Rituxan Infusion - Round 1 of 2

Yesterday was round one of my Rituxan infusion.

Things didn't go quite as smoothly during the appointment as they did my first 2 rounds (back in December '15), however post appointment was much better.

My appointment was at 9:00 and we got started right on time. 

About 9:45 I stared having intense, sharp pain from the elbow down to my fingertips on the arm with the IV. After trying a few tricks and one more vein, the IV was moved to my inner elbow.

At about 10:30, I started having an allergic reaction to the medication. My legs started itching, I felt a tightness in my chest and my throat felt a little swollen.

The infusion was stopped and got an IV dose of Benedryl which almost made me pass out. It was intense. I was even slurring.

My Rheumatologist is not in on Mondays, but the on-call Doctor stopped in to check my heart and lungs and look for any signs of a rash on my legs. I was good, so we waited about 40 minutes and then fired the infusion back up.
In that wait time, I wolfed down a huge bowl of cantaloupe, a bag of trail mix, an electrolyte drink and a protein cookie. I think that it helped!

I was done at about 1:30 and out by 1:45. When I got home, I made some muffins, tidied up the kitchen a little then tried to get a little nap in, but I was having the worst leg "twitches" from sitting for so long.
It was driving me crazy, so I ended up walking on the treadmill for 30 minutes, which I think really helped.

I did start to get a little itchy again around 5:00, but taking another Benedryl took care of it.

The rest of the night was pretty normal. I just hung out in bed watching the Olympics. I was feeling a little tired and have had a headache, but have been a million times better than back in December.

I did have a little trouble sleeping last night, because my fibromyalgia (which hasn't been giving me much trouble lately, thanks to eating clean and getting more exercise) was making my heart do the "flip flop", so of course I was convinced I was having more of an allergic reaction and freaking out. This morning I have just have a headache and a hot, blotchy rash on my cheeks and around my eyes. Hopefully that will go away soon, as I get a little closer to the 24 hour mark. 

The fact that I haven't been sleeping and in pain since I got home yesterday (like last time) is really a testament to what this drug has done for me, and how far I've come since then. I'm praying that if this is the drug that is meant for me, that I'll be able to tolerate the 2nd round in two weeks.

I really have felt my friends and family with me through this and that meant the world to me. Thank you so much for the love and support! 

Maren

Great news!

If you haven’t heard it from me already, I was finally approved for my next round of Rituxan infusions! In fact, I have been approved through the next year, so that could potentially be two more rounds!

I just confirmed my appointment for Monday morning, the 8^th. I’ll then have the second infusion on Monday, the 22^nd.

While the anxiety has just started to set in, I am much more excited about the infusion this time around, and less scared.
My first infusion, I was excited yes, but mostly s#!tting in my pants. Once I didn’t die within 24 hours, I started to feel a little better about it ;-)

My most recent lab work showed improvement, however not yet totally in the clear.

From Dr. Grandits:
The labs show normal kidney and liver functions.
The blood cell counts are improving, improving red count and Hemoglobin improved.
The white count is lowish but stable and the size of the red cell is large (MCV) but again stable.
The platelets are normal in number.
Ok to continue your medications.

I have been struggling with my Dermatomyositis rashes, but keep plugging away with the topical medication that I have from my Dermatologist.
I’m only about halfway into the adjustment period for Plaquenil (aka Hydroxychloroquine), so it’s unknown if that is on board or not yet. I keep watching my skin for signs of improvement or at least a steady change, but nothing quite yet.

The rashes have been annoying, but whatever – I’m over it! I’m done wasting energy on them, or worrying about what they look like. If someone wants to think that I have some contagious skin disease and run away from me, then good for them.

DM Rash on Left Shoulder

Warning: No Makeup. LOL
DM Rash on Shoulders, Chest, Face and Scalp. Booo.

DM Rash on Upper Back and Shoulders

DM Rash on Right Shoulder/Bicep

I am happy to report that I have also been feeling awesome! I’m getting stronger every day and building my energy level so that I can do more without getting wiped out the following day (or two, or three)!
I am so lucky that my job allows me to save my energy for activities that I want to do, and also that I have breaks when I need them to get up and move around, or sit down and take a breather! 

I still struggle with little things here and there, but I am leaps and bounds from where I was just one year ago and couldn’t be more proud.
Example: First thing in the morning when I let the pups outside, it’s still a little hard for me to walk back up the stairs and it takes a little while for my muscles to get fired up and moving for the day. My thighs are also still the first thing to fatigue when I exercise. This is a million times better than last year when I could hardly walk up the stairs at all, and needed my husband’s help to move around. So, no complaints here!

