 36 months.

"While patients with rheumatic arthritis, particularly those with highly active disease, may be at a higher risk (up to several fold) for the development of lymphoma, the role of TNF blockers in the development of malignancy is unknown," labeling adds. Remicade and Enbrel labeling contain similar statements.

This meeting will be held March 4, 2003 at the Holiday Inn in Silver Spring, Md. beginning at 9 a.m.

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ADDING ADALIMUMAB TO METHOTREXATE IMPROVES OUTCOME IN RHEUMATOID ARTHRITIS
Laurie Barclay, MD - Jan. 30, 2003

Addition of the recently approved monoclonal antibody adalimumab to methotrexate treatment for rheumatoid arthritis (RA) provided significant, rapid, and sustained improvement in disease activity, according to the results of a double-blind, placebo-controlled trial reported in the January issue of Arthritis & Rheumatism.

"Over the last decade, methotrexate has become the treatment of choice for RA," write Michael E. Weinblatt, MD, from Brigham and Women's Hospital in Boston, Massachusetts, and colleagues. "Even when they respond fully to methotrexate therapy, patients experience less than 50% improvement."

In the Anti-tumor Necrosis Factor Research Study Program of the Monoclonal Antibody Adalimumab (ARMADA) trial, 271 patients with active RA were randomized to receive injections of adalimumab (20 mg, 40 mg, or 80 mg subcutaneously) or placebo every other week for 24 weeks while continuing their long-term stable dosage of methotrexate.

The proportion of patients meeting American College of Rheumatology criteria for 20% improvement (ACR20) at 24 weeks was significantly greater in the adalimumab plus methotrexate groups (47.8% for 20 mg, 67.2% for 40 mg, and 65.8% for 80 mg) than in the placebo plus methotrexate group (14.5%; P < .001).

Compared with an ACR50 response rate of 8.1% in the placebo group, ACR50 response rates were also better in the groups receiving adalimumab (31.9% for 20 mg, P = .003; 55.2% for 40 mg, P < .001; and 42.5% for 80 mg, P < .001). ACR70 response rate was 4.8% in the placebo group, 26.9% in the 40-mg group (P < .001), and 19.2% in the 80-mg group (P = .02).

Most patients receiving adalimumab achieved an ACR20 response at the first scheduled visit (week 1). Numbers of adverse events were similar in all groups. Study limitations include absence of another active treatment arm to allow comparison of the response to adalimumab with that to other known therapies.

"The addition of adalimumab at a dosage of 20 mg, 40 mg, or 80 mg administered subcutaneously every other week to long-term methotrexate therapy in patients with active RA provided significant, rapid, and sustained improvement in disease activity over 24 weeks compared with methotrexate plus placebo," the authors write. "Our findings suggest that adalimumab may be a new therapeutic option for patients with longstanding, active RA who have had an inadequate response to methotrexate."

Abbott Laboratories and Knoll Pharmaceuticals supported this trial and have financial arrangements with some of the study authors.

Source: Arthritis Rheum. 2003;48:35-45 and Reviewed by Gary D. Vogin, MD

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RHEUMATOID ARTHRITIS LINKED WITH INCREASED RISK OF CARDIOVASCULAR EVENTS NEW YORK (Reuters Health) January 23, 2003

Patients with rheumatoid arthritis (RA) appear to be at increased risk of myocardial infarction (MI), congestive heart failure (CHF), and probably stroke, according to a report published in the January issue of The Journal of Rheumatology.

Previous reports have shown a link between RA and cardiovascular disease mortality. However, cardiovascular disease morbidity and the risk of cardiovascular events in patients with rheumatoid arthritis have not been investigated.

Dr. Frederick Wolfe, from the Arthritis Research Center Foundation in Wichita, Kansas, and colleagues compared the incidence of adverse cardiovascular events in 9093 patients with RA and in 2479 patients with osteoarthritis. The patients completed a survey regarding past and current medical problems.

