An immunosuppressant druggie

As a companion post to the immunosuppressants, and continuing the "druggie" series (see "an antihistamine druggie"), here's one for that type of crowd.

Disclaimer for this type of post: Please remember that I am not a health professional of any kind. My notes represent my own experience and reactions to the drugs in the past and present. Your reactions may be different. Nor am I paid by anyone to say either good or bad things about the drugs.

General notes:

• In Israel (and possibly other countries), many of these drugs are not officially approved for atopic dermatitis, which means you'll have to get a special approval from the Ministry of Health (or FDA, or equivalent in your country). Your doctor should be able to explain how to request this approval, and/or do it him/herself.
  
• For all the listed drugs, make sure you read the instructions and leaflet really carefully.
  
• These are heavy artillery drugs, not to be taken lightly. Don't play around with'em.
  
• Follow whatever it says on the leaflet, including, if necessary:
• Avoiding alcohol
• Using extra contraceptives - getting pregnant is not a good idea while taking most or all of these drugs (see original post) .
• Whatever else it says on there!!! Don't argue, do it.
• Pay attention to any side effects you may suffer from.
  
• Go read the original post about immunosuppressants. This is just a companion to it.
  

Cyclosporine (Neoral, Sandimmune, etc.) - this is the most basic, and most often used immunosuppressant (at least in the department I'm treated in). It's well known for psoriasis and organ transplant. Generally, should not be used for long periods (over 3 months), although it can be, if necessary.
I've been on it for over 7 months now, although I finally seem to be on the right track for switching to a different drug. It worked (works) pretty well for me, but with one major caveat: I needed antibiotics nearly the whole period, for two reasons. (1) I kept catching the flu or getting my throat infected. I'm not a healthy person during the best of times and tend to catch anything that's around; much more so when on immunosuppressants. (2) My skin was also constantly getting infected, which did not help the skin to clear up. Folliculitis was a major issue and caused scratching.

Imuran (azathioprine) - an older generation drug. Considered a more slow-acting drug, but also one that can be taken for a long time with less severe effects. Didn't work for me at all, so I can't say much for it - sorry. Might work for you, or not. Prof. B. said that it does work on many patients, so maybe I'm the odd-man-out here.

Cellcept (mycophenolate mofetil) - a very new drug, as of this writing. It is supposedly in addition to cyclosporine, not instead of it. For me, it did the job terribly well, and I would recommend it warmly for most people. However (again - for me), it also had some pretty severe side effects which rendered the medication totally pointless. There was no way I could keep using it. [If you want, you can mail me privately and I'll expand.] Point being - take it if your doctor suggests, but be very aware of any ill effects. What with this drug being so new, even the experts aren't totally sure of how prevalent the various side-effects are. Note: in some countries (Israel included), this drug may not yet be approved or included in the subsidized drug list, especially not for atopic. Israelis, be ready to pay top dollar (err, shekel) for this one.

Methotrexate - a drug also used to treat certain types of cancer. I am now switching to this; so far, so good, but we'll have to wait and see. It is usually given once a week, not every day. There is some cross-drug interaction with cyclosporine, so make sure your dermatologist is aware that you're taking both. From what I understand, it is common to give a test dosage first and see what the body's reaction is, and only then up the dosage. Plus, this is the one drug I've seen that specifies birth defects caused from the male parent as well as the female. There's also some potential issues with blood clotting, which can be overcome by taking folic acid in a very specific manner. Ask your expert to make sure this is discussed.

More drugs will be added if I have the pleasure to interact with them...

Immunosuppressants for Atopic Dermatitis

I talked about treatments and what constitutes treatment. Now, as the wise Rafiki said, "it is time". Time to talk about immunosuppressants for Atopic, what they are and what they do, the dangers and complications, and (soon) the different types available to you.

Immunosuppressants are drugs that an expert dermatologist can prescribe for you. Their basic effect is, well, what their name says: they suppress your immune system. [As an aside, their main usage is "in organ transplant surgery to prevent organ rejection" (taken from Answers.com) and sometimes they are originally chemotherapeutic agents].

Don't try this "at home", i.e. without the benefit of an expert. Do not, I repeat, do not count on your physician to cut it. He or she may know you best but they do not know the effects of these drugs best. Let the experts do their job; dermatologists spent four or five extra years studying this, and they treat cases like you all the time. And definitely do not take them without medical advice at all! Don't even think about it.

Why could this be good for you? Basically, your immune system working over-hard, "panicking" and fighting things that aren't really dangerous to you (namely, allergens). This useless fight is causing you to itch, scratch, etc. Therefore, telling your system to "cool it" means it should stop fighting so hard. So it should cause an improvement in your situation. Several immunosuppressants have been consistently shown to cause improvement in many cases of atopic.