So, Monday is the day! I have a few days off of work for each infusion, in case I’m groggy/foggy/not feeling awesome afterwards.
I cannot tell you how absolutely thrilled and grateful I am to receive this life-changing medication again. To know that I will continue to feel better and to improve makes me jump for joy. It feels so great to be able to walk around, be active and enjoy my life off of the couch! I am just over the moon.

I plan to have more great things to report! This weekend will be a fun one, so hopefully it will keep my mind off of any nerves and help me stay focused on the prize and keeping positive.

Thank you for your love and support!
M

Happy Almost July!

Hello there!

I thought that I would give a little update, so that my next post doesn’t rival War and Peace [again].

First off, the Patient Representative with my Rheumatologist is still working the case to present to my insurance to request the next Rituxan infusion. I went in last week for a tuberculosis (TB) test, which somehow would help my case (I didn’t even ask why at this point, I just did it).

I’m not too far off the plan for an early June infusion, but am starting to get a little anxious, since I have had a few changes to my symptoms that have made me a little uneasy. I feel that they are most likely due to some recent medication changes (will elaborate in a sec), but nonetheless, I am always wondering what will happen when my last infusion wears off.

The rash on my face is finally gone thanks to my 20 (okay, it's actually 4) different prescription cremes! My amazing Dermatologist has also recommended that I switch from my Triamcinlone (steroid creme) to my Tacrolimus ointment for my DM rash, since it's getting so painful, which can be an indication of thinning skin. Fun stuff. 

Some "educational" photos for fun:

Dermatomyositis rash

Ragged cuticles and nail fold telangiectasias.
Both very common in Dermatomyositis patients.

Gottron's Papules suck.

To refresh your memory, my last rheumatologist appointment was on May 26^th. At that time, my labs showed that my red and white blood cell counts were getting low. I was at 4 tablets of Azathioprine, and we decreased to 2. We also added Dapsone to see if it helped my skin rashes. 

First, this is a little embarrassing, but I’ll just come right out with it. Brown urine. 
I drink about 80-100 ounces of water a day, so my urine is typically clear, however I began noticing that in the morning, it was brown. 

On the medication leaflet that I was given with the [new] Dapsone prescription, it said to seek immediate medical attention if this occurred (since it could mean kidney disease), so I messaged Dr. Grandits, who ordered some labs along with my TB testing. 

I had also started to get really tired again, feeling like I needed to take a nap in the afternoon, and heading to lay down in bed after cleaning up after dinner. No Bueno. This is what I had just gotten away from.

After a few messages back and forth with Dr. Grandits, I told her that I just wasn’t feeling comfortable with the Dapsone, and was worried about my counts getting lower. I also don’t really want to get on a drug that will likely be long term that could be dangerous for me, and I don’t want to be tired all the time anymore…

6/29/16
Hi Dr. Grandits,

I’ve been thinking about your message from last night. I talked about it with my husband, who reminded me that I have been getting much more tired in the past month and have been heading into bed very early, which is something that I had gotten away from.

The red blood counts are a little concerning to me. I haven’t had a great feeling about the Dapsone, and the rashes on my back are pretty painful. I think that I would like to just move on.

I know that we had discussed trying the Cyclosporine next, however to avoid possibly having to get off and then get back on the Azathioprine if it doesn’t do the trick, I think that I would really like to skip ahead to door #3 and try the Plaquenil next.

Do you think that this would be okay to do? Does the Plaquenil tend to lower the red or white blood cells counts as well?

Thank you so much for all of your help and guidance through these medication changes.

Maren

----- Message -----

Dear Maren,
That is reasonable, the hydroxychloroquine is a more gentle drug in terms of affecting the bone marrow and other organs. 

You can stop the dapsone, no need to taper. I have sent a prescription for the hydroxychloroquine to your pharmacy, start with one tab daily x 2 weeks, then go to 2 tabs daily. 

Let me know how you are doing.
Martha Grandits, M.D. 6/29/2016 11:34 AM

So! I head back in for a checkup and labs towards the end of July. 

Hopefully I will have more information about the Rituxan infusion, my labs will be looking better, and I’ll be feeling less tired and have less skin rashes, too!

Until then, I hope that you are all enjoying the summer. The weather is gorgeous here in MN today!

Thank you for your love and support!
XO, M

Happy June!

Lots to touch on in this post! I’ll try to be quick! 