On multivariate analysis, RA patients were more than twice as likely as osteoarthritis patients to have experienced an MI. In addition, RA patients were 43% more likely to have a history of CHF and 70% more likely to report current stroke. For RA patients, the lifetime prevalence's of MI, CHF, and stroke were 4.14%, 2.34%, and 3.02%, respectively.

"To our knowledge, this is the first study examining cardiovascular and/or cerebrovascular disease morbidity among RA patients," the investigators note.

The present findings indicate that RA is, in fact, associated with increased cardiovascular disease morbidity. "As such, the effects of RA on morbidity as well as mortality should be accounted for in estimates of the RA burden of illness and should be considered in future studies examining therapies for RA," the authors conclude.

J Rheumatol 2003;30:36-40.

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COMBINING ANAKINRA AND ETANERCEPT RAISES INFECTION RISK
By Richard Woodman LONDON (Reuters Health) February 6, 2003

The European Medicines Evaluation Agency has warned of an increased risk of serious infection and neutropenia in patients treated concurrently with the arthritis drugs anakinra (Kineret; Amgen) and etanercept (Enbrel; Wyeth and Amgen).

In a statement, it said results of a clinical trial sponsored by Amgen showed that 7% of rheumatoid arthritis patients who received both medications at the same time had developed serious infections. Two percent of patients also developed neutropenia.

A special warning has now been added to the label of both drugs saying that concurrent administration is not recommended because of the increased risk.

The purpose of the trial, which involved 242 patients, was to compare the efficacy and safety of Enbrel 25 mg biweekly alone with Enbrel plus Kineret 100 mg daily.

The incidence of infection and of neutropenia was higher in the combination arm and there was no therapeutic advantage, the EMEA said.

Last month, the EMEA advised physicians to "use caution" when prescribing Enbrel in patients with congestive heart failure because of the possibility that the therapy might worsen their condition.

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ANCOM BLOOD PRESSURE TABLETS RECALLED
WebMD Medical News reviewed by Michael Smith, MD - Date of recall: Jan. 17, 2003

What is being recalled: In cooperation with the FDA, Herbsland Inc. is recalling all 100-tablet bottles of Ancom Anti-Hypertensive Compound Tablets. The over-the-counter product has not been approved by the FDA. Ancom contains several prescription drug ingredients, including the diuretic (water pill) hydrochlorothiazide, the anxiety drug Valium, and the nausea drug Phenergan.

The recall applies to all lots of the drug, which were sold without prescription to consumers through distributors and retail stores in the New York city area and nationwide via the Internet.

The bottles were sold in a cardboard carton that bear the product's name as "Ancom tablets, Anti-Hypertensive compound" and display the manufacturer's name as Shanghai Pharmaceutical Industry Corp., Shanghai, China. The label also has Chinese markings and a pink and blue vertical stripe with white lettering.

Side effects: According to the FDA, this combination of potent ingredients poses potentially serious health risks, including sedation, depression, and possibly life-threatening blood abnormalities. No illnesses have been reported to date.

What to do: Consumers who have used this product and experience any side effects should seek advice from their doctor for evaluation and treatment of their high blood pressure.

Consumers who purchased Ancom Anti-Hypertensive Compound Tablets are urged to discontinue use of the product immediately and return it to the place of purchase for a full refund. Consumers with questions may contact the company at 1-917-480-9107.

The FDA requests that any adverse reactions experienced with the use of this product also be reported to the FDA's MedWatch Program by phone at 1-800-FDA-1088, by Fax at 1-800-FDA-0178, by mail at MedWatch, HF-2, FDA, 5600 Fishers Lane, Rockville, MD 20852-9787, or on the MedWatch website at http://www.fda.gov/medwatch.

Manufacturer: Shanghai Pharmaceutical Industry Corp., Shanghai, China., distributed by Herbsland Inc.

SOURCE: News release, FDA © 2003 WebMD Inc. All rights reserved.