Why could this be bad for you? Well, immunosuppressants are heavy artillery. There are several effects, first and foremost - a higher sensitivity to contagious diseases. You should be careful not to come in too close contact with too many people, especially if you know they're sick. What's more, there can be interference with all sorts of normal bodily functions. During the time you're taking them, you should be under nearly constant "surveillance": complete blood count (CBC - the most basic blood test) and blood tests for liver and kidney functions, as well as blood pressure. The exact battery of tests you should undergo varies with the precise medication.

What else should you know?

Using immunosuppressants should clear up your atopic symptoms, including infections (via a complex mechanism that I don't entirely understand), but there is a possibility that you will be more vulnerable to skin infections, such as folliculitis, in which case you may need to add antibiotics as a backup player (or switch to a different immunosuppressant). Consult your doctor!

Note for the sexually active -

• females: for most of these drugs (if not all), you need to avoid pregnancy during the whole period of taking the medicine, and potentially for awhile after you stop. Plus, some of these drugs may reduce the efficiency of The Pill, so make sure you talk to your doctor about this, and add alternative contraception (condoms or otherwise).
• males: mostly there should be no problem, but double-check. At least one of these drugs (methotrexate) may cause birth defects in an unborn child if your partner gets pregnant. Best to be on the safe side and ask your doctor.
  

So, when should you take them?

First of all, it's important to note that it's not totally your decision to make. An expert doctor (usually a dermatologist) will decide whether or not your situation and specific condition merits this kind of treatment. Of course, you do have some choice here - you can (a) suggest it in case your doctor doesn't, or (b) refuse to take it if your doctor does suggest it.

But let's take a look at the criteria. An expert dermatologist may look at:

• How widespread your atopic is (are you erythrodermic?)
• How resistant your case is (did you respond to other treatment? topical cortisons? maybe UV?)
• How badly is atopic affecting your life (how much is it interfering with your day-to-day life?)
• How do your blood tests look before you start the drug (as mentioned earlier - are liver and kidney functions OK?)
  
• And potentially other things... see warning signs, and remember, I'm no doctor.

A separate post is coming up with the different types of drugs available to you.

And I'm off.

Hospital, take 2.

This time I'm entering in a much better situation, relative to last time.

Still feel pretty awful, though.

It was just recommended this time, not required really. But the situation was going downhill so quickly I felt it would be better to listen to the good doctor.

And I'm off.

Comment on affected body areas

And if you need further convincing, here's another reason why an ounce of prevention is worth a pound of cure.

When things get bad, for any reason, you may make the following discovery the hard way (as I have myself many times). Areas of your body that were previously totally clean and unaffected may react and become part of your general scratching repertoire. And once affected, they will rarely truly stop being part of the sensitive skin.

Example: when I started with braces, I had to use a neck brace (back in the day when they needed those). The skin on the back of my neck started itching, and has not really stopped since. Before this episode it had never been itchy at all.

Similar situations have happened with my scalp, the back of my hands, the tops of my feet and even the palms of my hand and my fingers (when the shit really hit the fan, if you'll excuse my French). Some of these areas go back to normal at some points in time but then flare up again and again at other times.

So watch out for the signs. And take care of yourself even when things are looking up.

What constitutes a treatment

So, what constitutes a treatment for Atopic Dermatitis - according to conventional medicine, anyway?

According to Dr. H (dermatologist), here's what can constitute a treatment (I'm pretty sure he meant for medium to severe atopic):

1. Topical Steroids. Topical means on the spot, or in plain English, creams spread on your skin. in order to actually treat the atopic, they need to have steroids (cortisons) in them.
   
2. Immunosuppressants. These agents may calm your atopic dermatitis by way of lowering the resistance of your entire immune system.
   
3. Phototherapy - certain types of UV rays may be helpful for some cases of atopic dermatitis.
   

Now, each of these treatments has its own dangers and complications, I won't go into details right now. Let's just say, "don't try this at home". Consult an expert for the right options for you.

In a future post I'll write, accordingly, what doesn't constitute an actual treatment (but may well act as prevention).

One word of caution, according to Prof. B. (dermatologist): Systemic steroids (i.e. taken through the mouth, injected, etc.) should NOT be used for atopic, as they tend to cause a rebound reaction once the drug is discontinued. There is evidently a major difference in opinion among doctors on this point. Allergists and physicians may tend to recommend this type of treatment because it is effective for asthma and so assume it will work for atopic as well. Personally, I've experienced the rebound effect in both times I've taken systemic steroids. Readers beware.