Aside from a nasty cold that hung around for a few weeks at the end of April, I have been doing really well, and the lack of posting has certainly been a "No News is Good News" situation! 

Hip pain update – gone! Whaaa?? I stopped using my beloved recumbent bicycle and the deep pain in my hips and thighs went away. So, for now I have not seen an orthopedic specialist. I just hopped back on that horse, I mean “bike” this week. So if the pain comes back you know where I’ll be headed.

I did learn that the MRI did not scan low enough to view the muscle tissue in the thighs. This was a little bit of a bummer, since I am always hoping to learn more about the current situation within the muscles and an MRI is the best way to see it.

In regard to the degeneration seen on the spine, Dr. Grandits said, “The mild degenerative change in the lumbar spine and previously in the neck are usually age related, or also can be related to trauma. It is not reversible, exercising, keeping muscles toned to support joints if important.” Good – I’m working on that!

I did have a check-up the week before last.

5/5/16 Labs 

The labs look good.

The muscle enzymes are normal. No systemic inflammation detected. 

There is no liver, kidney, or blood cell count abnormalities except a mildly low white cell count. 

The lyme screen is negative.

As a preventative, I asked Dr. Grandits if we could routinely check for Lymes during the warmer months. She had to fill out a reason on the lab request to which she selected “fatigue”, to which I asked, “Oh, was “paranoia” not an option?” She laughed, so that was the highlight of my appointment.

While she did report that my labs looked good, there were quite a few numbers in the highs and lows that have not been before. This is one of the many reasons that I recommend keeping your own records.

So, I sent her the following message:

Hi Dr. Grandits, 

Thank you for sending the labs so quickly. I had a few questions regarding my results. 

First, I noticed that the Lipid Panel mentioned that I was fasting and I was not. Would this change the results? 

Next, I noticed that there were quite a few new results in the high (Lymphocytes, MCH, MCV) and low (Red Blood Count, White Blood Count, Absolute Neutrophils) zones. 

Do these changes indicate anything that I should be concerned of, or that I could make changes to help correct? 

Given the lab results, do you feel that it is okay to go ahead with the Dapsone? 

Thank you!
Maren

Dr. Grandits responded:

“The lipid panel would likely be better (improved) if you were fasting.
The blood counts constantly fluctuate day to day with contributions from medications, general health, illnesses. Your changes are most likely medication related as you did increase the azathioprine...
The levels are ok to start dapsone...”

A quick tangent…

Here is a view of my own lab document. Because of this documentation, I am able to ask questions about my own labs that make sense to me. 

Having my blog has also been a great tool to look up how I was doing at a certain point in time. My doctor’s records are often only a peek into any given period, whereas this blog has become an invaluable tool, especially now that I have a smart phone that allows me to quickly look up information at appointments with various doctors, along with the new patient portals, which are great for labs as well.

While I always trust my doctors for the final word, their information and knowledge really isn’t helpful to me if it’s not absorbed by my own brain, and my brain likes spreadsheets.

Back to last week’s appointment!

My skin symptoms have not been getting any better, and honestly, I’m at a breaking point with it all. Every day is a new kind of rash somewhere. They itch, burn, and are not always pretty to look at. My dermatologist really wanted me to try Plaquenil for this, since she had been reading about it’s effectiveness with Dermatomyositis (DM) skin symptoms, even though it didn’t seem to do much in the past for the internal part of the disease.

Dr. Grandits has been noticeably less enthusiastic about this option, and always recommends an alternative. When I asked her the other day, she just said that she doesn’t think that it has been very effective for her patients, and would like it if we tried some other options first.

So, I took a quick 4 day blast of prednisone to wipe my system clear (for lack of a better term) and we have started a new [for me] drug called Dapsone, which was created to fight the skin symptoms of leprosy. Aside from a slight hit to my ego, I’m willing to give it a shot.

I am decreasing the Azathiprine back down to two tablets (which, in my mind, that is the culprit for the worsened skin symptoms).

I currently have a small, but very painful DM rash between my right shoulder and neck, so I have been watching this closely as I slowly increase my dosage of the new drug. And, my hands have been a hot mess for a while, so I’m keeping a close eye on them as well. After a week and a few days of the Dapsone, at two tablets, the burning of the rash is gone (although it is still a little red) and the burning/itching of the Gottron’s Papules on my hands has subsided.