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Editors Note: When you think you may be having a bad day, remember the woman in the following story.

BRAIN CANCER PATIENT SUES OVER ARREST TACOMA, Wash. (AP)

A woman with a brain tumor filed a lawsuit against Walgreens, saying when she arrived to pick up her painkiller prescription one day, a pharmacist had her arrested.

In a lawsuit filed Thursday in Pierce County Superior Court, Shannon O'Brien, 35, said she went to the drive-up window at a Walgreen Drug Store two blocks from her home last July 7. The pharmacist on duty thought she had faked her Percocet prescription and called police, the lawsuit stated.

``I was in hysterics--crying, very upset and very embarrassed,'' O'Brien told The Associated Press on Thursday. ``They could have checked my records. I've had the same medicine every month.''

A woman who answered the phone at the pharmacy Thursday directed inquiries to the Walgreen's regional office in Bellevue, where a telephone message was not immediately returned. A spokeswoman based at Walgreen Co. headquarters in Deerfield, Ill., said Friday she could not comment on pending litigation.

O'Brien's lawyer, Mike Withey, said he didn't know what led the pharmacist to suspect O'Brien of faking her prescription. According to the lawsuit, when the pharmacist called the University of Washington Medical Center's neurosurgery department to ask about it, he was told O'Brien's doctor, Alexander Spence, was unavailable, so the prescription couldn't be confirmed right away.

That's when the pharmacist called Tacoma police, the lawsuit said. O'Brien was still sitting in her car at the drive-up window when they arrived.

O'Brien, who was first diagnosed with a brain tumor in 1994, said she told the officer who handcuffed her that he could call her doctor or her nurse to verify the prescription.

``I told him I had brain cancer, and I had a medical information card inside my wallet,'' she said. ``It didn't matter to him. He didn't believe anything I was telling him.''

O'Brien's family posted bail that night, but she was still without her medicine. She was arraigned the next day; as a condition of her release, she was required to attend a session at a drug treatment facility.

Her lawyer eventually succeeded in getting the felony prescription fraud charge dropped--after her doctor provided confirming information to the Pierce County prosecutor's office. The pharmacist was not immediately reachable by telephone for comment. Copyright 2003, The Associated Press.

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Editor's note: Since Methotrexate is part of our everyday language and many of us are currently using it, the following information is provided for educational and reference purposes.

EVERYTHING YOU EVER WANTED TO KNOW ABOUT METHOTREXATE

GENERIC NAME: methotrexate - BRAND NAMES: Rheumatrex, Trexall

DRUG CLASS AND MECHANISM: Methotrexate is classified as an antimetabolite drug, which means it is capable of blocking the metabolism of cells. As a result of this effect, it has been found helpful in treating certain diseases associated with abnormally rapid cell growth, such as cancer of the breast and psoriasis. Recently, methotrexate has been shown to be effective in inducing miscarriage, for example in patients with ectopic pregnancy. This effect of methotrexate is attributed to its action of killing the rapidly growing cells of the placenta. It has also been found very helpful in treating rheumatoid arthritis, although its mechanism of action in this illness is not known. It seems to work, in part by altering aspects of immune function, which may play a role in causing rheumatoid arthritis.

PRESCRIPTION: yes - GENERIC AVAILABLE: yes

PREPARATIONS: Injectable: 25mg/ml; Tablet: 2.5mg (Rheumatrex), and 5, 7.5, 10 and 15 mg (Trexall).

STORAGE: Store between 59 and 77degrees F in a sealed container, avoid light.

PRESCRIBED FOR: Methotrexate is used for cancer treatment generally in higher doses than for other uses, and is often administered intravenously or intramuscularly. Methotrexate is used to treat psoriasis, an inflammatory skin disease, as well as the arthritis that occurs in 10 percent of these patients (psoriatic arthritis). It is also used to treat active rheumatoid arthritis in adults and children. It is also used to treat other rheumatic diseases, including polymyositis and systemic lupus erythematosus. Methotrexate has been used to induce miscarriage in patients with ectopic pregnancy.

