Foot Health: Biological Therapies

All right. So here we are to talk about biologics and how they can impact foot health, particularly for patients who have rheumatoid arthritis. So I think we're all aware of the new treatment regime that we've got here. So if you just see they've got biologics coming in now and actually it's quite a lot of patients in the country that are accessing biologic. And so what we'd like to talk about is the impact of foot health but taking into consideration having biologics with that. By using biologics, we're aiming to reduce the inflammation and hopefully, reduce the pain that patients get in their feet, prevent deformities from occurring if you start them early enough, If you've already got deformities and then you come on to taking biologics, we then just try to look at managing problems that might occur. Okay, so the first area that we want to have a look at is identifying places on your feet that might cause a problem. So if you can see in these pictures here, we've got the top of feet and perhaps the side, but also the bottoms as well. So this might not be the case for everyone that they're quite prominent as you see here in the pictures, but it's worth looking for any areas on your feet that could potentially cause harm. So if we look here, we're looking for anything that could be rubbed, that might get red, could get scab on it, or might cause yourself a break in the skin. And like I said, these areas could be anywhere. So it could be toes, could be the sides of the feet, could be along the bottom. And really, these areas are vulnerable to rubs from things like footwear mostly, and pressure from walking. So if you're on biologics and suddenly you're feeling a lot better, you are more active on your feet. Suddenly, doing a lot more steps and the tissues under a lot more stress than it was before and this is when these problems could occur. And when we talk about problems occurring, mostly we're worried about wounds. And we'll go into why in a second. Okay, so preventing these rubs and wounds from happening is quite easy. The first step is obviously identifying the areas that could come of harm. And then there's many devices that can simply protect areas like gel sleeves, we can make molded devices, and as you see in the picture there, just offloading the prominence with some felt. Footwear is very important. So you need enough depth that there's no pressure from the sides or the tops on these places. And we can also issue insoles. And really, the reason we want to avoid any of this happening is because we don't want any wounds. So if you're on biologics, your immune system is reduced quite severely. And that means that you're slower to heal. So you haven't got the inflammatory response to make those wounds heal as quickly. You've therefore got a wound for a longer period of time. And because your immune system is reduced, you're more at risk than of picking up infections. And infections are really what we need to avoid. If you get an infection, your body hasn't got the defense to fight it off. So it can spread quite quickly and it can become quite severe. So all in all, we need to start by preventing it from happening in the first place by identifying these areas. And if you do get a rub or wound or anything like that, the most important factor is to get it checked very quickly. So ask practice nurse or your doctor or if your podiatry service can fit you in, that's brilliant. And what you can do at home is pop a plaster on straight away. So moving on to infection in more depth. We've spoken about being immuno-suppressed. But when you are immuno-suppressed, you don't get the signs that virus, obvious, as someone who's not on biologics. So before, if you got an infection, you might get very hot, red, throbbing area and we see that's not the case so much in patients who are on any of the biologic drugs. So it's looking for subtle changes really, something that's a little bit more tender, a bit pinker than usual, or looking at the skin, is it all intact. If you do you notice that there's a problem or you're concerned, the point we want to highlight the most is if you're due to have an injection or you're due to go for an infusion of your biologics, then just take a second and have it checked first. Delay that injection by a day or so if you can and it just makes everything a lot easier, and it reduces that risk of an infection spreading. Okay, so prior to being on biologics, it might be that your mobility was reduced and you weren't doing so much due to pain or other problems. So now if you're feeling better and you're on your biologic drugs, you might be doing more activity. And if you think that the muscles might have become weak and we weren't using them so much. If suddenly you're increasing your activity levels, and it's worth bearing in mind that these structures might become overused and become quite tired. If this is the case, you might find the areas around the ankle or the feet become quite tender and warm. And this is the tendon trying to tell you it's not very happy. Podiatrists can help here and we can help by issuing temporary ankle braces, strapping, footwear, advice, and insoles in particular. And the best thing that you can do if you notice a change is to report it to your podiatrists quite quickly, because otherwise you can get ongoing problems that result from this information around the tendons. So what you can do you while you're waiting to see a podiatrist is perhaps wear some supportive footwear that have fastening and lace-up or strap. Try applying ice to the area if it's quite warm. So if it's on the inside of your ankle, pops some peas on, five minutes, three times a day. That helps take down some of that information and help the tendon along its way. If you're not taking tablet version of anti-inflammatory drugs, there are gels on the market that you can rub on to the skin in that area. You just need to make sure that you are able to take anti-inflammatories, and you can't take them at the same time as the tablets. But it is very important because if tendons go on being inflamed and you're trying to do more activity, then you can lead to the tendon not functioning very well. And that can lead to foot deformities and foot problems. And obviously, what we want is we want to be much more active and leading an active, busy lifestyle. So if you notice any changes in shape or any hot swollen areas, it's really worth reporting it to us straight away. So if when you checked your feet, you notice a change in area that might have a rub, cut, blister or an area that you're worried about, it's best to have that checked. And if you're due to have your Humira injection. or something like that or your infusion, it's just worth delaying it until you've had that area of concern checked. If there is a problem, the last thing you'd want to do is take your injection and then an infection develops and becomes quite nasty, quite quickly. So by avoiding having infusion or injection, you can just postpone any of those problems from happening. When you say, avoid your injection, does that include the methotrexate injection, you'd have on weekly basis? When we talk about delaying injections, we're just talking about the biologics specifically. So you continue with your disease modifiers as normal, although this does depend on the area of your rheumatology service, so it's always worth checking with your rheumatology service first. You mentioned foot surgery and coming off your biologic drugs when you have foot surgery. Does that apply to surgery in other areas as well? The advice is to delay biologics before surgery. This doesn't matter if it's orthopedic surgery, skin surgery, or something like nail surgery for ingrown toe nails. It depends again, which area your rheumatology department is in. Everyone has their own local guidance and the surgeons will also have their own guidance. So it's worth checking first, before you have your surgery that how long, in advance, you need to postpone your biologic injection or infusion. If it's an injection you give yourself, it can be a couple of weeks. If you're having something like rituximab infusions, then there's a safe period so many months after the infusion or you can have it just before you have your next infusion.