I can go up to 4 tablets, but if the symptoms start to respond, I can hold at that count. If, after a few months, the Dapsone doesn’t do the trick, I’ll try a drug called Cyclosporine (which would also take the place of both the Dapsone and Azathiprine). I can’t remember why this one scared me a little more than the Dapsone, which is why it is the second choice… apparently I didn’t feel the need to write that down in my notes. If then the Cyclosporine doesn’t help, we will finally try the Plaquenil once again.

I also asked about a Biotin supplement, which many of the people in my support groups take to help grown new, healthy hair after losing it from the various drugs. It also can reportedly help maintain healthy skin. I have lost a considerable amount of hair since last fall, but thankfully, prefer my hair to be short, so it doesn’t bother me. The only thing that is a little weird is having less eyelashes than I am used to, but they’re coming back. I also know that my hair is coming back since there are 2” long hairs sticking up all over my head.

To avoid the risk of trying too many new things at once, and then not knowing which is helping, I will wait on trying Biotin, at least until I land on a drug to help with my rashes.

I did stop using the CoQ10 because I just didn’t notice any difference in the way that I felt. I noticed a bigger change when I switched to Almond Milk! I take enough pills, so I was glad to ditch this one.

Lastly, Rituxan! We are currently going through the pre-approval process for my 2^nd round of infusions. Hopefully we will stay on track to have them this month, although it is already taking longer than I anticipated.

I have continued to feel a little more tired since my last post. While, still leaps and bounds ahead of how I felt before, it is definitely different than where I was at about the 2 month mark after the first round of infusions.

If my insurance doesn’t cover it, I can’t receive it. So, I have been really hoping that Blue Cross can understand my need for this drug, even though it isn’t on their policy listing of diseases approved to receive it.
Rituxan has given me a part of my life back that I feared was gone. I suppose if I cannot get the infusion again, I will forever be grateful for being able to have these past 6 months and knowing the feeling of being able to walk around and be lightly active again. But, I have to admit that I would also be devastated, scared.

Dr. Grandits did recently attend a conference where they discussed whether two infusions were necessary (versus just trying one per round) for keeping DM under control or in remission.
This would not be an option quite yet for me, since I’m still trying to get to that point, but I hope that it is something that they learn more about in the future, as maybe it will encourage more insurance companies to allow patients to receive this drug.

So, now we wait! As soon as I hear back about the infusion, I’ll update!

In other news, I have now lost 20 pounds since the first of the year, and my glucose is now back in the healthy zone. I did also have my cholesterol checked (the aforementioned "Lipid Panel"), and that was all over the place.
Dr. Grandits said, “The Hemoglobin A1C is very good, no diabetes indications. The cholesterol is mildly elevated for the total, of the components the triglycerides are mildly above normal, the HDL (good) cholesterol level is good and the LDL (bad) cholesterol level is also good (130).” 

I did a little homework (thank you, Google) about triglycerides and they are can become elevated with poorly controlled diabetes (nope), underactive thyroid (nope), kidney disease (nope), regularly eating more calories than you burn (not any more), drinking a lot of alcohol (not any more), obesity or too much fat around the waistline (BINGO!). Apparently steroids can elevate triglycerides as well, and I have been on prednisone quite a bit in the past year.

My primary physician said that my results would have likely been "better" had I been fasting, but ordered an A1C test for herself after I shared the results with her. I'll update on those results when I have them.

I still have 25 pounds to lose to get back to my healthy weight/size; hopefully as I continue on this path, I’ll get all of these numbers back where they should be! I have enough s#it going on in my life to risk getting heart disease or having a stroke.

Lastly, this past May was [the new] Myositis Awareness Month!
Before, Myositis just got one day in September for the whole year! Now we get the month of May to increase awareness of these diseases.

The average myositis patient sees 10 different doctors and waits over 3.5 years before getting a proper diagnosis. Please visit myositis.org to learn more, and consider either making a donation to The Myositis Association or spreading the word yourself!

I feel like in the 6 years since my diagnosis, I am finally feeling some momentum with the research and “marketing” of the disease. As information is available to more doctors, and the amount of accurate diagnoses increases, so do the number of people affected by myositis (patients, friends, families), and the need/desire for improved research and medication grows! I am really hoping that I will be able to see a significant positive change for myositis patients in my lifetime, especially for all the precious Juvenile Dermatomyositis Warriors!! 

I want to thank you all for not only supporting me, but for taking the time to learn with me over the course of the last 6 years. It has been a bumpy ride, but I am better because of it. I have learned so much about all the wonderful people who love and support me and my family. I am truly blessed.

Hope that everyone's summer is off to a great start!

XO,

Maren