DOSING: May be taken with or without food. For rheumatoid arthritis and psoriasis, the dose of methotrexate is given WEEKLY, whether by injection or orally. For psoriasis, the weekly dose is often divided into three doses given at 12-hour intervals each week. This has been shown to be more effective, as it relates to the natural growth cycling of the skin.

DRUG INTERACTIONS: Because methotrexate can cause serious liver disease, patients with alcoholism or liver disease should not receive it. Patients should curtail alcohol consumption while taking methotrexate. Methotrexate can suppress the body's immunity. Therefore, any symptoms of infection should be reported to the doctor. Patients with underlying immune deficiency diseases should not receive methotrexate. A dry, non-productive cough can be a result of rare lung toxicity. Methotrexate can impair fertility, decrease sperm count and cause menstrual dysfunction. Safety and effectiveness has not been established in children.

PREGNANCY: Methotrexate should not be used in pregnancy, as it can be toxic to the embryo and can cause fetal defects and spontaneous abortion (miscarriage). It should be discontinued prior to conception if used in either partner. Male patients should stop taking methotrexate at least 3 months prior to a planned conception and females should discontinue use for at least one ovulatory cycle before conception.

SIDE EFFECTS: Methotrexate can be well tolerated, but also can cause severe toxicity, which is usually related to the dose taken. The most frequent reactions include mouth sores, stomach upset, and low white blood counts. Methotrexate can cause severe toxicity of the liver and bone marrow, which require regular monitoring with blood testing. It can cause headache and drowsiness, which may resolve if the dose is lowered. Methotrexate can cause itching, skin rash, dizziness, and hair loss. A dry, non-productive cough can be a result of a rare lung toxicity.

Methotrexate is a Disease Modifying Anti Rheumatic Drug (DMARD). Originally used as a chemotherapy drug to treat certain kinds of cancer, methotrexate was found to be beneficial in those with inflammatory arthritis and/or psoriasis. It may be taken by mouth or via injection.

FDA approved: December 1953. Average annual cost: $605.86 - 17.5mg orally per week

Brand Names and International Availability:

Abitrexate (US); Biotrexate (India); Brimexate (Italy); Canceren (Korea); Emthexat (Sweden); Emthexate (Netherlands, Belgium, Norway, Portugal, Spain, Greece, Hong-Kong, Philippines, Taiwan, Thailand, Korea, Israel); Farmitrexat (Germany, Indonesia); Farmotrex (Denmark); Folex (US); Lantarel (Germany); Ledertrexate (Australia, New-Zealand, Netherlands, Belgium, France, Portugal, Finland, Mexico); Maxtrex (England, Philippines); Mexate (Philippines); Metex (Germany); Methoblastin (Australia, New-Zealand); Methotrexate (Australia, Peru, Japan, Hong-Kong, Indonesia, Malaysia, Philippines, Taiwan, Thailand, South-Africa, Israel, US); Methotrexato (Argentina); Metotrexato (Colombia); Mexate (US); MTX (Malaysia, Korea); Neotrexate (India); Rheumatrex (US); Texate (Mexico); Texate-T (Mexico); Tremetex; Trexan (Finland, Taiwan); Trixilem (Mexico); Xaken (Mexico);

How does it work? It is not known exactly how methotrexate works in inflammatory arthritis. It is suspected the benefit comes from its effect on the immune system.

Methotrexate tablets are available in 2.5mgs. Usual dosage is 7.5mg -20mg weekly. Higher doses may be used to treat more severe cases and psoriasis.

When used for the treatment of rheumatic diseases and psoriasis, methotrexate is almost always taken ONCE A WEEK. Oral methotrexate may be taken with or without food. Injectable methotrexate may usually be self-injected after proper instruction from a health care professional.

Methotrexate is known to cause miscarriages. DO NOT take methotrexate if you suspect you may be pregnant. Pregnancy should be avoided if either partner is receiving methotrexate.

Methotrexate should be avoided in nursing mothers.

Methotrexate should be avoided in those with a history of liver disease.

Drug Interactions: Oral antibiotics such as tetracycline may decrease the absorption of methotrexate.

The potential for liver damage is increased with the use of alcohol while on methotrexate. Alcohol should be avoided.

Because of the potent nature of this medicine, be sure to tell your doctor about any other medicines you are taking, including nonprescription medicines and vitamins.

These side effects are not considered serious but are certainly annoying for those experiencing them.

The most frequently reported side effects include fatigue, nausea, headache, dizziness, diarrhea, mouth sores, increased sensitivity to the sun, loss of appetite, "brain fog", mood alterations, and hair loss. Many of these side effects are more noticeable the day of and the day following your weekly dose. Many people have found that taking methotrexate before bed allows them to sleep through many of annoying symptoms. These side effects may decrease over time. The severity of these side effects may be decreased by taking oral folic acid supplements.

More serious side effects that you should report right away include dry non-productive cough, fever, black stools, unusual bleeding or bruising, vomiting, persistent sore throat, and yellow skin or eyes.

Methotrexate has the potential to cause liver damage, lung disease and bone marrow suppression. Although usually seen with higher doses than used to treat rheumatic diseases, these can occur with low, weekly doses.

Signs of a possible allergic reaction are rash, swelling and difficulty breathing. These symptoms should be reported immediately.

Precautions & Special Notes: Due to the potential for sun sensitivity exposure to direct sunlight should be avoided. If you are in the sun please wear protective clothing and strong sun block.

You will be required to have frequent blood work while on this medication. It is very important that you keep all lab and doctor's appointments.

Never stop the use of methotrexate unless instructed by your physician. Avoid the use of alcohol while on this drug. Unless instructed otherwise, make sure you drink plenty of water the day before and after your weekly dose. You may want to schedule your dose on a day when you have no plans for the next day, until you find out exactly how you react to the drug. Methotrexate suppresses the immune system. Avoid exposure to illnesses and viruses when possible.

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QUICK TIPS FOR USING ONLINE HEALTH INFORMATION WITH YOU PHYSICIAN
By Howard LeWine, M.D. Harvard Medical School Special Commentary

Patients can play a role in working with their doctors not only to use Web information more effectively, but also to improve their care. 1. Let your doctor know what sites you are accessing for health information. Your doctor may be immediately familiar with the sites, or he or she can check them out later to form an opinion of their credibility. 2. Don't expect your physician to be a 24/7 health-information center. Both the Internet and the health/medical research field move rapidly. Even the best-informed, Web-savvy physician cannot keep up with everything. With participation, your doctor can be your gravitational force to help you pull in the information that's best for you. Further, find out whether your hospital, clinic, or insurance plan offers health information. 3. Use information to become a well-prepared patient - don't use the materials you find online to second-guess your doctor. The Web enhances care; it doesn't replace it. Often there is no absolute "right" answer. If you have found information that is different from what your doctor suggests, ask about it rather than challenging his or her attempts to help you. 4. Realize that even the best health information has its limits. Health information on the Web, on TV, or in print aims to reach a wide audience. Even if it feels the information is aimed directly at you, your health circumstances are unique. Partner your own research with your doctor's knowledge of you as an individual.

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It is good to be back from a restful time in the warm sun of the Caribbean. The combination of all my medications, including methotrexate, topical creams and sunlight, has allowed me a temporary level of reprieve from Psoriatic Arthritis.

Enjoy the simple things. Laugh often, long and loud. Laugh until you gasp for breath.

Good Health to All,

Jack Nicholas
Newsletter Editor
Cornishpro@aol.com
Issue 2003 3/01/03 -3